human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES The objective of this study was to assess the effectiveness of government regulation of private pharmacy practice in a low-income country . METHODS The intervention comprised inspections of the pharmacies , information , and distribution of documents to drug sellers and sanctions . It was implemented at two different intensity levels , active and regular intervention . The methods used to assess the effect of the interventions were interviews with the district drug inspectors , drug sellers and customers , inspection of drug purchases , and indicator surveys of pharmacies . Indicators for pharmacy-specific quality as well as for dispensing quality were developed . RESULTS The main finding was one of strong overall improvements from initially low levels . The improvements were particularly marked by increases in the availability of essential material s for dispensing by 34 % and in order in the pharmacy by 19 % . Information given to customers increased from 35 % to 51 % and the mixing of different drugs in the same package went down from 17 % to 9 % . The pharmacies in the active intervention districts showed greater improvements for four of the six indicators , although statistically significant compared with the regular intervention districts only for the essential material s indicator . CONCLUSIONS It was concluded that the regulatory activities have probably been an important factor behind the service quality improvements . It appeared feasible as well as effective to regulate private pharmacy practice in this particular low-income setting OBJECTIVE The study was carried out to evaluate short term effects of one to one educational intervention approach , conducted with 40 drug sellers in order to improve the private sector 's practice s , compliance and performance in using the national treatment guidelines for malaria and other common childhood ( diarrhoea , acute respiratory tract infection-ARI ) illnesses in Kibaha district-Tanzania . METHODS The training took place one month after baseline data collection . Data collection was undertaken eight months after training and the effects of training was evaluated . The 40 drug stores were divided into 20 intervention and 20 control facilities . Trained  nurses  were used as clients who posed as caretakers of sick under-five children needing medication . The drug dispensers/sellers knowledge of anti-malarials and other drugs and their dispensing practice s was assessed . RESULTS The intervention seemed to have had a significant impact on knowledge pattern for prescribing and dispensing practice s of drug stores for some common childhood illnesses but not in other control drug stores/shops . About 90 % ( n=18 ) of shops prescribed to clients , the approved first-line anti-malarial drug for uncomplicated malaria ( sulfadoxine-pyrimethamine ) , as compared to only 55 % ( n=11 ) of the control shops . CONCLUSION Changing the private sectors ' knowledge , behaviour and practice s/performance may be a slow and difficult process . The intervention approach applied in this study seems to be feasible at district-level . This strategy can be applied in all districts of Tanzania with the aim of achieving significant improvements in knowledge , behaviour , compliance , improving performance and practice s of drug sellers in drug stores/shops . However , other alternative strategies are needed to influence drug sellers'/dispensers ' compliance and performance . Thus , the overall impact on performance and practice s in these facilities will remain at moderate level for quite sometime unless national policies , other programs and stakeholders are involved actively Background Pneumonia is a leading cause of death among children under five years of age . The Integrated Management of Childhood Illness strategy can improve the quality of care for pneumonia and other common illnesses in developing countries , but adherence to these guidelines could be improved . We evaluated an intervention in Benin to support health worker adherence to the guidelines after training , focusing on pneumonia case management . Methods We conducted a r and omized trial . After a health facility survey in 1999 to assess health care quality before Integrated Management of Childhood Illness training , health workers received training plus either study supports ( job aids , non-financial incentives and supervision of workers and supervisors ) or " usual " supports . Follow-up surveys were conducted in 2001 , 2002 and 2004 . Outcomes were indicators of health care quality for Integrated Management-defined pneumonia . Further analyses included a graphical pathway analysis and multivariable logistic regression modelling to identify factors influencing case-management quality . Results We observed 301 consultations of children with non-severe pneumonia that were performed by 128 health workers in 88 