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Improving Patient Adherence Improving Patient Adherence with Job Aids, Niger with Job Aids, Niger Wendy Edson, Maina Boucar, Peggy Koniz-Booher, Sabou Djbrina, Ibrahima Mahamane
Improving Patient AdherenceImproving Patient Adherencewith Job Aids, Nigerwith Job Aids, Niger
Wendy Edson, Maina Boucar,Peggy Koniz-Booher,
Sabou Djbrina, IbrahimaMahamane
Study PurposeStudy Purpose
To develop and evaluate the effectiveness of job aids to improve caretaker compliance
with antibiotic regimens for thetreatment of pneumonia inchildren.
RationaleRationale
Improving patient counselingand improving adherence to theantibiotic regimen will curb thedevelopment of antimicrobialresistance.
Target Study PopulationTarget Study Population
Mostly illiterate caretakers ofchildren with pneumonia andtreated as outpatients in BoboyeDistrict, NigerHealth care workers at clinics
Step 1: Formative ResearchStep 1: Formative ResearchHealth center– What information is currently given to the
caretaker?– What are the reasons for not counseling?
Caretaker– What are the cultural beliefs?– How is information disseminated traditionally?– How are antibiotics used in the home?
Step 1: Formative ResearchStep 1: Formative ResearchMethods of data collection– Health worker observations– Focus groups caretakers– Key informant interviews
Results: Care-seekingResults: Care-seekingbehaviorbehavior
Pneumonia is considered a serious illnessConstraints to seeking care:– Cost of the visit, usually borne by the
father– Availability of cotrimoxazole in the
market at the same cost as a health visitCotrimoxazole is considered effective byparents, well tolerated and easy to use
Results: Patient CounselingResults: Patient CounselingIn Niger only 2 or 3 days of the 5-daycourse is given (Caretaker must return forthe rest)Healthcare workers offered littlecounseling on administration of antibioticAntibiotic given in paper cone sometimeswith marks to indicate dosage
Results: AntibioticResults: AntibioticAdministrationAdministration
Crushed tablet with finger and mixed withavailable waterMedication was not stored properly athome
Results: CommunicationResults: Communication
Most respected information sources werehealth workers and regional radioMost could not read or write, some coulddistinguish letters and numbers.Were familiar with pictures of diarrhea,polio, HIV, etc.
Step 2: Development of theStep 2: Development of thejob aidsjob aids
Held workshop to present results tonational, regional and district levelparticipantsFormed technical committee tooversee development of materials
Workshop participants
Birni, Niger, September 2000
Image for Job AidImage for Job Aid
Prepare tablet by crushing with a spoon andmixing with clean water
Image for Job AidImage for Job Aid
Father is involved in care of childGive medication with a spoon
Image for Job AidImage for Job Aid
Store medication in a safe placeOut of the reach of children
Image for Job AidImage for Job Aid
Finish entire package of medicine
Technical CommitteeTechnical Committee
Counseling CardCounseling Card
Counseling Card - TextCounseling Card - Text
Medication EnvelopeMedication Envelope
PosterPoster
InterpersonalCommunicationand Job AidsTraining Manual
Step 3: Test the effectivenessStep 3: Test the effectivenessof the job aidsof the job aids
Experimental Study Design– 4 control sites, 4 experimental sites
Intervention– Interpersonal communication training– Use of job aids (poster, counseling
card, envelopes)
Step 3: Test the effectivenessStep 3: Test the effectivenessof the job aidsof the job aids
Data Collection methodology– Caretakers interviewed after clinic visit– Caretakers visited in their homes 4-5
days after clinic visit– Healthcare workers observed at 2
points in study– Nov. 2000 to April 2001
Child CharacteristicsChild Characteristics
Control N = 327
Experimental N = 348
Child Age (mean)
18.3 mos 18.2 mos
% Male 49% 54%
Birth Order (mean)
3.5 3.7
Maternal CharacteristicsMaternal Characteristics
ControlN = 327
ExperimentalN = 348
Age(Mean)
27.2 yrs 27.9 yrs
% noschooling 57% 49%
% Married 97% 96%
Household CharacteristicsHousehold CharacteristicsControlN = 327
ExperimentalN = 348
Size of HH* 7.4 persons 9.3 persons
Ethnic Grp*% Peul% Djerma% Haoussa
18%74%7%
6%89%1%
% with radio* 44% 68%
* p < .001
Results: Use of Clean WaterResults: Use of Clean Water
73
94
0
20
40
60
80
100
Use of CleanWater
Perc
enta
ge
Control Experimental
*P< .001
Results: Antibiotic StorageResults: Antibiotic Storage
87 91
0
20
40
60
80
100
Stored AntibioticCorrectly*
Perc
enta
ge
Control Experimental
*P = .04
Results: Patient AdherenceResults: Patient Adherence
7689
0
20
40
60
80
100
CorrectAdherence
Perc
enta
ge
Control Experimental
*P< .001
Results: Follow-upResults: Follow-upAppointmentAppointment
58
79
0
20
40
60
80
100
Kept Follow-upAppt
Perc
enta
ge
Control Experimental
*P< .001
Results: Maternal KnowledgeResults: Maternal Knowledge
99 99 97 93 98 99
0
20
40
60
80
100
Correct number ofpills
Correct timeduring day*
Correct number ofdays
Control Experimental
*P = .01
Results: Perceived Child’sResults: Perceived Child’sHealthHealth
3547
0
20
40
60
80
100
Health ImprovedCompletely
Perc
enta
ge
Control Experimental
*P< .001
ConclusionsConclusions
Preliminary ResultsFurther analyses– effect of health worker and clinicRecommendations– Change national policy so that a
full dose is given at first visit
DevelopmentDevelopment of a Case of a CaseManagementManagement Map Map in in Uganda Uganda
Barbara Kerstiëns, MD, MPHQuality Assurance Project
Johns Hopkins University
Presented byPresented by
Wendy Edson, PhD, RN, MPHQuality Assurance Project
Case Management MapCase Management Map(CMM)(CMM)
Job aid and medical recordBased on critical pathway approach “optimal sequencing and timing of
interventions by medical staff for aparticular condition...”
(Coffey 1992)
CMM FormatCMM Format
Rows: Activities(Monitoring,Treatment,Medication, Diet,Patient counseling)Columns: Time(Day, Hour, Month)
Steps in CMM DevelopmentSteps in CMM Development
Selection of the conditionSelection of the teamDefinition of scope of theprotocolDescription of currentprocess of management
Steps in CMM DevelopmentSteps in CMM Development
Definition of format of CMMDevelopment of prototypeDevelopment of monitoringplanDevelopment ofimplementation plan
Steps in CMM DevelopmentSteps in CMM Development
ImplementationMonitoring and problemsolving
Challenges During DevelopmentChallenges During Development
Team membership keptchangingNot enough intern physiciansNo familiarity with criticalpathwayUnavailability of needed supplies(MgSO4, reflex hammers)
Results - Improved patientResults - Improved patientoutcomesoutcomes
Before After(06/98- 06/99) (09/99-09/00)
n=36 n=50Progress to eclampsia 17% 6%# of maternal deaths 5.5% 3.1%Live delivery 56% 83%
