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Beynon F, Langet H, Bohle LF, Awasthi S, Ndiaye O, Machoki M’Imunya J, Masanja H, Horton S, Ba M, Cicconi S, Emmanuel-Fabula M, Faye PM, Glass TR, Keitel K, Kumar D, Kumar G, Levine GA, Matata L, Mhalu G, Miheso A, Mjungu D, Njiri F, Reus E, Ruffo M, Schär F, Sharma K, Storey HL, Masanja I, Wyss K, D’Acremont V. The Tools for Integrated Management of Childhood Illness (TIMCI) study protocol: a multi-country mixed-method evaluation of pulse oximetry and clinical decision support algorithms. Glob Health Action 2024; 17:2326253. [PMID: 38683158 PMCID: PMC11060010 DOI: 10.1080/16549716.2024.2326253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 02/25/2024] [Indexed: 05/01/2024] Open
Abstract
Effective and sustainable strategies are needed to address the burden of preventable deaths among children under-five in resource-constrained settings. The Tools for Integrated Management of Childhood Illness (TIMCI) project aims to support healthcare providers to identify and manage severe illness, whilst promoting resource stewardship, by introducing pulse oximetry and clinical decision support algorithms (CDSAs) to primary care facilities in India, Kenya, Senegal and Tanzania. Health impact is assessed through: a pragmatic parallel group, superiority cluster randomised controlled trial (RCT), with primary care facilities randomly allocated (1:1) in India to pulse oximetry or control, and (1:1:1) in Tanzania to pulse oximetry plus CDSA, pulse oximetry, or control; and through a quasi-experimental pre-post study in Kenya and Senegal. Devices are implemented with guidance and training, mentorship, and community engagement. Sociodemographic and clinical data are collected from caregivers and records of enrolled sick children aged 0-59 months at study facilities, with phone follow-up on Day 7 (and Day 28 in the RCT). The primary outcomes assessed for the RCT are severe complications (mortality and secondary hospitalisations) by Day 7 and primary hospitalisations (within 24 hours and with referral); and, for the pre-post study, referrals and antibiotic. Secondary outcomes on other aspects of health status, hypoxaemia, referral, follow-up and antimicrobial prescription are also evaluated. In all countries, embedded mixed-method studies further evaluate the effects of the intervention on care and care processes, implementation, cost and cost-effectiveness. Pilot and baseline studies started mid-2021, RCT and post-intervention mid-2022, with anticipated completion mid-2023 and first results late-2023. Study approval has been granted by all relevant institutional review boards, national and WHO ethical review committees. Findings will be shared with communities, healthcare providers, Ministries of Health and other local, national and international stakeholders to facilitate evidence-based decision-making on scale-up.Study registration: NCT04910750 and NCT05065320.
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Affiliation(s)
- Fenella Beynon
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Faculty of Science, University of Basel, Basel, Switzerland
| | - Hélène Langet
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Faculty of Science, University of Basel, Basel, Switzerland
| | - Leah F. Bohle
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Faculty of Science, University of Basel, Basel, Switzerland
| | - Shally Awasthi
- Department of Paediatrics, King George’s Medical University, Lucknow, India
| | - Ousmane Ndiaye
- Faculté de médecine, Université Cheikh Anta Diop, Dakar, Senegal
| | | | | | - Susan Horton
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
| | | | - Silvia Cicconi
- Faculty of Science, University of Basel, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | | | - Papa Moctar Faye
- Faculté de médecine, Université Cheikh Anta Diop, Dakar, Senegal
| | - Tracy R. Glass
- Faculty of Science, University of Basel, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Kristina Keitel
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Division of Pediatric Emergency Medicine, Department of Pediatrics,Inselspital, University of Bern, Bern, Switzerland
| | - Divas Kumar
- Department of Paediatrics, King George’s Medical University, Lucknow, India
| | - Gaurav Kumar
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Faculty of Science, University of Basel, Basel, Switzerland
| | - Gillian A. Levine
- Faculty of Science, University of Basel, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Lena Matata
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Faculty of Science, University of Basel, Basel, Switzerland
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Grace Mhalu
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | | | - Francis Njiri
- College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Elisabeth Reus
- Faculty of Science, University of Basel, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | | | - Fabian Schär
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Faculty of Science, University of Basel, Basel, Switzerland
| | | | | | - Irene Masanja
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Kaspar Wyss
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Faculty of Science, University of Basel, Basel, Switzerland
| | - Valérie D’Acremont
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Digital Global Health Department, Centre for Primary Care and PublicHealth (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - TIMCI Collaborator Group
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Faculty of Science, University of Basel, Basel, Switzerland
- Department of Paediatrics, King George’s Medical University, Lucknow, India
- Faculté de médecine, Université Cheikh Anta Diop, Dakar, Senegal
- College of Health Sciences, University of Nairobi, Nairobi, Kenya
- Directorate, Ifakara Health Institute, Dar es Salaam, Tanzania
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
- PATH
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Division of Pediatric Emergency Medicine, Department of Pediatrics,Inselspital, University of Bern, Bern, Switzerland
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
- Digital Global Health Department, Centre for Primary Care and PublicHealth (Unisanté), University of Lausanne, Lausanne, Switzerland
