The thesis was undertaken in the context of the Research on the Economics of ACT (REACT) project, which sought to improve the diagnosis and treatment of uncomplicated malaria in Cameroon and Nigeria. The project was implemented in four phases: formative research; intervention design; evaluation; and dissemination. By taking a phased approach the project sought to design interventions to address problems identified during the formative research and respond to the interests of policy-makers. As such, the project evolved differently in each country. An overview of REACT is provided in Section 3.2.
30 Wilfred Mbacham, and Professor Obinna Onwujewke. I joined the project as a co-
investigator after funding had been secured, though before any research commenced. I made a substantial scientific contribution to the project, and coordinated research activities and managed research teams in Cameroon and Nigeria.
The research contained in this thesis includes work conducted in the context of REACT, but for which I had a lead responsibility and undertook with considerable independence. I led the design and analysis of patient exit surveys and provider surveys in Cameroon and Nigeria, which included the development of research instruments, training of field teams to pilot and administer the surveys, and analysis of the survey data. Chapters 4 and 5 present the main findings of the exit surveys. These findings identified priorities for intervention.
From my reading on theory-based evaluation, I wanted to ensure the selection and design of interventions was founded on a conceptual and empirical understanding of the patient- provider interaction. This included a literature review on interventions to improve providers’ practice in diagnosing and treating malaria (Section 2.2). I independently developed the search strategy, identified relevant papers, synthesized the evidence and interpreted the findings. The review was written up as a working paper for REACT and was approved by the principal investigators. Chapters 6 and 7 contain additional analyses on the knowledge, stated and revealed preferences of providers. For each, I led the
conception of the research question, undertook the analysis, and prepared the research paper. I received support from my PhD supervisor, though the work was conducted with considerable independence and my co-authors understood this research was intended to contribute to a PhD.
My research was particularly pertinent to the selection and design of interventions in Cameroon as a decision was made to focus on malaria case management at public and mission facilities, where providers are routinely responsible for diagnosis and the choice
31 agreed REACT should develop training interventions that not only sought to improve providers’ knowledge of the malaria treatment guidelines, but also explicitly sought to change their practice. I led workshops with the Cameroon study team to develop the content of the training. During this design phase, I also prepared a logic model to articulate the causal mechanisms by which the training was expected to change providers’
knowledge and practice (Section 3.2).
The trial design was led by the principal investigators, with support from co-investigators, including myself, Bonnie Cundill, a statistician, and Clare Chandler, social scientist. The trial protocol is included in Section 3.3.
Chapter 8 presents the economic evaluation I conducted in Cameroon. I led the design and analysis of the economic evaluation. I oversaw the collection of patient exit surveys and managed a Research Assistant, Tom Drake, who collected data on the cost of the
interventions and the facility costs of malaria diagnosis and treatment. I worked independently on the cost-effectiveness and prepared the research paper. Co-authors provided feedback on a full draft and approved the final paper.
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