Informal Healthcare Providers Research Articles

Conditional cash transfers, spillovers, and informal health care: Evidence from Peru.

Conditional cash transfer programs have become instrumental in encouraging the use of formal health services in developing countries, but little is known about their effect on the use of low-quality informal care. Using a large survey of Peruvian rural households and a regression discontinuity design, we find a sizeable reduction in the use of informal health care providers not only by targeted but also by nontargeted members of households that qualify for the program. This indicates the existence of spillover effects within the household. We also provide evidence that beyond the direct increase in income, the availability of better information about institutional services is a potential mechanism that drives these effects.

Integrated review of healthcare provider postnatal newborn care recommendations in Sub‐Saharan Africa

To (1) identify formal and informal healthcare provider knowledge and counselling on newborn care recommendations; (2) identify care guidelines used; and (3) determine healthcare provider training regarding recommendations. In sub-Saharan Africa, many newborn deaths occur in the community between days two to 42 of life. Formal and informal healthcare providers, including nurses and community health workers, counsel newborn caregivers but little is known about their recommendations. Integrative review of studies conducted 2000-2018 after search of PubMed, CINAHL, Embase, and African healthcare journals. Study quality was assessed and findings synthesized. Twelve qualitative, quantitative, or mixed-methods studies (quality good to poor) from seven countries were included. Eleven reported on one to three recommendations; one study reported on eight recommendations. Knowledge or counselling on feeding, cord care, recognizing illness, referrals, informal treatment, home visits, immunizations, follow-up examinations, thermal care, low birthweight, and bed net usage were reported. Formal healthcare providers gave recommendations in only two studies. Four studies documented use of guidelines. Six studies reported on training. Studies were primarily descriptive, limiting quality. Feeding and cord care recommendations were prioritized. Care guidelines were underutilized. Additional training on recommendations is needed. These findings regarding healthcare providers align with other regions with high neonatal mortality. Research is needed to improve and sustain knowledge, counselling, and guideline usage among providers to address neonatal mortality. The unique role of nurses to promote newborn health appears under-researched. Nurse professionalization and specialization may contribute to sustained knowledge of and counselling on newborn recommendations. As countries adopt universal health care, policies that enable formal providers to encourage maternal-newborn engagement in newborn health promotion before transition to the community are needed. Collaboration between formal and informal providers may improve dissemination of recommendations and contribute to gains in newborn health.

Antibiotic Prescribing by Informal Healthcare Providers for Common Illnesses: A Repeated Cross-Sectional Study in Rural India.

Informal healthcare providers (IHCPs) are predominant healthcare providers in rural India, who prescribe without formal training. Antibiotic prescription by IHCPs could provide crucial information for controlling antibiotic resistance. The aim of this study is to determine the practices and seasonal changes in antibiotic prescribing for common illnesses by IHCPs. A repeated cross-sectional study was conducted over 18 months, covering different seasons in the rural demographic surveillance site, at Ujjain, India. Prescriptions given to outpatients by 12 IHCPs were collected. In total, 15,322 prescriptions for 323 different complaint combinations were analyzed, of which 11,336 (74%) included antibiotics. The results showed that 14,620 (95%) of antibiotics prescribed were broad spectrum and the most commonly prescribed were fluoroquinolones (4771,31%), followed by penicillin with an extended spectrum (4119,27%) and third-generation cephalosporin (3069,20%). Antibiotics were prescribed more frequently in oral and dental problems (1126,88%), fever (3569,87%), and upper respiratory tract infections (3273, 81%); more during the monsoon season (2350,76%); and more frequently to children (3340,81%) than to adults (7996,71%). The study concludes that antibiotics were the more commonly prescribed drugs compared to other medications for common illnesses, most of which are broad-spectrum antibiotics, a situation that warrants further investigations followed by immediate and coordinated efforts to reduce unnecessary antibiotic prescriptions by IHCPs.

