Interdisciplinary Qualitative Research in Global Developmentprovides a sorely needed practical introduction to the interdisciplinary and increasingly complex field of global development research, and ...it does so in a concise format can easily be taken into the field.
In southeast Asia, antibiotic prescription in febrile patients attending primary care is common, and a probable contributor to the high burden of antimicrobial resistance. The objective of this trial ...was to explore whether C-reactive protein (CRP) testing at point of care could rationalise antibiotic prescription in primary care, comparing two proposed thresholds to classify CRP concentrations as low or high to guide antibiotic treatment.
We did a multicentre, open-label, randomised, controlled trial in participants aged at least 1 year with a documented fever or a chief complaint of fever (regardless of previous antibiotic intake and comorbidities other than malignancies) recruited from six public primary care units in Thailand and three primary care clinics and one outpatient department in Myanmar. Individuals were randomly assigned using a computer-based randomisation system at a ratio of 1:1:1 to either the control group or one of two CRP testing groups, which used thresholds of 20 mg/L (group A) or 40 mg/L CRP (group B) to guide antibiotic prescription. Health-care providers were masked to allocation between the two intervention groups but not to the control group. The primary outcome was the prescription of any antibiotic from day 0 to day 5 and the proportion of patients who were prescribed an antibiotic when CRP concentrations were above and below the 20 mg/L or 40 mg/L thresholds. The primary outcome was analysed in the intention-to-treat and per-protocol populations. The trial is registered with ClinicalTrials.gov, number NCT02758821, and is now completed.
Between June 8, 2016, and Aug 25, 2017, we recruited 2410 patients, of whom 803 patients were randomly assigned to CRP group A, 800 to CRP group B, and 807 to the control group. 598 patients in CRP group A, 593 in CRP group B, and 767 in the control group had follow-up data for both day 5 and day 14 and had been prescribed antibiotics (or not) in accordance with test results (per-protocol population). During the trial, 318 (39%) of 807 patients in the control group were prescribed an antibiotic by day 5, compared with 290 (36%) of 803 patients in CRP group A and 275 (34%) of 800 in CRP group B. The adjusted odds ratio (aOR) of 0·80 (95% CI 0·65–0·98) and risk difference of −5·0 percentage points (95% CI −9·7 to −0·3) between group B and the control group were significant, although lower than anticipated, whereas the reduction in prescribing in group A compared with the control group was not significant (aOR 0·86 0·70–1·06; risk difference −3·3 percentage points –8·0 to 1·4). Patients with high CRP concentrations in both intervention groups were more likely to be prescribed an antibiotic than in the control group (CRP ≥20 mg/L: group A vs control group, p<0·0001; CRP ≥40 mg/L: group B vs control group, p<0·0001), and those with low CRP concentrations were more likely to have an antibiotic withheld (CRP <20 mg/L: group A vs control group, p<0·0001; CRP <40 mg/L: group B vs control group, p<0·0001). 24 serious adverse events were recorded, consisting of 23 hospital admissions and one death, which occurred in CRP group A. Only one serious adverse event was thought to be possibly related to the study (a hospital admission in CRP group A).
In febrile patients attending primary care, testing for CRP at point of care with a threshold of 40 mg/L resulted in a modest but significant reduction in antibiotic prescribing, with patients with high CRP being more likely to be prescribed an antibiotic, and no evidence of a difference in clinical outcomes. This study extends the evidence base from lower-income settings supporting the use of CRP tests to rationalise antibiotic use in primary care patients with an acute febrile illness. A key limitation of this study is the individual rather than cluster randomised study design which might have resulted in contamination between the study groups, reducing the effect size of the intervention.
Wellcome Trust Institutional Strategic Support Fund grant (105605/Z/14/Z) and Foundation for Innovative New Diagnostics (FIND) funding from the Australian Government.
Three decades of mobile phone diffusion, thousands of mobile-phone-based health projects worldwide ("mHealth"), and tens of thousands of health applications in Apple's iTunes store, but fundamental ...questions about the effect of phone diffusion on people's healthcare behaviour remain unanswered. Empirical, theoretical, and methodological gaps in the study of mobile phones and health reinforce each other and lead to simplifying assumptions that mobile phones are a ubiquitous and neutral platform for interventions to improve health and healthcare. This contradicts what we know from the technology adoption literature. This thesis explores the theoretical link between mobile phone diffusion and healthcare access; develops and tests a new multidimensional indicator of mobile phone adoption; and analyses the effects of phone use on people's healthcare-seeking behaviour. My mixed methods research design - implemented in rural Rajasthan (India) and Gansu (China) - involves qualitative research with 231 participants and primary survey data from 800 persons. My research yields a qualitatively grounded framework that describes the accessibility and suitability of mobile phones in healthcare-seeking processes, the heterogeneous outcomes of phone use and non-use on healthcare access, and the uneven equity consequences in this process. Quantitative analysis based on the framework finds that mobile phone use in rural India and China increases access to healthcare, but it also invites more complex and delayed health behaviours and the over-use of scarce healthcare resources. Moreover, increasing phone-aided health action threatens to marginalise socio-economically disadvantaged groups further. I present here the first quantitative evidence on how mobile phone adoption influences healthcare-seeking behaviour. This challenges the common view that mHealth interventions operate on a neutral platform and draws attention to potential targeting, user acceptance, and sustainability problems. The framework and tools developed in this thesis can support policy considerations for health systems to evaluate and address the healthcare implications of mobile phone diffusion.
Three decades of mobile phone diffusion, thousands of mobile-phone-based health projects worldwide ("mHealth"), and tens of thousands of health applications in Apple's iTunes store, but fundamental ...questions about the effect of phone diffusion on people's healthcare behaviour remain unanswered. Empirical, theoretical, and methodological gaps in the study of mobile phones and health reinforce each other and lead to simplifying assumptions that mobile phones are a ubiquitous and neutral platform for interventions to improve health and healthcare. This contradicts what we know from the technology adoption literature. This thesis explores the theoretical link between mobile phone diffusion and healthcare access; develops and tests a new multidimensional indicator of mobile phone adoption; and analyses the effects of phone use on people's healthcare-seeking behaviour. My mixed methods research design - implemented in rural Rajasthan (India) and Gansu (China) - involves qualitative research with 231 participants and primary survey data from 800 persons. My research yields a qualitatively grounded framework that describes the accessibility and suitability of mobile phones in healthcare-seeking processes, the heterogeneous outcomes of phone use and non-use on healthcare access, and the uneven equity consequences in this process. Quantitative analysis based on the framework finds that mobile phone use in rural India and China increases access to healthcare, but it also invites more complex and delayed health behaviours and the over-use of scarce healthcare resources. Moreover, increasing phone-aided health action threatens to marginalise socio-economically disadvantaged groups further. I present here the first quantitative evidence on how mobile phone adoption influences healthcare-seeking behaviour. This challenges the common view that mHealth interventions operate on a neutral platform and draws attention to potential targeting, user acceptance, and sustainability problems. The framework and tools developed in this thesis can support policy considerations for health systems to evaluate and address the healthcare implications of mobile phone diffusion.
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