Oral Presentation 20th Lancefield International Symposium on Streptococci and Streptococcal Diseases 2017

Our stepped-wedge, community randomised trial to improve secondary prophylaxis delivery for Aboriginal people with acute rheumatic fever (ARF)/rheumatic heart disease (RHD) did not achieve intended outcomes… Why? (#53)

Clancy Read 1 , Anna Ralph 2 , Ross Bailie 3 , Adrienne Kirby 4 , Vanessa Johnston 5 , Bart Currie 5 , Graeme Maguire 6 , Keith Edwards 7 , Jessica de Dassel 5 , Alice Mitchell 5 , Jonathan Carapetis 1
  1. Telethon Kids Institute, Subiaco, WESTERN AUSTRALIA, Australia
  2. Department of Medicine, Royal Darwin Hospital , Global and Tropical health, Menzies School of health Research, Darwin, Northern Territory, Australia
  3. Centre for Rural Health , University of Sydney, Sydney, New South Wales, Australia
  4. National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
  5. Menzies School of Health Research, Darwin, Northern Territory, Australia
  6. BakerIDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
  7. Paediatric Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia

Background: A stepped-wedge, community randomised trial was implemented in Australia’s Northern Territory to test whether a clinic-level intervention could improve prophylaxis delivery for Aboriginal people with ARF/RHD. Ten clinics received a multifaceted intervention which supported them to develop and implement strategies to improve penicillin delivery and RHD care, aligned with themes of the Chronic Care Model. The proportion of patients receiving ≥80% of scheduled injections in the intensive phase (126/304 [41.5%]) did not improve compared with baseline (141/304 [46.4%]), odds ratio 0.78 (95% CI 0.54 to 1.11). An overarching theory-driven evaluation framework guided the analysis of qualitative data to explain the reasons for the study not achieving its primary outcome.

Methods: The intervention’s effectiveness, efficiency, process, fidelity, performance and context was evaluated. Pre and post interviews with participants (n=166), quarterly project officer observational reports (n=50), and detailed tracking of action plans (n=10) and implemented action items (n=252) provided primary qualitative data.

Findings: Low level of intervention uptake and exposure was documented affecting causal processes, thus attainment of outcomes. Acceptability and completeness of the intervention and its components, barriers to implementation and organizational change strongly contributed to intervention effectiveness.  All sites highlight the significance of context in assessing why an intervention may be implementable and effective in one setting but not another.

Conclusion: Despite implementing a comprehensive health system strengthening strategy, we did not find a significant improvement in adherence to ARF secondary prophylaxis. Other strategies for improved ARF prevention, including Group A Streptococcal prevention and treatment are required.