"Without antibiotics, I cannot treat": A qualitative study of antibiotic use in Paschim Bardhaman district of West Bengal, India.

BackgroundMisuse of antibiotics is a well-known driver of antibiotic resistance. Given the decentralized model of the Indian health system and the shortage of allopathic doctors in rural areas, a wide variety of healthcare providers cater to the needs of patients in urban and rural settings. This qualitative study explores the drivers of antibiotic use among formal and informal healthcare providers as well as patients accessing care at primary health centers across Paschim Bardhaman district in West Bengal.Materials and methodsWe conducted 28 semi-structured, in-depth interviews with four groups of healthcare providers (allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers) as well as patients accessing care at primary health centers and hospitals across Paschim Bardhaman district. Qualitative data was analyzed using the framework method in an inductive and deductive manner.ResultsOur results indicate that patients demand antibiotics from healthcare providers and seek the fastest cure possible, which influences the prescription choices of healthcare providers, particularly informal health providers. Many allopathic doctors provide antibiotics without any clinical indication due to inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions. Pharmaceutical company representatives actively network with informal health providers and formal healthcare providers alike, and regularly visit providers even in remote areas to market newer antibiotics. Allopathic doctors and informal health providers frequently blame the other party for being responsible for antibiotic resistance, and yet both display interdependence in referring patients to one another.ConclusionsA holistic approach to curbing antibiotic resistance in West Bengal and other parts of India should focus on strengthening the capacity of the existing public health system to deliver on its promises, improving patient education and counseling, and including informal providers and pharmaceutical company representatives in community-level antibiotic stewardship efforts.

Awareness as a dimension of health care access: exploring the case of rural palliative care provision in Canada

In Canada, the rural elderly population is increasing in size, as is their need for palliative care services in these settings. This analysis aims to identify awareness-associated barriers to delivering rural palliative care services, along with suggestions for improving service delivery from the perspective of local health care providers. A total of 40 semi-structured interviews with various formal and informal health care providers were conducted in four rural and/or remote Canadian communities with limited palliative care resources. Interview data were thematically coded using Penchansky and Thomas' five dimensions of access (i.e. availability, (geographic) accessibility, accommodation, acceptability and affordability). Saurman's recently added sixth dimension of access - awareness - was also identified while coding and subsequently became the primary focus of this analysis. Identified barriers to palliative care awareness and suggestions on how to enhance this awareness, and ultimately palliative care delivery, corresponded with three key themes arising from the data: limited palliative care knowledge/education, communication and coordination. Participants recognized the need for more palliative care education, open lines of communication and better coordination of palliative care initiatives and local resources in their communities. These findings suggest that identifying the barriers to palliative care awareness in rural communities may be foundational to addressing barriers to the other five dimensions of access. A thorough understanding of these three areas of awareness knowledge, communication and coordination, as well as the connections between them, may help enhance how rural palliative care is delivered in the future.

Feasibility of engaging "Village Doctors" in the Community-based Integrated Management of Childhood Illness (C-IMCI): experience from rural Bangladesh.