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Peiffer-Smadja N, Descousse S, Courrèges E, Nganbou A, Jeanmougin P, Birgand G, Lénaud S, Beaumont AL, Durand C, Delory T, Le Bel J, Bouvet E, Lariven S, D'Ortenzio E, Konaté I, Bouyou-Akotet MK, Ouedraogo AS, Kouakou GA, Poda A, Akpovo C, Lescure FX, Tanon A. Implementation of a Clinical Decision Support System for Antimicrobial Prescribing in Sub-Saharan Africa: Multisectoral Qualitative Study. J Med Internet Res 2024; 26:e45122. [PMID: 39374065 DOI: 10.2196/45122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/10/2023] [Accepted: 06/20/2024] [Indexed: 10/08/2024] Open
Abstract
BACKGROUND Suboptimal use of antimicrobials is a driver of antimicrobial resistance in West Africa. Clinical decision support systems (CDSSs) can facilitate access to updated and reliable recommendations. OBJECTIVE This study aimed to assess contextual factors that could facilitate the implementation of a CDSS for antimicrobial prescribing in West Africa and Central Africa and to identify tailored implementation strategies. METHODS This qualitative study was conducted through 21 semistructured individual interviews via videoconference with health care professionals between September and December 2020. Participants were recruited using purposive sampling in a transnational capacity-building network for hospital preparedness in West Africa. The interview guide included multiple constructs derived from the Consolidated Framework for Implementation Research. Interviews were transcribed, and data were analyzed using thematic analysis. RESULTS The panel of participants included health practitioners (12/21, 57%), health actors trained in engineering (2/21, 10%), project managers (3/21, 14%), antimicrobial resistance research experts (2/21, 10%), a clinical microbiologist (1/21, 5%), and an anthropologist (1/21, 5%). Contextual factors influencing the implementation of eHealth tools existed at the individual, health care system, and national levels. At the individual level, the main challenge was to design a user-centered CDSS adapted to the prescriber's clinical routine and structural constraints. Most of the participants stated that the CDSS should not only target physicians in academic hospitals who can use their network to disseminate the tool but also general practitioners, primary care nurses, midwives, and other health care workers who are the main prescribers of antimicrobials in rural areas of West Africa. The heterogeneity in antimicrobial prescribing training among prescribers was a significant challenge to the use of a common CDSS. At the country level, weak pharmaceutical regulations, the lack of official guidelines for antimicrobial prescribing, limited access to clinical microbiology laboratories, self-medication, and disparity in health care coverage lead to inappropriate antimicrobial use and could limit the implementation and diffusion of CDSS for antimicrobial prescribing. Participants emphasized the importance of building a solid eHealth ecosystem in their countries by establishing academic partnerships, developing physician networks, and involving diverse stakeholders to address challenges. Additional implementation strategies included conducting a local needs assessment, identifying early adopters, promoting network weaving, using implementation advisers, and creating a learning collaborative. Participants noted that a CDSS for antimicrobial prescribing could be a powerful tool for the development and dissemination of official guidelines for infectious diseases in West Africa. CONCLUSIONS These results suggest that a CDSS for antimicrobial prescribing adapted for nonspecialized prescribers could have a role in improving clinical decisions. They also confirm the relevance of adopting a cross-disciplinary approach with participants from different backgrounds to assess contextual factors, including social, political, and economic determinants.
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Affiliation(s)
- Nathan Peiffer-Smadja
- Université Paris Cité et Université Sorbonne Paris Nord, Inserm, IAME, Paris, France
- Antibioclic Steering Committee, Paris, France
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Sophie Descousse
- Université Paris Cité et Université Sorbonne Paris Nord, Inserm, IAME, Paris, France
| | - Elsa Courrèges
- Université Paris Cité et Université Sorbonne Paris Nord, Inserm, IAME, Paris, France
| | - Audrey Nganbou
- Université Paris Cité et Université Sorbonne Paris Nord, Inserm, IAME, Paris, France
| | | | - Gabriel Birgand
- CPias, Centre Hospitalo-Universitaire de Nantes, Nantes, France
| | - Séverin Lénaud
- CHU de Treichville, Centre Hospitalo-universitaire de Treichville, Abidjan, Cote D'Ivoire
| | - Anne-Lise Beaumont
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Claire Durand
- Université Paris Cité et Université Sorbonne Paris Nord, Inserm, IAME, Paris, France
| | - Tristan Delory
- Antibioclic Steering Committee, Paris, France
- Innovation and Clinical Research Unit, Annecy-Genevois Hospital, Epagny-Metz-Tessy, France
| | - Josselin Le Bel
- Université Paris Cité et Université Sorbonne Paris Nord, Inserm, IAME, Paris, France
- Antibioclic Steering Committee, Paris, France
- Department of General Practice, Université Paris Diderot, Université de Paris, Paris, France
| | - Elisabeth Bouvet
- Antibioclic Steering Committee, Paris, France
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Sylvie Lariven
- Antibioclic Steering Committee, Paris, France
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Eric D'Ortenzio
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
- ANRS - Maladies infectieuses émergentes, INSERM, Paris, France
| | | | | | | | | | - Armel Poda
- CHU Bobo Dioulasso, Bobo Dioulasso, Burkina Faso
| | | | - François-Xavier Lescure
- Université Paris Cité et Université Sorbonne Paris Nord, Inserm, IAME, Paris, France
- Antibioclic Steering Committee, Paris, France
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
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Kiemde F, Nkeramahame J, Ibarz AB, Dittrich S, Olliaro P, Valia D, Rouamba T, Kabore B, Kone AN, Sawadogo S, Bere AW, Some DY, Some AM, Compaore A, Horgan P, Weber S, Keller T, Tinto H. Impact of a package of point-of-care diagnostic tests, a clinical diagnostic algorithm and adherence training on antibiotic prescriptions for the management of non-severe acute febrile illness in primary health facilities during the COVID-19 pandemic in Burkina Faso. BMC Infect Dis 2024; 24:870. [PMID: 39192209 PMCID: PMC11351252 DOI: 10.1186/s12879-024-09787-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 08/21/2024] [Indexed: 08/29/2024] Open
