Safety and upscaling of remote consulting for long-term conditions in primary health care in Nigeria and Tanzania (REaCH trials): stepped-wedge trials of training, mobile data allowance, and implementation

Background In-person health care poses risks to health workers and patients during pandemics. Remote consultations can mitigate these risks. The REaCH intervention comprised training and mobile data allowance provision for mobile phones to support remotely delivered primary care in Africa compared with no training and mobile data allowance. The aim of this study was to estimate the effects of REaCH among adults with non-communicable diseases on remote and face-to-face consultation rates, patient safety, and trustworthiness of consultations.Methods In these two independent stepped-wedge cluster randomised controlled trials, we enrolled 20 primary care clusters in each of two settings (Oyo State, Nigeria, and Morogoro Region, Tanzania). Eligible clusters had 100 or more patients with diabetes, hypertension, and cardiovascular or pulmonary disease employing five health workers. Clusters were computer-randomised to one of ten (Nigeria) or one of seven (Tanzania) sequences to receive the REaCH intervention. Only outcome assessors were masked. Primary outcomes were consultation, prescription, and investigation rates, and trustworthiness collected monthly for 12 months (Nigeria) and 9 months (Tanzania) from open cohorts. Ten randomly sampled consulting patients per cluster-month completed patient reported outcome measures. This trial was registered with ISRCTN, ISRCTN17941313.Findings Overall, 40 clusters comprising 8776 (Nigeria) and 3246 (Tanzania) patients' open cohort data were analysed (6377 [72<middle dot>7%] of 8776 females in Nigeria, and 2235 [68<middle dot>9%] of 3246 females in Tanzania). The mean age of the participants was 55<middle dot>3 years (SD 13<middle dot>9) in Nigeria and 59<middle dot>2 years (14<middle dot>2) in Tanzania. In Nigeria, no evidence of change in face-to-face consulting rate was observed (rate ratio [RR] 1<middle dot>06, 95% CI 0<middle dot>98 to 1<middle dot>09; p=0<middle dot>16); however, remote consultations increased four-fold (4<middle dot>44, 1<middle dot>34 to >10; p=0<middle dot>01). In Tanzania, face-to-face (0<middle dot>94, 0<middle dot>61 to 1<middle dot>67; p=0<middle dot>99) and remote consulting rates (1<middle dot>17, 0<middle dot>56 to 5<middle dot>57; p=0<middle dot>39) were unchanged. There was no evidence of difference in prescribing rates (Nigeria: 1<middle dot>05, 0<middle dot>60 to 1<middle dot>14; p=0<middle dot>23; Tanzania: 0<middle dot>92, 0<middle dot>60 to 1<middle dot>67; p=0<middle dot>97), investigation rates (Nigeria: 1<middle dot>06, 0<middle dot>23 to 2<middle dot>12; p=0<middle dot>49; Tanzania: 1<middle dot>15, 0<middle dot>35 to 1<middle dot>64; 0<middle dot>58) or trustworthiness scores (Nigeria: mean difference 0<middle dot>05, 95% CI -0<middle dot>45 to 0<middle dot>42; p=0<middle dot>89; Tanzania: 0<middle dot>07, -0<middle dot>15 to 0<middle dot>76; p=0<middle dot>70).Interpretation REaCH can be implemented and could improve intervention versus control health-care access. Remote consultations appear safe and trustworthy, supporting universal health coverage.