BackgroundInformal health care providers particularly “village doctors” are the first point of care for under-five childhood illnesses in rural Bangladesh. We engaged village doctors as part of the Multi-Country Evaluation (MCE) of Integrated Management of Childhood Illness (IMCI) and assessed their management of sick under-five children before and after a modified IMCI training, supplemented with ongoing monitoring and supportive supervision.MethodsIn 2003-2004, 144 village doctors across 131 IMCI intervention villages in Matlab Bangladesh participated in a two-day IMCI training; 135 of which completed pre- and post-training evaluation tests. In 2007, 38 IMCI-trained village doctors completed an end-of-project knowledge retention test. Village doctor prescription practices for sick under-five children were examined through household surveys, and routine monitoring visits. In-depth interviews were done with mothers seeking care from village doctors.ResultsVillage doctors’ knowledge on the assessment and management of childhood illnesses improved significantly after training; knowledge of danger signs of pneumonia and severe pneumonia increased from 39% to 78% (P < 0.0001) and from 17% to 47% (P < 0.0001) respectively. Knowledge on the correct management of severe pneumonia increased from 62% to 84% (P < 0.0001), and diarrhoea management improved from 65% to 82% (P = 0.0005). Village doctors retained this knowledge over three years except for home management of pneumonia. No significant differences were observed in prescribing practices for diarrhoea and pneumonia management between trained and untrained village doctors. Village doctors were accessible to communities; 76% had cell phones; almost all attended home calls, and did not charge consultation fees. Nearly all (91%) received incentives from pharmaceutical representatives.ConclusionsVillage doctors have the capacity to learn and retain knowledge on the appropriate management of under-five illnesses. Training alone did not improve inappropriate antibiotic prescription practices. Intensive monitoring and efforts to target key actors including pharmaceutical companies, which influence village doctors dispensing practices, and implementation of mechanisms to track and regulate these providers are necessary for future engagement in management of under-five childhood illnesses.

Exploring mental health practice among Traditional health practitioners: a qualitative study in rural Kenya

BackgroundInvolvement of traditional health practitioners (THPs) in the form of collaboration with the formal health care system is suggested to improve the pathways to mental health care in Kenya, yet understanding of the current traditional practice and THPs’ perspectives is lacking. The aim of this study was to explore the views of THPs with respect to their mental health practice.MethodsThis study qualitatively explored the views of THPs, using four focus group discussions (FDGs) each consisting of 8–10 traditional and faith healers, resulting in a total of 36 participants. Thematic content analysis using a grounded theory approach was performed using QSR NVivo 10. Emerging topics were identified and examined by re-reading the transcripts several times and constantly re-sorting the material.ResultsFour themes that reflect THPs’ mental health practice perspectives emerged as follows: 1) Categorization of mental illness; 2) Diagnostics in traditional mental health practice; 3) Treatments and challenges in current traditional mental health practice; and 4) Solutions to improve traditional mental health practice.ConclusionsThese themes provide insight into the perspectives of Kenyan traditional and faith healers on their mental health practice, in an attempt to offer a meaningful contribution to the debate on collaboration between informal and formal health care providers in improving mental health services in Kenya. Furthermore, the presented challenges and solutions can inform policy makers in their task to improve and scale up mental health services in resource-poor areas in Kenya. Addressing these issues would be a first step towards understanding the solid foundation of traditional medicine that is necessary before collaboration can be successfully attempted. Further research is also recommended to assess patients’ needs and explore potential forms of collaboration, in order to achieve sustainable improvement in the mental health care pathways for patients.

Building a Rehabilitative Care Measurement Instrument to Improve the Patient Experience

ObjectiveTo develop and test face and content validity, and user interface design of a rehabilitative care patient experience measure. DesignMixed methods, cross-sectional validation study that included subject matter expert input. Cognitive interviewing tested user interface and design. SettingOutpatient rehabilitative care settings. ParticipantsSubject matter experts (n=3), health care providers (n=137), and patients and caregivers (n=5) contributed to the question development. Convenience and snowball sampling were used to recruit rehabilitative care patients postdischarge (n=9) for cognitive interviews to optimize survey design and user interface (N=154). InterventionsNot applicable. Main Outcome MeasureThis novel survey instrument measures 6 concepts previously identified as key to outpatient rehabilitative care patients’ experience: ecosystem issues, client and informal caregiver engagement, patient and health care provider relations, pain and functional status, group and individual identity, and open-ended feedback. Results502 survey questions from psychometrically tested instruments, secondary data from a related ethnographic study, and consultations with health care providers, patients, caregivers, and subject matter experts, were analyzed to create a 10-item questionnaire representing 6 key constructs that influence patient experience quality. Cognitive interviewing with 9 patients (3 rounds of 3 participants each), produced 3 progressively edited versions of the survey instrument. A final version required no further modifications. DiscussionRehabilitative care clients have characteristics that differentiate their experience from that of other sectors and patient groups, warranting a distinct experience measure. The survey instrument includes a parsimonious set of questions that address strategic issues in the ongoing improvement of care delivery and the patient experience in the rehabilitative care sector. ConclusionThe rehabilitative care patient experience survey instrument developed has an acceptable user interface, and content and face validity. Psychometric testing of the survey instrument is reported elsewhere.