public and private health facilities . Although outcomes improved in both intervention and control groups , we found no statistically significant difference between groups . However , training proceeded slowly , and low- quality care from untrained health workers diluted intervention effects . Per- protocol analyses suggested that health workers with training plus study supports performed better than those with training plus usual supports ( 20.4 and 19.2 percentage-point improvements for recommended treatment [ p = 0.08 ] and " recommended or adequate " treatment [ p = 0.01 ] , respectively ) . Both groups tended to perform better than untrained health workers . Analyses of treatment errors revealed that incomplete assessment and difficulties processing clinical findings led to missed pneumonia diagnoses , and missed diagnoses led to inadequate treatment . Increased supervision frequency was associated with better care ( odds ratio for recommended treatment = 2.1 [ 95 % confidence interval : 1.1 - 3.9 ] per additional supervisory visit ) . Conclusion Integrated Management of Childhood Illness training was useful , but insufficient , to achieve high- quality pneumonia case management . Our study supports led to additional improvements , although large gaps in performance still remained . A simple graphical pathway analysis can identify specific , common errors that health workers make in the case-management process ; this information could be used to target quality improvement activities , such as supervision ( Clinical Trials.gov number NCT00510679 ) Background Provider misconceptions and biases about contraceptive methods are major barriers to family planning access for women in low- and middle-income countries , including Jordan .  Evidence -Based Medicine ( EBM ) programs aim to reduce biases and misconceptions by providing doctors with the most up-to- date scientific evidence on contraceptive methods . Methods We evaluate the effects of an EBM program  conducted in Jordan on private providers ’ knowledge , attitudes , and practice s. Family planning providers r and omly assigned to a treatment group were invited to attend a roundtable seminar on the injectable contraceptive Depot Medroxy Progesterone Acetate ( DMPA ) , and to receive two 15 min one-on-one educational visits that reinforce the messages from the seminar . Results There was low compliance with the EBM program . The study fails to detect an impact on providers ’ knowledge of DMPA ’s side effects or on reported clinical practice s. There is suggestive evidence of a positive impact on providers ’ attitudes toward and confidence in prescribing the contraceptive to their patients . There is also evidence of positive selection into program participation . Conclusions We conclude that EBM may not be effective as a st and -alone program targeting a family planning method with a high level of provider and consumer bias . Evidence of positive selection into program participation underscores the importance of r and omization to avoid overestimating the true effects of interventions .Trial registration AEA RCT Registry , AEA RCT R0000539 , Background Inappropriate treatment of malaria is widely reported particularly in areas where there is poor access to health facilities and self-treatment of fevers with anti-malarial drugs bought in shops is the most common form of care-seeking . The main objective of the study was to examine the impact of introducing rapid diagnostic tests for malaria ( mRDTs ) in registered drug shops in Ug and a , with the aim to increase appropriate treatment of malaria with artemisinin-based combination therapy ( ACT ) in patients seeking treatment for fever in drug shops . Methods A cluster-r and omized trial of introducing mRDTs in registered drug shops was implemented in 20 geographical clusters of drug shops in Mukono district , central Ug and a. Ten clusters were r and omly allocated to the intervention ( diagnostic confirmation of malaria by mRDT followed by ACT ) and ten clusters to the control arm ( presumptive treatment of fevers with ACT ) . Treatment decisions by providers were vali date d by microscopy on a reference blood slide collected at the time of consultation . The primary outcome was the proportion of febrile patients receiving appropriate treatment with ACT defined as : malaria patients with microscopically-confirmed presence of parasites in a peripheral blood smear receiving ACT or rectal artesunate , and patients with no malaria parasites not given ACT . Findings A total of 15,517 eligible patients ( 8672 intervention and 6845 control ) received treatment for fever between January-December 2011 . The proportion of febrile patients who received appropriate ACT treatment was 72·9 % versus 33·7 % in the control arm ; a difference of 36·1 % ( 95 % CI : 21·3 – 50·9 ) , p<0·001 . The majority of patients with fever in the intervention arm accepted to purchase an mRDT ( 97·8 % ) , of whom 58·5 % tested mRDT-positive . Drug shop vendors adhered to the mRDT results , reducing over-treatment of malaria by 72·6 % ( 95 % CI : 46·7– 98·4 ) , p<0·001 ) compared to drug shop vendors using presumptive diagnosis ( control arm ) . Conclusion Diagnostic testing with mRDTs compared to presumptive treatment of fevers implemented in registered drug shops substantially improved appropriate treatment of malaria with ACT . Trial Registration Clinical Trials.gov NCT01194557 In a cluster r and omized trial , Beth Kangwana and colleagues find that provision of subsidized packs of the malaria therapy artemether-lumefantrine to shops more than doubled the proportion of children with fever who received drugs promptly Background Malaria is a major public health problem in Ug and a and the current policy recommends introduction of rapid diagnostic tests for malaria ( RDTs ) to facilitate effective case management . However , provision of RDTs in drug shops potentially raises a new set of issues , such as adherence to RDTs results , management of severe illnesses , referral of patients , and relationship with caretakers . The main objective of the study was to examine the impact of introducing  RDTs in registered drug shops in Ug and a and document lessons and policy implication s for future scale-up of malaria control in the private health sector . Methods A cluster-r and omized trial introducing RDTs into registered drug shops was implemented in central Ug and a from October 2010 to July 2012 . An evaluation was undertaken to assess the impact and the processes involved with the introduction of RDTs into drug shops , the lessons learned and policy implication s. Results Introducing RDTs into drug shops was feasible . To scale-up this intervention however , drug shop practice s need to be regulated since the registration process was not clear , supervision was inadequate and record keeping was poor . Although initially it was anticipated that introducing a new practice of record keeping would be cumbersome , but at evaluation this was not found to be a constraint . This presents an important lesson for introducing health management information system into drug shops . Involving stakeholders , especially the district health team , in the design was important for ownership and sustainability . The involvement of village health teams in community sensitization to the new malaria treatment and diagnosis policy was a success and this strategy is recommended for future interventions . Conclusion Introducing RDTs into drug shops was feasible and it increased appropriate treatment of malaria with artemisinin-based combination therapy . It is anticipated that the lessons presented will help better implementation of similar interventions in the private sector Objective To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present , with the aim of reducing current massive overdiagnosis and overtreatment of malaria . Design Cluster r and omized trial of 24 clusters of shops . Setting Dangme West , a poor rural district of Ghana . Participants Shops and their clients , both adults and children . Interventions Providing rapid diagnostic tests with realistic training . Main outcome measures The primary outcome was the proportion of clients testing negative for malaria by a double-read research blood slide who received an artemisinin combination therapy or other antimalarial .  Secondary outcomes were use of antibiotics and antipyretics , and safety . Results Of 4603 clients , 3424 ( 74.4 % ) tested negative by double-read research slides . The proportion of slide-negative clients who received any antimalarial was 590/1854 ( 32 % ) in the intervention arm and 1378/1570 ( 88 % ) in the control arm ( adjusted risk ratio 0.41 ( 95 % CI 0.29 to 0.58 ) , P<0.0001 ) . Treatment was in high agreement with rapid diagnostic test result . Of those who were slide-positive , 690/787 ( 87.8 % ) in the intervention arm and 347/392 ( 88.5 % ) in the control arm received an  artemisinin combination therapy  ( adjusted risk ratio 0.96 ( 0.84 to 1.09 ) ) . There was no evidence of antibiotics being substituted for antimalarials . Overall , 1954/2641 ( 74 % ) clients in the intervention arm and 539/1962 ( 27 % ) in the control arm received appropriate treatment ( adjusted risk ratio 2.39 ( 1.69 to 3.39 ) , P<0.0001 ) . No safety concerns were identified . Conclusions Most patients with fever in Africa present to the private sector . In this trial , providing rapid diagnostic tests for malaria in the private drug retail sector significantly reduced dispensing of antimalarials to patients without malaria , did not reduce prescribing of antimalarials to true malaria cases , and appeared safe . Rapid diagnostic tests should be considered for the 
    Output:
    
agent
