TY - JOUR
T1 - Safety and upscaling of remote consulting for long-term conditions in primary health care in Nigeria and Tanzania (REaCH trials)
T2 - stepped-wedge trials of training, mobile data allowance, and implementation
AU - Sturt, Jackie
AU - Harding, Richard
AU - Nkhoma, Kennedy
AU - Rogers, Rebecca
N1 - Publisher Copyright:
Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.
Funding Information:
We wish to thank members of the Trial Steering Committee: Jeremy Dale (University of Warwick), Doyin Odubanjo (University of Ibadan), and Eric Van Praag (freelance Public Health Adviser, Dar-es-Salam), and thank members of the Data Monitoring Ethics Committee: Funmilola OlaOlorun (University of Ibadan), Segun Bello (University of Ibadan), and Gabriel Upunda (St Francis University College of Health and Allied Sciences, Dar-es-Salam) for their careful scrutiny and guidance of the twin trials. From Tanzania, we are grateful to the primary care leadership of Kusirye Ukio and medical officers in charge, and district medical officers from Ulanga, Malinyi, Mlimba, Kilosa, and Mvomero districts, and Town Medical Officer from Ifakara. From Nigeria, we thank the leadership of the Oyo State Primary Health Care Board and the University College Hospital Community Health Centres. Both trial sites worked closely with data collectors to obtain, manage, and process the large quantities of data, and we acknowledge Marcusy Balagaju, Frola Theophil Stephano in Tanzania, and Abiola Oladejo, Omolara Popoola, Daniel Ayinmoro, Habeeb Alabi, Oluwatoyin Oluyinka, Precious Ayodele, Rebecca Ojuade, and Abiodun Alliu in Nigeria for their important contributions. We thank Ahmed Olanrewaju for IT support making the REaCH training available in Nigeria. Supporting qualitative analysis with the University of Warwick team, we thank Chinwe M Onuegbu and Wendy Higman. We are grateful to Samantha Shaw, Publication Coach, King's College London for their review of earlier drafts. Our utmost gratitude lies with the health workers and the patients who generously participated in the research. We acknowledge funding from The UK Research and Innovation Collective Fund and support from the National Institute for Health and Care Research Applied Research Collaboration West Midlands, University of Birmingham, UK.
Funding Information:
We wish to thank members of the Trial Steering Committee: Jeremy Dale (University of Warwick), Doyin Odubanjo (University of Ibadan), and Eric Van Praag (freelance Public Health Adviser, Dar-es-Salam), and thank members of the Data Monitoring Ethics Committee: Funmilola OlaOlorun (University of Ibadan), Segun Bello (University of Ibadan), and Gabriel Upunda (St Francis University College of Health and Allied Sciences, Dar-es-Salam) for their careful scrutiny and guidance of the twin trials. From Tanzania, we are grateful to the primary care leadership of Kusirye Ukio and medical officers in charge, and district medical officers from Ulanga, Malinyi, Mlimba, Kilosa, and Mvomero districts, and Town Medical Officer from Ifakara. From Nigeria, we thank the leadership of the Oyo State Primary Health Care Board and the University College Hospital Community Health Centres. Both trial sites worked closely with data collectors to obtain, manage, and process the large quantities of data, and we acknowledge Marcusy Balagaju, Frola Theophil Stephano in Tanzania, and Abiola Oladejo, Omolara Popoola, Daniel Ayinmoro, Habeeb Alabi, Oluwatoyin Oluyinka, Precious Ayodele, Rebecca Ojuade, and Abiodun Alliu in Nigeria for their important contributions. We thank Ahmed Olanrewaju for IT support making the REaCH training available in Nigeria. Supporting qualitative analysis with the University of Warwick team, we thank Chinwe M Onuegbu and Wendy Higman. We are grateful to Samantha Shaw, Publication Coach, King's College London for their review of earlier drafts. Our utmost gratitude lies with the health workers and the patients who generously participated in the research. We acknowledge funding from The UK Research and Innovation Collective Fund and support from the National Institute for Health and Care Research Applied Research Collaboration West Midlands, University of Birmingham, UK.