Psychometric Testing of a Rehabilitative Care Patient Experience Instrument

ObjectiveTo evaluate the internal consistency and test-retest reliability, construct validity, and feasibility of the WatLX, a measure of the experience of patients in rehabilitative care. DesignMultisite, cross-sectional, and test-retest self-report study. SettingOutpatient rehabilitative care settings. ParticipantsThe WatLX was administered to English-speaking, cognitively intact outpatients (N=1174) over 18 years old who had completed a program of cardiac, musculoskeletal, neurologic, stroke, pulmonary, or speech language rehabilitative care, at 2 separate time points: (1) immediately following completion of their rehabilitation program, and (2) 2 weeks later (n=29). A subsequent feasibility study was conducted with 1013 patients from 19 clinics. InterventionsNot applicable. Main Outcome MeasuresThe WatLX measures 6 concepts, previously identified as key to outpatient rehabilitative care patients’ experience: (1) ecosystem issues, (2) client and informal caregiver engagement, (3) patient and health care provider relations, (4) pain and functional status, (5) group and individual identity, and (6) open-ended feedback. ResultsReliability analyses were conducted on 2 versions of the WatLX. Using a 7-point versus a 5-point Likert scale resulted in higher internal consistency and reliability scores. Cronbach’s alpha coefficients were .863 and .957 for the 5- and 7-point scale, respectively, and the ICC scores were .827 and .880, respectively. The proof of concept study recruited 1013 patients with little interruption of workflow; results displayed strong internal consistency (Cronbach’s alpha coefficient =.906). There is evidence of ceiling effects. ConclusionsThe WatLX is a parsimonious question set that is feasible for administration in ambulatory rehabilitative care settings, and which shows promising psychometric properties.

Informal healthcare providers in India: Illegal and indispensable

The corresponding author who served in Supaul district of Bihar state of India as an Acute Flaccid Paralysis(AFP) Surveillance Medical Officer(SMO) with the World Health Organisation between May 2011 and July 2013,observed that the district had a preponderance of quackery. A look at the public healthcare system in the district with a population of 2.2 million shows just why this situation exists. According to the latest data available on government websites, the shortfall of Health Sub Centres, Primary Health Centres and Community Health Centres in Supaul district is an astonishing 58%,87% and 88% respectively. These numbers are not significantly different from the numbers for the rest of the state of Bihar. There is no evidence of any political will to tackle this shocking shortfall. The Bihar government has actually reduced the allocation to health for the financial year 2017-18 to Rs.7001.52 crore from Rs.8234.70 crore in 2016-17.Estimates say 70 to 80 percent of healthcare providers in India are informal providers. This ratio can go upto 30 informal providers for every public sector doctor in certain rural areas. Upto 75 percent of primary care visits in rural areas can be to an informal provider. If we must have equitable access to healthcare in India,it would be imperative to involve these informal providers.

