We aim to deliver internationally unique evidence on a remote consulting training scheme, whether it is effective in increasing remote consulting, whether it affects face to face consulting, and whether it changes patient reports of trustworthiness and changes specified indicators of the safety of healthcare consultations in primary health care in Tanzania and Nigeria. Alongside runs south-south collaboration with Uganda and Kenya. We propose two trials to deliver evidence for different African contexts. A process evaluation will inform implementation across East and West Africa.

REaCH training will increase the rate of remote consulting. This remote consulting will not affect patient trust in, and the safety of, primary care consultations for long-term conditions.

Our primary (1-2) and secondary (3-6) research questions ask to what extent does REaCH training effect

1. Patient consultation rates delivered face-to-face and remotely? 
2. Patient perceptions of the trustworthiness of health workers providing consultations? 
3. The medical prescription issue rate?
4. Consultation default rates? 
5. Medical investigation issue rate? 
6. Patient health activation levels? 

Intervention

REaCH training is designed to increase the use and quality of remote consulting. Our definition of remote consulting is when a person with a perceived health need consults a healthcare provider using a mobile phone. They will use the internet or telecommunications infrastructure and will use SMART phones or feature phones to communicate. Our LMIC definition includes consultations using non-mobile technology (eg a computer in a community centre or a shared fixed telephone line in a remote rural village).

REaCH training uses a blended learning Moodle app and cascade process which support the delivery of trustworthy, safe and scalable remote primary healthcare. REaCH trainees are Doctors/Nurses/Medical Officers who work for primary healthcare facilities in Tanzania and Nigeria (tier 1 trainees). They subsequently cascade training in local languages to health workers in their team (tier 2 trainees). Tier 1 training consists of 20 hours of self-directed learning plus local tutor/peer time over 2/3 weeks using a smartphone. Tier 2 training is cascaded remotely via feature phone or through locally established team meetings/training with prescribed social distancing. REaCH is informed by the TRAIN framework for optimising sustainability of changes in healthcare delivery following a cascaded learning process in LMIC. Further details about REaCH training, including a sample presentation of materials can be found here COVID19: Health worker training for digital care delivery (warwick.ac.uk).

Tanzanian pilot

In 2018 REaCH was delivered and positively evaluated by two face-to-face cohorts of medical officers. Between April and June 2020, REaCH was digitised, delivered and evaluated by 14 Tanzanian medical officers from five primary care facilities. In response, we adapted the Moodle app for stronger/weaker network capacities and made curriculum revisions.

We propose two identical trials in contrasting countries with marginalised populations. The first is rural/remote, low income populations in Tanzania in East Africa. The second is urban and peri-urban in middle income populations in Nigeria in West Africa.

Our primary (1-3) and secondary (4-5) outcomes

1. Trust in healthcare provider: Physician Humanistic Behaviour Questionnaire (PHBQ) determines the degree to which healthcare providers communicate humanistically with their patients. Humanistic communications engender trust between the patient and the healthcare worker. The PHBQ has face and content validity with patients and health workers for assessing these behaviours during remote consultations. Each month a random sample of the included patient population within each cluster will complete the PHBQ.
2. Consultation rates by mode of delivery: All consultations with the included patient population and the mode of delivery will be recorded and extracted from paper-based facility registers.
3. Patient safety: Data will be captured on all prescriptions issued and collected to included the patient population. Change in number is an indicator of changes in safety and confidence.
4. Patient engagement with their health: Patient Activation Measure (PAM-13) aims to understand the knowledge, beliefs and skills required by people to enable them to manage their long-term conditions.
5. Patient safety: Captured by counting the number of investigations processed by the facility monthly and matching these to the patient’s consultation type. An increase may indicate a higher safety threshold when the person cannot be examined. A decrease may indicate missed health needs. Evidence from the secondary outcomes will be explored in the process evaluation.

Process evaluation

The process evaluation is exploring patient and health worker experiences of remote consulting, its impact on healthcare, and enablers/impediments.

In each country, for all clusters, we are collecting data about the Tier 1 and Tier 2 training process and the feasibility of the implementation of remote consulting. Additionally, in the first five clusters that receive the intervention, we are collecting and analysing prescription data (before and after the training) and semi-structured interviews with the REaCH training facilitators, facility manager, trainees and patients (6 months post training of Tier 2 trainees, to allow time for implementation).

With trainees and facility managers, we are exploring the experience of REaCH training/support and cascade, facility plans for and use of remote healthcare, what is working or not and why, and changes needed/made to enable remote consulting (e.g. facility expenditure on airtime/phones/appointment system). With patient trial participants, we are exploring their experience of remote consulting and its impact on their healthcare.

All data is being collected via phone or using social distancing at primary care facilities. Interviews are being audio-recorded and transcribed/translated into English.

Analysis

The trials are being analysed using a generalised linear mixed-model approach, standard for stepped-wedge trials. Data from each time point will be considered a repeated cross-section, given difficulty linking patients between months. Data will be at the individual level. For count data outcomes (consultation and prescription rates), a Poisson model will be used, and for continuous outcomes (patient trust and activation scores) a linear model. Qualitative analysis will be based on our theoretical frameworks, alert to emerging themes and coding frameworks developed through online analysis workshops. We will use framework analysis for comparison across transcripts to the identified themes, their repetitions and variations, paying particular attention to the influence of context.

The evaluation consists of two stepped-wedge cluster randomised trials running concurrently in Nigeria and Tanzania. The REaCH intervention will be rolled out to all clusters over the course of the trial in a staggered fashion and the order that clusters receive the intervention will be randomised. The evaluation will comprise both the quantitative trial outcomes and a process evaluation. The evaluation in each country will be conducted independently; comparisons between results will be predominantly qualitative. As a secondary analysis we will estimate the between country difference in treatment effects, although the trials are not designed for this purpose. 

A total of 56 health facilities have been recruited and divided into 40 clusters; 20 clusters per country randomized in groups of 2 to form a sequence, to receive REaCH training staggered over 12 months.

Funding

This project is funded by the UKRI Collective Fund. Additional funding supporting the development of the REaCH training include:

• Sturt J, Griffiths FE, Pemba S. How can Remote Consulting Training for health workers in rural Tanzania be optimised to support upscaling to remote and marginalised communities of East and West Africa? King’s Together 01.07.20-31.12.2020. £10,000
• Griffiths FE, Sturt J, Arvanitis T, Cave JAK, Harris B, Lilford RJ. Co-produced mobile consulting for remote, marginalised communities in Africa. UKRI Collective Fund 01/05/2020 – 30/04/2021. £137,858

Data is being collected at monthly time points. Trials are being conducted separately in Tanzania and Nigeria to evaluate outcomes in different LMIC contexts (rural/urban, middle/low income and West/East Africa).

We hope to achieve the following outputs, outcomes and impact:

• Digitally optimised REaCH training on royalty-free license ideal for LMIC organisations where digital infrastructures are limited/variable. This prepares for ongoing COVID-19 peaks and strengthens health care systems. Access to the training can be applied for here COVID19: Health worker training for digital care delivery (warwick.ac.uk)
• The realisation of the first international trial evidence on quality and safety of remote health consulting informing policy briefs. These influence delivery of sustainable resources/regulation to enable adaption as technological infrastructures strengthen.
• Populations offered greater protection from COVID-19 impacts. Women mobile users have strengthened/broadened confidence in remote/digital services
• Establishment of a clinical trials unit in Nigeria and strengthened clinical trial capability in Tanzania
• Networks of primary care facilities for future research
• Patient registers at rural and remote health facilities in Tanzania, to enable improved understanding of local population health needs.