Publisher Copyright:
© 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license
PY - 2023/11/1
Y1 - 2023/11/1
N2 - BACKGROUND: In-person health care poses risks to health workers and patients during pandemics. Remote consultations can mitigate these risks. The REaCH intervention comprised training and mobile data allowance provision for mobile phones to support remotely delivered primary care in Africa compared with no training and mobile data allowance. The aim of this study was to estimate the effects of REaCH among adults with non-communicable diseases on remote and face-to-face consultation rates, patient safety, and trustworthiness of consultations. METHODS: In these two independent stepped-wedge cluster randomised controlled trials, we enrolled 20 primary care clusters in each of two settings (Oyo State, Nigeria, and Morogoro Region, Tanzania). Eligible clusters had 100 or more patients with diabetes, hypertension, and cardiovascular or pulmonary disease employing five health workers. Clusters were computer-randomised to one of ten (Nigeria) or one of seven (Tanzania) sequences to receive the REaCH intervention. Only outcome assessors were masked. Primary outcomes were consultation, prescription, and investigation rates, and trustworthiness collected monthly for 12 months (Nigeria) and 9 months (Tanzania) from open cohorts. Ten randomly sampled consulting patients per cluster-month completed patient reported outcome measures. This trial was registered with ISRCTN, ISRCTN17941313. FINDINGS: Overall, 40 clusters comprising 8776 (Nigeria) and 3246 (Tanzania) patients' open cohort data were analysed (6377 [72·7%] of 8776 females in Nigeria, and 2235 [68·9%] of 3246 females in Tanzania). The mean age of the participants was 55·3 years (SD 13·9) in Nigeria and 59·2 years (14·2) in Tanzania. In Nigeria, no evidence of change in face-to-face consulting rate was observed (rate ratio [RR] 1·06, 95% CI 0·98 to 1·09; p=0·16); however, remote consultations increased four-fold (4·44, 1·34 to >10; p=0·01). In Tanzania, face-to-face (0·94, 0·61 to 1·67; p=0·99) and remote consulting rates (1·17, 0·56 to 5·57; p=0·39) were unchanged. There was no evidence of difference in prescribing rates (Nigeria: 1·05, 0·60 to 1·14; p=0·23; Tanzania: 0·92, 0·60 to 1·67; p=0·97), investigation rates (Nigeria: 1·06, 0·23 to 2·12; p=0·49; Tanzania: 1·15, 0·35 to 1·64; 0·58) or trustworthiness scores (Nigeria: mean difference 0·05, 95% CI -0·45 to 0·42; p=0·89; Tanzania: 0·07, -0·15 to 0·76; p=0·70). INTERPRETATION: REaCH can be implemented and could improve intervention versus control health-care access. Remote consultations appear safe and trustworthy, supporting universal health coverage. FUNDING: The UK Research and Innovation Collective Fund. TRANSLATIONS: For the Swahili and Yoruba translations of the abstract see Supplementary Materials section.
AB - BACKGROUND: In-person health care poses risks to health workers and patients during pandemics. Remote consultations can mitigate these risks. The REaCH intervention comprised training and mobile data allowance provision for mobile phones to support remotely delivered primary care in Africa compared with no training and mobile data allowance. The aim of this study was to estimate the effects of REaCH among adults with non-communicable diseases on remote and face-to-face consultation rates, patient safety, and trustworthiness of consultations. METHODS: In these two independent stepped-wedge cluster randomised controlled trials, we enrolled 20 primary care clusters in each of two settings (Oyo State, Nigeria, and Morogoro Region, Tanzania). Eligible clusters had 100 or more patients with diabetes, hypertension, and cardiovascular or pulmonary disease employing five health workers. Clusters were computer-randomised to one of ten (Nigeria) or one of seven (Tanzania) sequences to receive the REaCH intervention. Only outcome assessors were masked. Primary outcomes were consultation, prescription, and investigation rates, and trustworthiness collected monthly for 12 months (Nigeria) and 9 months (Tanzania) from open cohorts. Ten randomly sampled consulting patients per cluster-month completed patient reported outcome measures. This trial was registered with ISRCTN, ISRCTN17941313. FINDINGS: Overall, 40 clusters comprising 8776 (Nigeria) and 3246 (Tanzania) patients' open cohort data were analysed (6377 [72·7%] of 8776 females in Nigeria, and 2235 [68·9%] of 3246 females in Tanzania). The mean age of the participants was 55·3 years (SD 13·9) in Nigeria and 59·2 years (14·2) in Tanzania. In Nigeria, no evidence of change in face-to-face consulting rate was observed (rate ratio [RR] 1·06, 95% CI 0·98 to 1·09; p=0·16); however, remote consultations increased four-fold (4·44, 1·34 to >10; p=0·01). In Tanzania, face-to-face (0·94, 0·61 to 1·67; p=0·99) and remote consulting rates (1·17, 0·56 to 5·57; p=0·39) were unchanged. There was no evidence of difference in prescribing rates (Nigeria: 1·05, 0·60 to 1·14; p=0·23; Tanzania: 0·92, 0·60 to 1·67; p=0·97), investigation rates (Nigeria: 1·06, 0·23 to 2·12; p=0·49; Tanzania: 1·15, 0·35 to 1·64; 0·58) or trustworthiness scores (Nigeria: mean difference 0·05, 95% CI -0·45 to 0·42; p=0·89; Tanzania: 0·07, -0·15 to 0·76; p=0·70). INTERPRETATION: REaCH can be implemented and could improve intervention versus control health-care access. Remote consultations appear safe and trustworthy, supporting universal health coverage. FUNDING: The UK Research and Innovation Collective Fund. TRANSLATIONS: For the Swahili and Yoruba translations of the abstract see Supplementary Materials section.
KW - remote consulting
KW - LMIC
KW - Primary care
KW - Telemedicine
KW - Workforce development
KW - Universal health coverage
UR - http://www.scopus.com/inward/record.url?scp=85174202643&partnerID=8YFLogxK
U2 - 10.1016/S2214-109X(23)00411-4
DO - 10.1016/S2214-109X(23)00411-4
M3 - Article
SN - 2214-109X
VL - 11
SP - e1753-e1764
JO - The Lancet Global Health
JF - The Lancet Global Health
IS - 11
ER -