Lost in care pathway: a qualitative investigation on the health system delay of extra pulmonary tuberculosis patients in Bangladesh

BackgroundAlthough extra pulmonary tuberculosis (EPTB) has long been known as a major public health concern globally, the complex healthcare-seeking pathways of EPTB patients are not widely studied. This study aims to explore the pattern of healthcare-seeking pathways of rural and urban EPTB patients registered with the BRAC TB control programme. BRAC is a Bangladesh-based non-governmental organization dedicated to alleviating poverty through empowering the poor.MethodData were collected through 60 in-depth interviews with rural and urban EPTB patients in Bangladesh.ResultsThe findings reveal that the rural EPTB patients encountered a substantial diagnostic delay as compared to the urban patients. However, the difference between the average number of healthcare providers consulted by the rural verses the urban EPTB patients was not significant. This study also shows that the healthcare-seeking journey of rural and urban EPTB patients usually starts either at pharmacies or private facilities. Through exploring the detailed nature of the pathway, this study reveals the ways in which non-medical informants, mainly relatives and friends, can benefit patients.ConclusionsThe private and informal healthcare providers should receive appropriate training on the diagnosis of EPTB. Such training could effectively shorten the long and complex healthcare-seeking pathways of EPTB patients.

Utilization of mobile phones for accessing menstrual regulation services among low-income women in Bangladesh: a qualitative analysis

BackgroundAs many as one-third of all pregnancies in Bangladesh are unplanned, with nearly one-half of these pregnancies ending in either menstrual regulation (MR) or illegal clandestine abortion. Although MR is provided free of charge, or at a nominal cost, through the public sector and various non-profits organizations, many women face barriers in accessing safe, affordable MR and post-MR care. Mobile health (mHealth) services present a promising platform for increasing access to MR among low-income women at risk for clandestine abortion. We sought to investigate the knowledge, attitudes and practices regarding mHealth of both MR clients and formal and informal sexual and reproductive healthcare providers in urban and rural low-income settlements in Bangladesh.MethodsA total of 58 interviews were conducted with MR clients, formal MR providers, and informal MR providers in four low-income settlements in the Dhaka and Sylhet districts of Bangladesh. Interview data was coded and qualitatively analysed for themes using standard qualitative research practices.ResultsOur findings suggest that low-income MR clients in Bangladesh have an inadequate understanding of how to use their mobile phones to obtain health service information or counselling related to MR, and correspondingly low levels of formal or informal mHealth service utilization. Few were aware of any formal mHealth services in place in their communities, despite the fact that providers stated that hotlines were available. Overall, MR clients expressed positive opinions of mHealth services as a means of improving women’s access to affordable and timely MR. Formal and informal MR providers believed that mobile phones had benefits with respect to information dissemination and making appointments, but emphasized the necessity of in-person consultations for effective sexual and reproductive healthcare.ConclusionsWe report low utilization yet high acceptability of mHealth services among low-income MR clients in Bangladesh. Expanding formal and informal mHealth services targeted towards MR – and increasing publicity of these services in low-income communities – may help increase timely access to accurate MR information and formal providers among women at risk for clandestine abortion. While expanding formal and informal mHealth services for SRHR in Bangladesh may be useful in disseminating information about MR and connecting women with formal providers, in-person visits remain necessary for adequate treatment.

Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria.

One of the consequences of ineffective governments is that they leave space for unlicensed and unregulated informal providers without formal training to deliver a large proportion of health services. Without institutions that facilitate appropriate health care transactions, patients tend to navigate health care markets from one inappropriate provider to another, receiving sub-optimal care, before they find appropriate providers; all the while incurring personal transaction costs. But the top-down interventions to address this barrier to accessing care are hampered by weak governments, as informal providers are entrenched in communities. To explore the role that communities could play in limiting informal providers, we applied the transaction costs theory of the firm which predicts that economic agents tend to organise production within firms when the costs of coordinating exchange through the market are greater than within a firm. In a realist analysis of qualitative data from Nigeria, we found that community health committees sometimes seek to limit informal providers in a manner that is consistent with the transaction costs theory of the firm. The committees deal not through legal sanction but by subtle influence and persuasion in a slow and faltering process of institutional change, leveraging the authority and resources available within their community, and from governments and NGOs. First, they provide information to reduce the market share controlled by informal providers, and then regulation to keep informal providers at bay while making the formal provider more competitive. When these efforts are ineffective or insufficient, committees are faced with a “make-or-buy” decision. The “make” decision involves coordination to co-produce formal health services and facilitate referrals from informal to formal providers. What sometimes results is a quasi-firm—informal and formal providers are networked in a single but loose production unit. These findings suggest that efforts to limit informal providers should seek to, among other things, augment existing community responses.