Abstract
OBJECTIVE To assess the impact of an intervention package on the prescription of antibiotic and subsequently the rate of clinical recovery for non-severe acute febrile illnesses at primary health centers. METHODS Patients over 6 months of age presenting to primary health care centres with fever or history of fever within the past 7 days were randomized to receive either the intervention package constituted of point-of-care tests including COVID-19 antigen tests, a diagnostic algorithm and training and communication packages, or the standard practice. The primary outcomes were antibiotic prescriptions at Day 0 (D0) and the clinical recovery at Day 7 (D7). Secondary outcomes were non-adherence of participants and parents/caregivers to prescriptions, health workers' non-adherence to the algorithm, and the safety of the intervention. RESULTS A total of 1098 patients were enrolled. 551 (50.2%) were randomized to receive the intervention versus 547 (49.8%) received standard care. 1054 (96.0%) completed follow-up and all of them recovered at D7 in both arms. The proportion of patients with antibiotic prescriptions at D0 were 33.2% (183/551) in the intervention arm versus 58.1% (318/547) under standard care, risk difference (RD) -24.9 (95% CI -30.6 to -19.2, p < 0.001), corresponding to one more antibiotic saved every four (95% CI: 3 to 5) consultations. This reduction was also statistically significant in children from 6 to 59 months (RD -34.5; 95% CI -41.7 to -27.3; p < 0.001), patients over 18 years (RD -35.9; 95%CI -58.5 to -13.4; p = 0.002), patients with negative malaria test (RD -46.9; 95% CI -53.9 to -39.8; p < 0.001), those with a respiratory diagnosis (RD -48.9; 95% CI -56.9 to -41.0, p < 0.001) and those not vaccinated against COVID-19 (-24.8% 95%CI -30.7 to -18.9, p-value: <0.001). A significant reduction in non-adherence to prescription by patients was reported (RD -7.1; 95% CI -10.9 to -3.3; p < 0.001). CONCLUSION The intervention was associated with significant reductions of antibiotic prescriptions and non-adherence, chiefly among patients with non-malaria fever, those with respiratory symptoms and children below 5 years of age. The addition of COVID-19 testing did not have a major impact on antibiotic use at primary health centers. TRIAL REGISTRATION Clinitrial.gov; NCT04081051 registered on 06/09/2019.
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Affiliation(s)
- Francois Kiemde
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso.
| | | | | | - Sabine Dittrich
- FIND, Geneva, Switzerland
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Deggendorf Institute of Technology, European Campus Rottal Inn, Pfarrkirchen, Germany
| | - Piero Olliaro
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Daniel Valia
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso
| | - Toussaint Rouamba
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso
| | - Berenger Kabore
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso
| | - Alima Nadine Kone
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso
| | - Seydou Sawadogo
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso
| | - Antonia Windkouni Bere
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso
| | - Diane Yirgnur Some
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso
| | - Athanase Mwinessobaonfou Some
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso
| | - Adelaide Compaore
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso
| | - Philip Horgan
- FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, UK
- Evidence and Impact Oxford, Oxford, UK
| | | | | | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, 11 BP 218, Ouaga CMS 11 , Nanoro, Burkina Faso
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Saouadogo I, Massom DM, Kabore SS, Fomete Djatsa RK, Seu J, Ngangue P. Perceived Benefits and Disadvantages Associated with the Use of the Electronic Consultation Register by Health Providers in the Health District of Toma, Burkina Faso. Int J MCH AIDS 2024; 13:e002. [PMID: 38694895 PMCID: PMC11008583 DOI: 10.25259/ijma_650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/28/2024] [Indexed: 05/04/2024] Open
Abstract
Background and Objective Most countries in sub-Saharan Africa need to catch up in integrating information and communication technologies (ICT) into their health systems. This is mainly because of the need for more infrastructure that allows for reasonable use of the technologies. To support the actions of the Ministry of Health of Burkina Faso, a Non-governmental Organization (NGO) has implemented the integrated electronic diagnostic approach (IeDA) Project. The project includes the deployment of an electronic consultation register (ECR). This article aims to explore the perceptions of healthcare providers on the benefits and disadvantages of using the ECR. Methods We conducted a qualitative, descriptive study through individual semi-structured interviews with healthcare providers. Data were collected in the Toma health district in December 2021. In addition, a thematic analysis was performed using NVivo software. Results Thirty-five healthcare workers were interviewed (19 nurses, 7 midwives, 6 mobile community health and hygiene workers, and 3 birth attendants). Two main themes emerged from our analyses, which are the advantages and disadvantages perceived by ECR users. Our data suggest that using the ECR had many benefits ranging from improving healthcare providers' knowledge and performance in terms of patients' care, assisting and helping in patient diagnosis and treatment and improving patient satisfaction. However, the participants also shared their negative perceptions about the ECR, mentioning that it increased their workload. They also reported lengthened consultation time and work duplication as the tool was still in its trial phase and was used along with the paper consultation register. Conclusion and Global Health Implications The ECR is an effective tool for diagnosis and management, which has several advantages and reasonably satisfies patients. However, disadvantages, including increased workload and lack of fluidity and stability of the system, must be considered to ensure better usability.
