A cluster-randomized trial of client and provider-directed financial interventions to align incentives with appropriate case management in retail medicine outlets: Results of the TESTsmART Trial in western Kenya.
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2024-01
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Abstract
ACTs are responsible for a substantial proportion of the global reduction in malaria mortality over the last ten years, made possible by publicly-funded subsidies making these drugs accessible and affordable in the private sector. However, inexpensive ACTs available in retail outlets have contributed substantially to overconsumption. We test an innovative, scalable strategy to target ACT-subsidies to clients with a confirmatory diagnosis. We supported malaria testing(mRDTs) in 39 medicine outlets in western Kenya, randomized to three study arms; control arm offering subsidized mRDT testing (0.4USD), client-directed intervention where all clients who received a positive RDT at the outlet were eligible for a free (fully-subsidized) ACT, and a combined client and provider directed intervention where clients with a positive RDT were eligible for free ACT and outlets received 0.1USD for every RDT performed. Our primary outcome was the proportion of ACT dispensed to individuals with a positive diagnostic test. Secondary outcomes included proportion of clients tested at the outlet and adherence to diagnostic test results. 43% of clients chose to test at the outlet. Test results informed treatment decisions, resulting in targeting of ACTs to confirmed malaria cases- 25.3% of test-negative clients purchased an ACT compared to 75% of untested clients. Client-directed and client+provider-directed interventions did not offer further improvements, compared to the control arm, in testing rates(RD = 0.09, 95%CI:-0.08,0.26) or dispensing of ACTs to test-positive clients(RD = 0.01,95% CI:-0.14, 0.16). Clients were often unaware of the price they paid for the ACT leading to uncertainty in whether the ACT subsidy was passed on to the client. This uncertainty undermines our ability to definitively conclude that client-directed subsidies are not effective for improving testing and appropriate treatment. We conclude that mRDTs could reduce ACT overconsumption in the private retail sector, but incentive structures are difficult to scale and their value to private providers is uncertain. Trial registration: ClinicalTrials.gov NCT04428307.
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Laktabai, Jeremiah, Emmah Kimachas, Joseph Kipkoech, Diana Menya, David Arthur, Yunji Zhou, Tabitha Chepkwony, Lucy Abel, et al. (2024). A cluster-randomized trial of client and provider-directed financial interventions to align incentives with appropriate case management in retail medicine outlets: Results of the TESTsmART Trial in western Kenya. PLOS global public health, 4(2). p. e0002451. 10.1371/journal.pgph.0002451 Retrieved from https://hdl.handle.net/10161/30758.
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Scholars@Duke
John Gallis
Overview
John currently collaborates with researchers and methodologists at the Duke Global Health Institute and the Duke Department of Biostatistics & Bioinformatics. His varied research experience includes design and analysis of weight loss-related randomized controlled trials (RCTs), design and analysis of cluster randomized trials (CRTs), and implementation of the multiphase optimization strategy (MOST). Recently, he has primarily worked with researchers examining the effects of interventions on maternal mental health and child health and development. His research interests include the design of CRTs and analysis methods for clustered data, among many other interests.
Education
Master of Science (Sc.M.) in Biostatistics. Johns Hopkins Bloomberg School of Public Health
Bachelor of Science (B.S.) in Mathematics: Southern Utah University
Links:
LinkedIn Profile: https://www.linkedin.com/in/john-gallis-2258b843/
Duke website: https://sites.duke.edu/johngallis/
Elizabeth Louise Turner
Dr. Turner is Associate Professor of Biostatistics and Global Health and serves as Director of the Research Design and Analysis Core of the Duke Global Health Institute. Her primary methodological focus is on the design and analysis of randomized controlled trials, particularly those that involve clustering such as cluster randomized trials (CRTs), stepped wedge CRTs and individually-randomized group treatment trials. She is expert in the implementation of trials in low resource settings, with a substantive focus on malaria, mental health and cardiovascular disease.
Dr. Turner joined the Department of Biostatistics & Bioinformatics and Duke Global Health Institute in March 2012 following four years as Research Fellow in the Department of Medical Statistics at the London School of Hygiene and Tropical Medicine (LSHTM). Since then, she has continued to hold a joint position with Duke's Global Health Institute (DGHI) where she serves as faculty statistician and collaborates with faculty and affiliates. Dr. Turner earned her undergraduate honors degree in Mathematics from the University of Warwick, UK, during which she spent an intercalated year at the Universite of Pierre et Marie Curie, Paris, France. She then earned her MSc and PhD in Statistics from McGill University, Canada, with her doctoral studies funded by the prestigious Commonwealth Scholarship.
Thanks to her participation in multi-disciplinary projects, Dr. turner has a great appreciation for the importance of good study design and data collection and is well aware that no fancy statistical analyses can save researchers from the scourge of bad data. Through those experiences and her teaching in different settings, including the UK, Canada, France and Tanzania, she is aware that statisticians and their collaborators sometimes “speak a different language”. As a result, her approach is very much one of translation, pragmatism and collaboration.
Further information about the Global Health Research Design and Analysis Core service can be found at:
https://globalhealth.duke.edu/dghi-research-design-analysis-core
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