The impact of training informal health care providers in India: A randomized controlled trial.

Health care providers without formal medical qualifications provide more than 70% of all primary care in rural India. Training these informal providers may be one way to improve the quality of care where few alternatives exist. We report on a randomized controlled trial assessing a program that provided 72 sessions of training over 9 months to 152 informal providers (out of 304). Using standardized patients ("mystery clients"), we assessed clinical practice for three different conditions to which both providers and trainers were blinded during the intervention, representative of the range of conditions that these providers normally diagnose and treat. Training increased correct case management by 7.9 percentage points (14.2%) but did not affect the use of unnecessary medicines and antibiotics. At a program cost of $175 per trainee, our results suggest that multitopic medical training offers an effective short-run strategy to improve health care.

P.2.h.005 - Characteristics of suicide attempters with high medical severity

To identify key dimensions of patients' experience across the rehabilitative care system and to recommend a framework to develop survey items that measure the rehabilitative care experience.Data were sourced from a literature review that searched MEDLINE (PubMed), CINAHL (Ebsco), and PsycINFO (APA PsycNET) databases from 2004 to 2014, the reference lists of the final accepted articles, and hand searches of relevant journals.Four reviewers performed the screening process on 2472 articles; 33 were included for analysis. Interrater reliability was confirmed through 2 rounds of title review and 1 round of abstract review, with an average κ score of .69.The final sample of 33 accepted articles was imported into a qualitative data analysis software application. Multiple levels of coding and a constant comparative methodology generated 6 themes. There were 502 discreet survey questions measuring patient experience that were categorized using the following dimensions: rehabilitative care ecosystem, client and informal caregiver engagement, patient and health care provider relation, pain and functional status, group and individual identity, and open ended.The most common survey questions examine the care delivery ecosystem (37%), the engagement of clients and their informal caregivers (24.9%), and the quality of relations between providers and patients (21.7%). Examination of patient's functional status and management of pain yielded (15.3%) of the instruments' questions.Currently available instruments and questions that measure patients' experience in rehabilitative care are unable to assess the performance of rehabilitative delivery systems that aspire to integrate care across the continuum. However, question panels derived from our 6 key themes may measure the key concepts that define rehabilitative care and facilitate measurement of patient experience at the system level.

Community readiness for adopting mHealth in rural Bangladesh: A qualitative exploration

IntroductionThere are increasing numbers of mHealth initiatives in middle and low income countries aimed at improving health outcomes. Bangladesh is no exception with more than 20 mobile health (mHealth) initiatives in place. A recent study in Bangladesh examined community readiness for mHealth using a framework based on quantitative data. Given the importance of a framework and the complementary role of qualitative exploration, this paper presents data from a qualitative study which complements findings from the quantitative study. MethodsThe study was conducted in the Chakaria sub-district of Bangladesh. In total, 37 in-depth interviews were conducted between December 2012 and March 2013. Participants included the general public, students, community leaders, school teachers, and formal and informal healthcare providers. Thematic analysis was used to develop a logical and relevant framework to examine community readiness. As in the quantitative exploration, this study approached the investigation with four types of readiness in mind: core readiness, technological readiness, human resource readiness and motivational readiness. ResultsCommunity members, community leaders and healthcare providers expressed their interest in the use of mHealth in rural Bangladesh. Awareness of mHealth and its advantages was low among uneducated people. Participants who have used mHealth were attracted to the speed of access to qualified healthcare providers, time savings and low cost. Some participants did not see the value of using mobile phones for healthcare compared to a face-to-face consultation. Illiteracy, lack of English language proficiency, lack of trust and technological incapability were identified as barriers to mHealth use. However, a sense of ownership, evidence of utility, a positive attitude to the use of mHealth, and intentions towards future use of mHealth were driving forces in the adoption of mHealth services. ConclusionsThis study re-affirmed the mHealth readiness conceptual framework with different dimensions of readiness and identified potential barriers and possible solutions for mHealth. Moving forward, emphasis should be placed on training users, providing low-cost services and improving trust of users.