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Affiliation(s)
- Issaka Saouadogo
- Institute for Interdisciplinary Research Training in Health Sciences and Education, Ouagadougou, Burkina Faso
| | - Douglas Mbang Massom
- Epidemiology, Intervention and Training Department, Epicentre, Yaounde, Cameroon
| | - Soutongnoma Safiata Kabore
- Institute for Interdisciplinary Research Training in Health Sciences and Education, Ouagadougou, Burkina Faso
| | - Ronny Kevin Fomete Djatsa
- Laboratory for Research on Economic and Social Transformations, Research Laboratory on Economic and Social Transformations, Cheikh Anta Diop University of Dakar, Senegal
| | - Josiane Seu
- Faculty of Nursing, Laval University, Quebec, Canada
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Horwood C, Haskins L, Mapumulo S, Connolly C, Luthuli S, Jensen C, Pansegrouw D, McKerrow N. Electronic Integrated Management of Childhood Illness (eIMCI): a randomized controlled trial to evaluate an electronic clinical decision-making support system for management of sick children in primary health care facilities in South Africa. BMC Health Serv Res 2024; 24:177. [PMID: 38331824 PMCID: PMC10851465 DOI: 10.1186/s12913-024-10547-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Electronic clinical decision-making support systems (eCDSS) aim to assist clinicians making complex patient management decisions and improve adherence to evidence-based guidelines. Integrated management of Childhood Illness (IMCI) provides guidelines for management of sick children attending primary health care clinics and is widely implemented globally. An electronic version of IMCI (eIMCI) was developed in South Africa. METHODS We conducted a cluster randomized controlled trial comparing management of sick children with eIMCI to the management when using paper-based IMCI (pIMCI) in one district in KwaZulu-Natal. From 31 clinics in the district, 15 were randomly assigned to intervention (eIMCI) or control (pIMCI) groups. Computers were deployed in eIMCI clinics, and one IMCI trained nurse was randomly selected to participate from each clinic. eIMCI participants received a one-day computer training, and all participants received a similar three-day IMCI update and two mentoring visits. A quantitative survey was conducted among mothers and sick children attending participating clinics to assess the quality of care provided by IMCI practitioners. Sick child assessments by participants in eIMCI and pIMCI groups were compared to assessment by an IMCI expert. RESULTS Self-reported computer skills were poor among all nurse participants. IMCI knowledge was similar in both groups. Among 291 enrolled children: 152 were in the eIMCI group; 139 in the pIMCI group. The mean number of enrolled children was 9.7 per clinic (range 7-12). IMCI implementation was sub-optimal in both eIMCI and pIMCI groups. eIMCI consultations took longer than pIMCI consultations (median duration 28 minutes vs 25 minutes; p = 0.02). eIMCI participants were less likely than pIMCI participants to correctly classify children for presenting symptoms, but were more likely to correctly classify for screening conditions, particularly malnutrition. eIMCI participants were less likely to provide all required medications (124/152; 81.6% vs 126/139; 91.6%, p= 0.026), and more likely to prescribe unnecessary medication (48/152; 31.6% vs 20/139; 14.4%, p = 0.004) compared to pIMCI participants. CONCLUSIONS Implementation of eIMCI failed to improve management of sick children, with poor IMCI implementation in both groups. Further research is needed to understand barriers to comprehensive implementation of both pIMCI and eIMCI. (349) CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov ID: BFC157/19, August 2019.
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Affiliation(s)
- C Horwood
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
| | - L Haskins
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - S Mapumulo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - C Connolly
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - S Luthuli
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - C Jensen
- Health Systems Strengthening Unit, Health Systems Trust, Durban, South Africa
| | - D Pansegrouw
- KwaZulu-Natal Department of Health, Ilembe District, Stanger, South Africa
| | - N McKerrow
- KwaZulu-Natal Department of Health, Paediatrics and Child Health, Pietermaritzburg, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
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6
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Tan R, Kavishe G, Luwanda LB, Kulinkina AV, Renggli S, Mangu C, Ashery G, Jorram M, Mtebene IE, Agrea P, Mhagama H, Vonlanthen A, Faivre V, Thabard J, Levine G, Le Pogam MA, Keitel K, Taffé P, Ntinginya N, Masanja H, D'Acremont V. A digital health algorithm to guide antibiotic prescription in pediatric outpatient care: a cluster randomized controlled trial. Nat Med 2024; 30:76-84. [PMID: 38110580 PMCID: PMC10803249 DOI: 10.1038/s41591-023-02633-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/06/2023] [Indexed: 12/20/2023]
Abstract
Excessive antibiotic use and antimicrobial resistance are major global public health threats. We developed ePOCT+, a digital clinical decision support algorithm in combination with C-reactive protein test, hemoglobin test, pulse oximeter and mentorship, to guide health-care providers in managing acutely sick children under 15 years old. To evaluate the impact of ePOCT+ compared to usual care, we conducted a cluster randomized controlled trial in Tanzanian primary care facilities. Over 11 months, 23,593 consultations were included from 20 ePOCT+ health facilities and 20,713 from 20 usual care facilities. The use of ePOCT+ in intervention facilities resulted in a reduction in the coprimary outcome of antibiotic prescription compared to usual care (23.2% versus 70.1%, adjusted difference -46.4%, 95% confidence interval (CI) -57.6 to -35.2). The coprimary outcome of day 7 clinical failure was noninferior in ePOCT+ facilities compared to usual care facilities (adjusted relative risk 0.97, 95% CI 0.85 to 1.10). There was no difference in the secondary safety outcomes of death and nonreferred secondary hospitalizations by day 7. Using ePOCT+ could help address the urgent problem of antimicrobial resistance by safely reducing antibiotic prescribing. Clinicaltrials.gov Identifier: NCT05144763.
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Affiliation(s)
- Rainer Tan
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
- University of Basel, Basel, Switzerland.