Authors ' conclusions Training probably improves quality of care ( i.e. adherence to recommended practice ) , regulation may improve quality of care , and we are uncertain about the effects of co‐ordination on quality of private for‐profit healthcare services in LMICs .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES The objective of this study was to assess the effectiveness of government regulation of private pharmacy practice in a low-income country . METHODS The intervention comprised inspections of the pharmacies , information , and distribution of documents to drug sellers and sanctions . It was implemented at two different intensity levels , active and regular intervention . The methods used to assess the effect of the interventions were interviews with the district drug inspectors , drug sellers and customers , inspection of drug purchases , and indicator surveys of pharmacies . Indicators for pharmacy-specific quality as well as for dispensing quality were developed . RESULTS The main finding was one of strong overall improvements from initially low levels . The improvements were particularly marked by increases in the availability of essential material s for dispensing by 34 % and in order in the pharmacy by 19 % . Information given to customers increased from 35 % to 51 % and the mixing of different drugs in the same package went down from 17 % to 9 % . The pharmacies in the active intervention districts showed greater improvements for four of the six indicators , although statistically significant compared with the regular intervention districts only for the essential material s indicator . CONCLUSIONS It was concluded that the regulatory activities have probably been an important factor behind the service quality improvements . It appeared feasible as well as effective to regulate private pharmacy practice in this particular low-income setting OBJECTIVE The study was carried out to evaluate short term effects of one to one educational intervention approach , conducted with 40 drug sellers in order to improve the private sector 's practice s , compliance and performance in using the national treatment guidelines for malaria and other common childhood ( diarrhoea , acute respiratory tract infection-ARI ) illnesses in Kibaha district-Tanzania . METHODS The training took place one month after baseline data collection . Data collection was undertaken eight months after training and the effects of training was evaluated . The 40 drug stores were divided into 20 intervention and 20 control facilities . Trained  nurses  were used as clients who posed as caretakers of sick under-five children needing medication . The drug dispensers/sellers knowledge of anti-malarials and other drugs and their dispensing practice s was assessed . RESULTS The intervention seemed to have had a significant impact on knowledge pattern for prescribing and dispensing practice s of drug stores for some common childhood illnesses but not in other control drug stores/shops . About 90 % ( n=18 ) of shops prescribed to clients , the approved first-line anti-malarial drug for uncomplicated malaria ( sulfadoxine-pyrimethamine ) , as compared to only 55 % ( n=11 ) of the control shops . CONCLUSION Changing the private sectors ' knowledge , behaviour and practice s/performance may be a slow and difficult process . The intervention approach applied in this study seems to be feasible at district-level . This strategy can be applied in all districts of Tanzania with the aim of achieving significant improvements in knowledge , behaviour , compliance , improving performance and practice s of drug sellers in drug stores/shops . However , other alternative strategies are needed to influence drug sellers'/dispensers ' compliance and performance . Thus , the overall impact on performance and practice s in these facilities will remain at moderate level for quite sometime unless national policies , other programs and stakeholders are involved actively Background Pneumonia is a leading cause of death among children under five years of age . The Integrated Management of Childhood Illness strategy can improve the quality of care for pneumonia and other common illnesses in developing countries , but adherence to these guidelines could be improved . We evaluated an intervention in Benin to support health worker adherence to the guidelines after training , focusing on pneumonia case management . Methods We conducted a r and omized trial . After a health facility survey in 1999 to assess health care quality before Integrated Management of Childhood Illness training , health workers received training plus either study supports ( job aids , non-financial incentives and supervision of workers and supervisors ) or " usual " supports . Follow-up surveys were conducted in 2001 , 2002 and 2004 . Outcomes were indicators of health care quality for Integrated Management-defined pneumonia . Further analyses included a graphical pathway analysis and multivariable logistic regression modelling to identify factors influencing case-management