Организации прямых продаж как неформальные провайдеры здравоохранения в России

This article analyzes how and why direct selling organizations (DSOs), or network companies, or multi-level marketing (MLM) companies can be counted among informal healthcare providers. The paper is based on the results of a qualitative field study conducted in 2013 in the Perm region as part of a larger project on the description of informal healthcare in Russia. The authors used semi-structured interviews with salespeople and observations of their workplaces, as well as interviews with doctors and local residents. Although network marketing of health products in Russia is not widely practiced, it demonstrates vitality in adverse conditions. Unlike many other countries, Russia’s main players are domestic companies that have successfully mastered imported direct selling technologies. The research reveals that these DSOs mimic healthcare institutions by not only medicalizing their products but also providing participants a diagnosis, medical advice, complementary and alternative medicine services, as well as education and promotion of healthy lifestyles. The salespeople’s self-presentation is ambiguous: They criticize official healthcare but demonstrate loyalty to the conventional biomedical model at the same time. This medical mimicry can be considered the side effect of marketing efforts to stimulate sales, the result of the DSOs’ policy to attract salespeople, the manifestation of mimetic isomorphism, and the result of the organizational specificity of DSOs, that is, expansion in the private sphere of members’ lives, including healthcare. In our opinion, none of these reasons is an acceptable explanation, and further work in this direction is necessary to understand informal healthcare markets.

Protocol: a 'One health' two year follow-up, mixed methods study on antibiotic resistance, focusing children under 5 and their environment in rural India.

BackgroundAntibiotic resistance has been referred to as ‘the greatest malice of the 21st century’ and a global action plan was adopted by the World Health Assembly in 2015. There is a wealth of independent studies regarding antibiotics and resistant bacteria in humans, animals and their environment, however, integrated studies are lacking, particularly ones that simultaneously also take into consideration the health related behaviour of participants and healthcare providers. Such, ‘One health’ studies are difficult to implement, because of the complex teamwork that they entail. This paper describes the protocol of a study that investigates ‘One health’ issues regarding antibiotic use and antibiotic resistance in children and their environment in Indian villages.Methods/DesignBoth quantitative and qualitative studies are planned for a cohort of children, from 6 villages, and their surrounding environment. Repeated or continues data collection is planned over 2 years for quantitative studies. Qualitative studies will be conducted once. Studies include parents’ health seeking behavior for their children (1–3 years of age at the onset), prescribing pattern of formal and informal healthcare providers, analysis of phenotypic antibiotic resistance of Escherichia coli from samples of stool from children and village animals, household drinking water, village source water and waste water, and investigation on molecular mechanisms governing resistance. Analysis of interrelationship of these with each other will also be done as basis for future interventions. Ethics approval has been obtained from the Institutional Ethics Committee R.D. Gardi Medical College, Ujjain, India (No: 2013/07/17-311).DiscussionThe findings of the study presented in this protocol will add to our knowledge about the multi-factorial nature of causes governing antibiotic use and antibiotic resistance from a ‘One health’ perspective. Our study will be the first of its kind addressing antibiotic use and resistance issues related to children in a One-health approach, particularly for rural India.