| | - Godfrey Kavishe
- National Institute of Medical Research - Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
| | - Lameck B Luwanda
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Alexandra V Kulinkina
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Sabine Renggli
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Chacha Mangu
- National Institute of Medical Research - Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
| | - Geofrey Ashery
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Margaret Jorram
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | | | - Peter Agrea
- National Institute of Medical Research - Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
| | - Humphrey Mhagama
- National Institute of Medical Research - Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
| | - Alan Vonlanthen
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Vincent Faivre
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Julien Thabard
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Gillian Levine
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Marie-Annick Le Pogam
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Kristina Keitel
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- Pediatric Emergency Department, Department of Pediatrics, University Hospital Bern, Bern, Switzerland
| | - Patrick Taffé
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Nyanda Ntinginya
- National Institute of Medical Research - Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
| | - Honorati Masanja
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Valérie D'Acremont
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
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7
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Le Bec E, Kam M, Aebischer Perone S, Boulle P, Cikomola JC, Gandur ME, Gehri M, Kehlenbrink S, Beran D. Using Clinical Vignettes to Understand the Complexity of Diagnosing Type 1 Diabetes in Sub-Saharan Africa. Res Rep Trop Med 2023; 14:111-120. [PMID: 38024811 PMCID: PMC10656429 DOI: 10.2147/rrtm.s397127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
Lack of awareness, access to insulin and diabetes care can result in high levels of morbidity and mortality for children with type 1 diabetes (T1DM) in sub-Saharan Africa (SSA). Improvements in access to insulin and diabetes management have improved outcomes in some settings. However, many people still present in diabetic ketoacidosis (DKA) in parallel to misdiagnosis of children with T1DM in contexts with high rates of communicable diseases. The aim of this study was to highlight the complexity of diagnosing pediatric T1DM in a healthcare environment dominated by infectious diseases and lack of adequate health system resources. This was done by developing clinical vignettes and recreating the hypothetico-deductive process of a clinician confronted with DKA in the absence of identification of pathognomonic elements of diabetes and with limited diagnostic tools. A non-systematic literature search for T1DM and DKA in SSA was conducted and used to construct clinical vignettes for children presenting in DKA. A broad differential diagnosis of the main conditions present in SSA was made, then used to construct a clinician's medical reasoning, and anticipate the results of different actions on the diagnostic process. An examination of the use of the digital based Integrated Management of Childhood Illness diagnostic algorithm was done, and an analysis of the software's efficiency in adequately diagnosing DKA was assessed. The main obstacles to diagnosis were low specificity of non-pathognomonic DKA symptoms and lack of tools to measure blood or urine glucose. Avenues for improvement include awareness of T1DM symptomatology in communities and health systems, and greater availability of diagnostic tests. Through this work clinical vignettes are shown to be a useful tool in analyzing the obstacles to underdiagnosis of diabetes, a technique that could be used for other pathologies in limited settings, for clinical teaching, research, and advocacy.
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Affiliation(s)
- Enora Le Bec
- Internal Medicine, Etablissements Hospitaliers du Nord Vaudois, Yverdon, Switzerland
| | - Madibele Kam
- Pediatric University Hospital Charles de Gaulle, Ouagadougou, Burkina Faso
| | - Sigiriya Aebischer Perone
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Health Unit, International Committee of the Red Cross, Geneva, Switzerland
| | | | | | | | - Mario Gehri
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Sylvia Kehlenbrink
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA, USA
| | - David Beran
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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8
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Maïga A, Ogyu A, Millogo RM, Lopez-Hernandez A, Labité MA, Labrique A, Agarwal S. Use of a digital job-aid in improving antenatal clinical protocols and quality of care in rural primary-level health facilities in Burkina Faso: a quasi-experimental evaluation. BMJ Open 2023; 13:e074770. [PMID: 37758675 PMCID: PMC10537835 DOI: 10.1136/bmjopen-2023-074770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE We assessed the impact of a digital clinical decision support (CDS) tool in improving health providers adherence to recommended antenatal protocols and service quality in rural primary-level health facilities in Burkina Faso. DESIGN A quasi-experimental evaluation based on a cross-sectional post-intervention assessment comparing the intervention district to a comparison group. SETTING AND PARTICIPANTS The study included 331 direct observations and exit interviews of pregnant women seeking antenatal care (ANC) across 48 rural primary-level health facilities in Burkina Faso in 2021. INTERVENTION Digital CDS tool to improve health providers adherence to recommended antenatal protocols. OUTCOME MEASURES We analysed the quality of care on both the supply and demand sides. Quality-of-care service scores were based on actual care provided and expected care according to standards. Pregnant women's knowledge of counselling and satisfaction score after receiving care were also calculated. Other outcomes included time of clinical encounter. RESULTS The overall quality of health service provision was comparable across intervention and comparison health facilities (52% vs 51%) despite there being a significantly higher proportion of lower skilled providers in the intervention arm (42.5% vs 17.8%). On average, ANC visits were longer in the intervention area (median 24 min, IQR 18) versus comparison area (median 12 min, IQR: 8). The intervention arm had a significantly higher score difference in women's knowledge of received counselling (16.4 points, 95% CI 10.37 to 22.49), and women's satisfaction (16.18 points, 95% CI: 9.95 to 22.40). CONCLUSION Digital CDS tools provide a valuable opportunity to achieve substantial improvements of the quality of ANC and broadly maternal and newborn health in settings with high burden mortality and less trained health cadres when adequately implemented.
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Affiliation(s)
- Abdoulaye Maïga
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anju Ogyu
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Roch Modeste Millogo
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-Zerbo, Ouagadougou, Centre, Burkina Faso
| | - Angelica Lopez-Hernandez
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Matè Alonyenyo Labité
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-Zerbo, Ouagadougou, Centre, Burkina Faso
| | - Alain Labrique
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Smisha Agarwal
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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9
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Beynon F, Guérin F, Lampariello R, Schmitz T, Tan R, Ratanaprayul N, Tamrat T, Pellé KG, Catho G, Keitel K, Masanja I, Rambaud-Althaus C. Digitalizing Clinical Guidelines: Experiences in the Development of Clinical Decision Support Algorithms for Management of Childhood Illness in Resource-Constrained Settings. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200439. [PMID: 37640492 PMCID: PMC10461705 DOI: 10.9745/ghsp-d-22-00439] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 06/13/2023] [Indexed: 08/31/2023]
Abstract
Clinical decision support systems (CDSSs) can strengthen the quality of integrated management of childhood illness (IMCI) in resource-constrained settings. Several IMCI-related CDSSs have been developed and implemented in recent years. Yet, despite having a shared starting point, the IMCI-related CDSSs are markedly varied due to the need for interpretation when translating narrative guidelines into decision logic combined with considerations of context and design choices. Between October 2019 and April 2021, we conducted a comparative analysis of 4 IMCI-related CDSSs. The extent of adaptations to IMCI varied, but common themes emerged. Scope was extended to cover a broader range of conditions. Content was added or modified to enhance precision, align with new evidence, and support rational resource use. Structure was modified to increase efficiency, improve usability, and prioritize care for severely ill children. The multistakeholder development processes involved syntheses of recommendations from existing guidelines and literature; creation and validation of clinical algorithms; and iterative development, implementation, and evaluation. The common themes surrounding adaptations of IMCI guidance highlight the complexities of digitalizing evidence-based recommendations and reinforce the rationale for leveraging standards for CDSS development, such as the World Health Organization's SMART Guidelines. Implementation through multistakeholder dialogue is critical to ensure CDSSs can effectively and equitably improve quality of care for children in resource-constrained settings.