quality . Results We observed 301 consultations of children with non-severe pneumonia that were performed by 128 health workers in 88 public and private health facilities . Although outcomes improved in both intervention and control groups , we found no statistically significant difference between groups . However , training proceeded slowly , and low- quality care from untrained health workers diluted intervention effects . Per- protocol analyses suggested that health workers with training plus study supports performed better than those with training plus usual supports ( 20.4 and 19.2 percentage-point improvements for recommended treatment [ p = 0.08 ] and " recommended or adequate " treatment [ p = 0.01 ] , respectively ) . Both groups tended to perform better than untrained health workers . Analyses of treatment errors revealed that incomplete assessment and difficulties processing clinical findings led to missed pneumonia diagnoses , and missed diagnoses led to inadequate treatment . Increased supervision frequency was associated with better care ( odds ratio for recommended treatment = 2.1 [ 95 % confidence interval : 1.1 - 3.9 ] per additional supervisory visit ) . Conclusion Integrated Management of Childhood Illness training was useful , but insufficient , to achieve high- quality pneumonia case management . Our study supports led to additional improvements , although large gaps in performance still remained . A simple graphical pathway analysis can identify specific , common errors that health workers make in the case-management process ; this information could be used to target quality improvement activities , such as supervision ( Clinical Trials.gov number NCT00510679 ) Background Provider misconceptions and biases about contraceptive methods are major barriers to family planning access for women in low- and middle-income countries , including Jordan .  Evidence -Based Medicine ( EBM ) programs aim to reduce biases and misconceptions by providing doctors with the most up-to- date scientific evidence on contraceptive methods . Methods We evaluate the effects of an EBM program  conducted in Jordan on private providers ’ knowledge , attitudes , and practice s. Family planning providers r and omly assigned to a treatment group were invited to attend a roundtable seminar on the injectable contraceptive Depot Medroxy Progesterone Acetate ( DMPA ) , and to receive two 15 min one-on-one educational visits that reinforce the messages from the seminar . Results There was low compliance with the EBM program . The study fails to detect an impact on providers ’ knowledge of DMPA ’s side effects or on reported clinical practice s. There is suggestive evidence of a positive impact on providers ’ attitudes toward and confidence in prescribing the contraceptive to their patients . There is also evidence of positive selection into program participation . Conclusions We conclude that EBM may not be effective as a st and -alone program targeting a family planning method with a high level of provider and consumer bias . Evidence of positive selection into program participation underscores the importance of r and omization to avoid overestimating the true effects of interventions .Trial registration AEA RCT Registry , AEA RCT R0000539 , Background Inappropriate treatment of malaria is widely reported particularly in areas where there is poor access to health facilities and self-treatment of fevers with anti-malarial drugs bought in shops is the most common form of care-seeking . The main objective of the study was to examine the impact of introducing rapid diagnostic tests for malaria ( mRDTs ) in registered drug shops in Ug and a , with the aim to increase appropriate treatment of malaria with artemisinin-based combination therapy ( ACT ) in patients seeking treatment for fever in drug shops . Methods A cluster-r and omized trial of introducing mRDTs in registered drug shops was implemented in 20 geographical clusters of drug shops in Mukono district , central Ug and a. Ten clusters were r and omly allocated to the intervention ( diagnostic confirmation of malaria by mRDT followed by ACT ) and ten clusters to the control arm ( presumptive treatment of fevers with ACT ) . Treatment decisions by providers were vali date d by microscopy on a reference blood slide collected at the time of consultation . The primary outcome was the proportion of febrile patients receiving appropriate treatment with ACT defined as : malaria patients with microscopically-confirmed presence of parasites in a peripheral blood smear receiving ACT or rectal artesunate , and patients with no malaria parasites not given ACT . Findings A total of 15,517 eligible patients ( 8672 intervention and 6845 control ) received treatment for fever between January-December 2011 . The proportion of febrile patients who received appropriate ACT treatment was 72·9 % versus 33·7 % in the control arm ; a difference of 36·1 % ( 95 % CI : 21·3 – 50·9 ) , p<0·001 . The majority of patients with fever in the intervention arm accepted to purchase an mRDT ( 97·8 % ) , of whom 58·5 % tested mRDT-positive . Drug shop vendors adhered to the mRDT results , reducing over-treatment of malaria by 72·6 % ( 95 % CI : 46·7– 98·4 ) , p<0·001 ) compared to drug shop vendors using presumptive diagnosis ( control arm ) . Conclusion Diagnostic testing with mRDTs compared to presumptive treatment of fevers implemented in registered drug shops substantially improved appropriate treatment of malaria with ACT . Trial Registration Clinical Trials.gov NCT01194557 In a cluster r and omized trial , Beth Kangwana and colleagues find that provision of subsidized packs of the malaria therapy artemether-lumefantrine to shops more than doubled the proportion of children with fever who received drugs promptly Background Malaria is a major public health problem in Ug and a and the current policy recommends introduction of rapid diagnostic tests for malaria ( RDTs ) to facilitate effective case management . However , provision of RDTs in drug shops potentially raises a new set of issues , such as adherence to RDTs results , management of severe illnesses , referral of patients , and relationship with caretakers . The main objective of the study was to examine the impact of introducing  RDTs in registered drug shops in Ug and a and document lessons and policy implication s for future scale-up of malaria control in the private health sector . Methods A cluster-r and omized trial introducing RDTs into registered drug shops was implemented in central Ug and a from October 2010 to July 2012 . An evaluation was undertaken to assess the impact and the processes involved with the introduction of RDTs into drug shops , the lessons learned and policy implication s. Results Introducing RDTs into drug shops was feasible . To scale-up this intervention however , drug shop practice s need to be regulated since the registration process was not clear , supervision was inadequate and record keeping was poor . Although initially it was anticipated that introducing a new practice of record keeping would be cumbersome , but at evaluation this was not found to be a constraint . This presents an important lesson for introducing health management information system into drug shops . Involving stakeholders , especially the district health team , in the design was important for ownership and sustainability . The involvement of village health teams in community sensitization to the new malaria treatment and diagnosis policy was a success and this strategy is recommended for future interventions . Conclusion Introducing RDTs into drug shops was feasible and it increased appropriate treatment of malaria with artemisinin-based combination therapy . It is anticipated that the lessons presented will help better implementation of similar interventions in the private sector Objective To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present , with the aim of reducing current massive overdiagnosis and overtreatment of malaria . Design Cluster r and omized trial of 24 clusters of shops . Setting Dangme West , a poor rural district of Ghana . Participants Shops and their clients , both adults and children . Interventions Providing rapid diagnostic tests with realistic training . Main outcome measures The primary outcome was the proportion of clients testing negative for malaria by a double-read research blood slide who received an artemisinin combination therapy or other antimalarial .  Secondary outcomes were use of antibiotics and antipyretics , and safety . Results Of 4603 clients , 3424 ( 74.4 % ) tested negative by double-read research slides . The proportion of slide-negative clients who received any antimalarial was 590/1854 ( 32 % ) in the intervention arm and 1378/1570 ( 88 % ) in the control arm ( adjusted risk ratio 0.41 ( 95 % CI 0.29 to 0.58 ) , P<0.0001 ) . Treatment was in high agreement with rapid diagnostic test result . Of those who were slide-positive , 690/787 ( 87.8 % ) in the intervention arm and 347/392 ( 88.5 % ) in the control arm received an  artemisinin combination therapy  ( adjusted risk ratio 0.96 ( 0.84 to 1.09 ) ) . There was no evidence of antibiotics being substituted for antimalarials . Overall , 1954/2641 ( 74 % ) clients in the intervention arm and 539/1962 ( 27 % ) in the control arm received appropriate treatment ( adjusted risk ratio 2.39 ( 1.69 to 3.39 ) , P<0.0001 ) . No safety concerns were identified . Conclusions Most patients with fever in Africa present to the private sector . In this trial , providing rapid diagnostic tests for malaria in the private drug retail sector significantly reduced dispensing of antimalarials to patients without malaria , did not reduce prescribing of antimalarials to true malaria cases , and appeared safe . Rapid diagnostic tests should be considered for the 
    Output:
    