Social support in the practices of informal providers: The case of patent and proprietary medicine vendors in Nigeria

The social and institutional environments in which informal healthcare providers operate shape their health and business practices, particularly in contexts where regulatory enforcement is weak. In this study, we adopt a social capital perspective to understanding the social networks on which proprietary and patent medicine vendors (PPMVs) in Nigeria rely for support in the operation of their shops. Data are drawn from 70 in-depth interviews with PPMVs in three states, including interviews with local leaders of the PPMV professional association. We find that PPMVs primarily relied on more senior colleagues and formal healthcare professionals for informational support, including information about new medicines and advice on how to treat specific cases of illness. For instrumental support, including finance, start-up assistance, and intervention with regulatory agencies, PPMVs relied on extended family, the PPMVs with whom they apprenticed, and the leaders of their professional association. PPMVs' networks also provided continual reinforcement of what constitutes good PPMV practice through admonishments to follow scope of practice limitations. These informal reminders, as well as monitoring activities conducted by the professional association, served to reinforce PPMVs' concern with avoiding negative customer health outcomes, which were perceived to be detrimental to their business reputations. That PPMVs' networks both encouraged practices to reduce the likelihood of poor health outcomes, and provided advice regarding customers' health conditions, highlights the potential impact of informal providers' access to different forms of social capital on their delivery of health services, as well as their success as microenterprises.

Use of standardised patients to assess quality of tuberculosis care: a pilot, cross-sectional study

Existing studies of the quality of tuberculosis care have relied on recall-based patient surveys, questionnaire surveys of knowledge, and prescription or medical record analysis, and the results mostly show the health-care provider's knowledge rather than actual practice. No study has used standardised patients to assess clinical practice. Therefore we aimed to assess quality of care for tuberculosis using such patients. We did a pilot, cross-sectional validation study of a convenience sample of consenting private health-care providers in low-income and middle-income areas of Delhi, India. We recruited standardised patients in apparently good health from the local community to present four cases (two of presumed tuberculosis and one each of confirmed tuberculosis and suspected multidrug-resistant tuberculosis) to a randomly allocated health-care provider. The key objective was to validate the standardised-patient method using three criteria: negligible risk and ability to avoid adverse events for providers and standardised patients, low detection rates of standardised patients by providers, and data accuracy across standardised patients and audio verification of standardised-patient recall. We also used medical vignettes to assess providers' knowledge of presumed tuberculosis. Correct case management was benchmarked using Standards for Tuberculosis Care in India (STCI). Between Feb 2, and March 28, 2014, we recruited and trained 17 standardised patients who had 250 interactions with 100 health-care providers, 29 of whom were qualified in allopathic medicine (ie, they had a Bachelor of Medicine & Surgery [MBBS] degree), 40 of whom practised alternative medicine, and 31 of whom were informal health-care providers with few or no qualifications. The interactions took place between April 1, and April 23, 2014. The proportion of detected standardised patients was low (11 [5%] detected out of 232 interactions among providers who completed the follow-up survey), and standardised patients' recall correlated highly with audio recordings (r=0·63 [95% CI 0·53-0·79]), with no safety concerns reported. The mean consultation length was 6 min (95% CI 5·5-6·6) with a mean of 6·18 (5·72-6·64) questions or examinations completed, representing 35% (33-38) of essential checklist items. Across all cases, only 52 (21% [16-26]) of 250 were correctly managed. Correct management was higher among MBBS-qualified doctors than other types of health-care provider (adjusted odds ratio 2·41 [95% CI 1·17-4·93]; p=0·0166). Of the 69 providers who completed the vignette, knowledge in the vignettes was more consistent with STCI than their actual clinical practice-eg, 50 (73%) ordered a chest radiograph or sputum test during the vignette compared with seven (10%) during the standardised-patient interaction; OR 0·04 (95% CI 0·02-0·11); p<0·0001. Standardised patients can be successfully implemented to assess tuberculosis care. Our data suggest a big gap between private provider knowledge and practice. Additional work is needed to substantiate our pilot data, understand the know-do gap in provider behaviour, and to identify the best approach to measure and improve the quality of tuberculosis care in India. Grand Challenges Canada, the Bill & Melinda Gates Foundation, Knowledge for Change Program, and the World Bank Development Research Group.