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Affiliation(s)
- Fenella Beynon
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | | | - Torsten Schmitz
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Rainer Tan
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Digital and Global Health Unit, Unisanté, Center for Primary Care and Public Health, Lausanne, Switzerland
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Natschja Ratanaprayul
- Department of Digital Health and Innovations, World Health Organization, Geneva, Switzerland
| | - Tigest Tamrat
- UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Gaud Catho
- Division of Infectious Diseases, Geneva University Hospital and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Global Health Institute, University of Geneva, Geneva, Switzerland
| | - Kristina Keitel
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Pediatric Emergency Medicine, Department of Pediatrics, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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10
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Kiemde F, Valia D, Kabore B, Rouamba T, Kone AN, Sawadogo S, Compaore A, Salami O, Horgan P, Moore CE, Dittrich S, Nkeramahame J, Olliaro P, Tinto H. A Randomized Trial to Assess the Impact of a Package of Diagnostic Tools and Diagnostic Algorithm on Antibiotic Prescriptions for the Management of Febrile Illnesses Among Children and Adolescents in Primary Health Facilities in Burkina Faso. Clin Infect Dis 2023; 77:S134-S144. [PMID: 37490742 PMCID: PMC10368409 DOI: 10.1093/cid/ciad331] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Low- and middle-income countries face significant challenges in differentiating bacterial from viral causes of febrile illnesses, leading to inappropriate use of antibiotics. This trial aimed to evaluate the impact of an intervention package comprising diagnostic tests, a diagnostic algorithm, and a training-and-communication package on antibiotic prescriptions and clinical outcomes. METHODS Patients aged 6 months to 18 years with fever or history of fever within the past 7 days with no focus, or a suspected respiratory tract infection, arriving at 2 health facilities were randomized to either the intervention package or standard practice. The primary outcomes were the proportions of patients who recovered at day 7 (D7) and patients prescribed antibiotics at day 0. RESULTS Of 1718 patients randomized, 1681 (97.8%; intervention: 844; control: 837) completed follow-up: 99.5% recovered at D7 in the intervention arm versus 100% in standard practice (P = .135). Antibiotics were prescribed to 40.6% of patients in the intervention group versus 57.5% in the control arm (risk ratio: 29.3%; 95% CI: 21.8-36.0%; risk difference [RD]: -16.8%; 95% CI: -21.7% to -12.0%; P < .001), which translates to 1 additional antibiotic prescription saved every 6 (95% CI: 5-8) consultations. This reduction was significant regardless of test results for malaria, but was greater in patients without malaria (RD: -46.0%; -54.7% to -37.4%; P < .001), those with a respiratory diagnosis (RD: -38.2%; -43.8% to -32.6%; P < .001), and in children 6-59 months old (RD: -20.4%; -26.0% to -14.9%; P < .001). Except for the period July-September, the reduction was consistent across the other quarters (P < .001). CONCLUSIONS The implementation of the package can reduce inappropriate antibiotic prescription without compromising clinical outcomes. CLINICAL TRIALS REGISTRATION clinicaltrials.gov; NCT04081051.
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Affiliation(s)
- Francois Kiemde
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Daniel Valia
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Berenger Kabore
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Toussaint Rouamba
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Alima Nadine Kone
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Seydou Sawadogo
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Adelaide Compaore
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | | | - Philip Horgan
- FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, United Kingdom
- Evidence and Impact Oxford, Oxford, United Kingdom
| | - Catrin E Moore
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, United Kingdom
- Centre for Neonatal and Pediatric Infection, Institute for Infection and Immunity, St George's University of London, London, United Kingdom
| | - Sabine Dittrich
- FIND, Geneva, Switzerland
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Deggendorf Institute of Technology, European Campus Rottal Inn, Pfarrkirchen, Germany
| | | | - Piero Olliaro
- FIND, Geneva, Switzerland
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
| | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
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11
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Nkeramahame J, Olliaro P, Horgan P, Dittrich S. Perspective on the Integration of Diagnostic Algorithms for Fever Management. Clin Infect Dis 2023; 77:S211-S213. [PMID: 37490737 PMCID: PMC10368406 DOI: 10.1093/cid/ciad325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
The AMR Diagnostics Use Accelerator Program was established to address antimicrobial resistance. Here, we bring into broad perspective the findings and missed opportunities of the first phase of the program and look toward the second phase.
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Affiliation(s)
| | - Piero Olliaro
- Medical Affairs, FIND, Geneva, Switzerland
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
| | - Philip Horgan
- Medical Affairs, FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, United Kingdom
- Department of Medicine, Evidence & Impact - Oxford, Oxford, United Kingdom
| | - Sabine Dittrich
- Medical Affairs, FIND, Geneva, Switzerland
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Deggendorf Institute of Technology, European Campus Rottal Inn, Pfarrkirchen, Germany
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12
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Horwood C, Luthuli S, Mapumulo S, Haskins L, Jensen C, Pansegrouw D, McKerrow N. Challenges of using e-health technologies to support clinical care in rural Africa: a longitudinal mixed methods study exploring primary health care nurses' experiences of using an electronic clinical decision support system (CDSS) in South Africa. BMC Health Serv Res 2023; 23:30. [PMID: 36639801 PMCID: PMC9840278 DOI: 10.1186/s12913-022-09001-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/21/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Electronic decision-making support systems (CDSSs) can support clinicians to make evidence-based, rational clinical decisions about patient management and have been effectively implemented in high-income settings. Integrated Management of Childhood Illness (IMCI) uses clinical algorithms to provide guidelines for management of sick children in primary health care clinics and is widely implemented in low income countries. A CDSS based on IMCI (eIMCI) was developed in South Africa. METHODS We undertook a mixed methods study to prospectively explore experiences of implementation from the perspective of newly-trained eIMCI practitioners. eIMCI uptake was monitored throughout implementation. In-depth interviews (IDIs) were conducted with selected participants before and after training, after mentoring, and after 6 months implementation. Participants were then invited to participate in focus group discussions (FGDs) to provide further insights into barriers to eIMCI implementation. RESULTS We conducted 36 IDIs with 9 participants between October 2020 and May 2021, and three FGDs with 11 participants in October 2021. Most participants spoke positively about eIMCI reporting that it was well received in the clinics, was simple to use, and improved the quality of clinical assessments. However, uptake of eIMCI across participating clinics was poor. Challenges reported included lack of computer skills which made simple tasks, like logging in or entering patient details, time consuming. Technical support was provided, but was time consuming to access so that eIMCI was sometimes unavailable. Other challenges included heavy workloads, and the perception that eIMCI took longer and disrupted participant's work. Poor alignment between recording requirements of eIMCI and other clinic programmes increased participant's administrative workload. All these factors were a disincentive to eIMCI uptake, frequently leading participants to revert to paper IMCI which was quicker and where they felt more confident. CONCLUSION Despite the potential of CDSSs to increase adherence to guidelines and improve clinical management and prescribing practices in resource constrained settings where clinical support is scarce, they have not been widely implemented. Careful attention should be paid to the work environment, work flow and skills of health workers prior to implementation, and ongoing health system support is required if health workers are to adopt these approaches (350).
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Affiliation(s)
- Christiane Horwood
- grid.16463.360000 0001 0723 4123Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Silondile Luthuli
- grid.16463.360000 0001 0723 4123Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Sphindile Mapumulo
- grid.16463.360000 0001 0723 4123Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Lyn Haskins
- grid.16463.360000 0001 0723 4123Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Cecilie Jensen
- grid.463338.90000 0001 2157 3236Health Systems Strengthening Unit, Health Systems Trust, Durban, South Africa
| | - Deidre Pansegrouw
- KwaZulu-Natal Department of Health, Ilembe District, KwaDukuza, South Africa
| | - Neil McKerrow
- KwaZulu-Natal Department of Health, Paediatrics and Child Health, Pietermaritzburg, South Africa ,grid.7836.a0000 0004 1937 1151Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa ,grid.16463.360000 0001 0723 4123Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
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13
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Blanchet K, Sanon VP, Sarrassat S, Somé AS. Realistic Evaluation of the Integrated Electronic Diagnosis Approach (IeDA) for the Management of Childhood Illnesses at Primary Health Facilities in Burkina Faso. Int J Health Policy Manag 2023; 12:6073. [PMID: 37579445 PMCID: PMC10125132 DOI: 10.34172/ijhpm.2022.6073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 11/19/2022] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND In 2014, Terre des Hommes (Tdh) together with the Ministry of Health (MoH) launched the Integrated electronic Diagnosis Approach (IeDA) intervention in two regions of Burkina Faso consisting of supplying every health centre with a digital algorithm. A realistic evaluation was conducted to understand the implementation process, the mechanisms by which the IeDA intervention lead to change. METHODS Data collection took place between January 2016 and October 2017. Direct observation in health centres were conducted. In-depth interviews were conducted with 154 individuals including 92 healthcare workers (HCW) from health centres, 16 officers from district health authorities, 6 members of health centre management committees. In addition, 5 focus groups were organised with carers. The initial coding was based on a preliminary list of codes inspired by the middle-range theory (MRT). RESULTS Our results showed that the adoption of the electronic protocol depended on a multiplicity of management practices including role distribution, team work, problem solving approach, task monitoring, training, supervision, support and recognition. Such changes lead to reorganising the health team and redistributing roles before and during consultation, and positive atmosphere that included recognition of each team member, organisational commitment and sense of belonging. Conditions for such management changes to be effective included open dialog at all levels of the system, a minimum of resources to cover the support services and supervision and regular discussions focusing on solving problems faced by health centre teams. CONCLUSION This project reinforces the point that in a successful diffusion of IeDA, it is necessary to combine the introduction of technology with support and management mechanisms. It also important to highlight that managers' attitude plays a great place in the success of the intervention: open dialog and respect are crucial dimensions. This is aligned with the findings from other studies.
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Affiliation(s)
- Karl Blanchet
- Geneva Centre of Humanitarian Studies, University of Geneva, Graduate Institute, Geneva, Switzerland
- London School of Hygiene and Tropical Medicine, London, UK
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14
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Tan R, Cobuccio L, Beynon F, Levine GA, Vaezipour N, Luwanda LB, Mangu C, Vonlanthen A, De Santis O, Salim N, Manji K, Naburi H, Chirande L, Matata L, Bulongeleje M, Moshiro R, Miheso A, Arimi P, Ndiaye O, Faye M, Thiongane A, Awasthi S, Sharma K, Kumar G, Van De Maat J, Kulinkina A, Rwandarwacu V, Dusengumuremyi T, Nkuranga JB, Rusingiza E, Tuyisenge L, Hartley MA, Faivre V, Thabard J, Keitel K, D’Acremont V. ePOCT+ and the medAL-suite: Development of an electronic clinical decision support algorithm and digital platform for pediatric outpatients in low- and middle-income countries. PLOS DIGITAL HEALTH 2023; 2:e0000170. [PMID: 36812607 PMCID: PMC9931356 DOI: 10.1371/journal.pdig.0000170] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/23/2022] [Indexed: 01/20/2023]
Abstract
Electronic clinical decision support algorithms (CDSAs) have been developed to address high childhood mortality and inappropriate antibiotic prescription by helping clinicians adhere to guidelines. Previously identified challenges of CDSAs include their limited scope, usability, and outdated clinical content. To address these challenges we developed ePOCT+, a CDSA for the care of pediatric outpatients in low- and middle-income settings, and the medical algorithm suite (medAL-suite), a software for the creation and execution of CDSAs. Following the principles of digital development, we aim to describe the process and lessons learnt from the development of ePOCT+ and the medAL-suite. In particular, this work outlines the systematic integrative development process in the design and implementation of these tools required to meet the needs of clinicians to improve uptake and quality of care. We considered the feasibility, acceptability and reliability of clinical signs and symptoms, as well as the diagnostic and prognostic performance of predictors. To assure clinical validity, and appropriateness for the country of implementation the algorithm underwent numerous reviews by clinical experts and health authorities from the implementing countries. The digitalization process involved the creation of medAL-creator, a digital platform which allows clinicians without IT programming skills to easily create the algorithms, and medAL-reader the mobile health (mHealth) application used by clinicians during the consultation. Extensive feasibility tests were done with feedback from end-users of multiple countries to improve the clinical algorithm and medAL-reader software. We hope that the development framework used for developing ePOCT+ will help support the development of other CDSAs, and that the open-source medAL-suite will enable others to easily and independently implement them. Further clinical validation studies are underway in Tanzania, Rwanda, Kenya, Senegal, and India.
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Affiliation(s)
- Rainer Tan
- Digital and Global Health Unit, Unisanté, Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- University of Basel, Basel, Switzerland
| | - Ludovico Cobuccio
- Digital and Global Health Unit, Unisanté, Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fenella Beynon
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Gillian A. Levine
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Nina Vaezipour
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Chacha Mangu
- National Institute of Medical Research–Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
| | - Alan Vonlanthen
- Information Technology & Digital Transformation sector, Unisanté, Center for Primary Care and Public Health, University of Lausanne, Switzerland
| | - Olga De Santis
- Digital and Global Health Unit, Unisanté, Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Nahya Salim
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences (MUHAS), Dar es Salaam, United Republic of Tanzania
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences (MUHAS), Dar es Salaam, United Republic of Tanzania
| | - Helga Naburi
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences (MUHAS), Dar es Salaam, United Republic of Tanzania
| | - Lulu Chirande
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences (MUHAS), Dar es Salaam, United Republic of Tanzania
| | - Lena Matata
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- University of Basel, Basel, Switzerland
| | | | - Robert Moshiro
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences (MUHAS), Dar es Salaam, United Republic of Tanzania
| | | | - Peter Arimi
- College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Ousmane Ndiaye
- Department of Pediatrics, Cheikh Anta Diop University, Dakar, Senegal
| | - Moctar Faye
- Department of Pediatrics, Cheikh Anta Diop University, Dakar, Senegal
| | - Aliou Thiongane
- Department of Pediatrics, Cheikh Anta Diop University, Dakar, Senegal
| | - Shally Awasthi
- Department of Pediatrics, King George’s Medical University, Lucknow, India
| | | | - Gaurav Kumar
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Josephine Van De Maat
- Radboudumc, Department of Internal Medicine and Radboudumc Center for Infectious Diseases, Nijmegen, Netherlands
| | - Alexandra Kulinkina
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Victor Rwandarwacu
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Théophile Dusengumuremyi
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Emmanuel Rusingiza
- University Teaching Hospital of Kigali, Kigali, Rwanda
- School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | | | - Mary-Anne Hartley
- Intelligent Global Health, Machine Learning and Optimization Laboratory, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Vincent Faivre
- Information Technology & Digital Transformation sector, Unisanté, Center for Primary Care and Public Health, University of Lausanne, Switzerland
| | - Julien Thabard
- Information Technology & Digital Transformation sector, Unisanté, Center for Primary Care and Public Health, University of Lausanne, Switzerland
| | - Kristina Keitel
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Paediatric Emergency Department, Department of Pediatrics, University Hospital Berne, Berne, Switzerland
| | - Valérie D’Acremont
- Digital and Global Health Unit, Unisanté, Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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15
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Hedible GB, Louart S, Neboua D, Catala L, Anago G, Sawadogo AG, Kargougou GD, Meda B, Kolié JS, Hema A, Keita S, Niome M, Savadogo AS, Peters-Bokol L, Agbeci H, Zair Z, Lenaud S, Vignon M, Ouedraogo Yugbare S, Abarry H, Diakite AA, Diallo IS, Lamontagne F, Briand V, Dahourou DL, Cousien A, Ridde V, Leroy V. Evaluation of the routine implementation of pulse oximeters into integrated management of childhood illness (IMCI) guidelines at primary health care level in West Africa: the AIRE mixed-methods research protocol. BMC Health Serv Res 2022; 22:1579. [PMID: 36566173 PMCID: PMC9789366 DOI: 10.1186/s12913-022-08982-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 12/16/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The AIRE operational project will evaluate the implementation of the routine Pulse Oximeter (PO) use in the integrated management of childhood illness (IMCI) strategy for children under-5 in primary health care centers (PHC) in West Africa. The introduction of PO should promote the accurate identification of hypoxemia (pulse blood oxygen saturation Sp02 < 90%) among all severe IMCI cases (respiratory and non-respiratory) to prompt their effective case management (oxygen, antibiotics and other required treatments) at hospital. We seek to understand how the routine use of PO integrated in IMCI outpatients works (or not), for whom, in what contexts and with what outcomes. METHODS The AIRE project is being implemented from 03/2020 to 12/2022 in 202 PHCs in four West African countries (Burkina Faso, Guinea, Mali, Niger) including 16 research PHCs (four per country). The research protocol will assess three complementary components using mixed quantitative and qualitative methods: a) context based on repeated cross-sectional surveys: baseline and aggregated monthly data from all PHCs on infrastructure, staffing, accessibility, equipment, PO use, severe cases and care; b) the process across PHCs by assessing acceptability, fidelity, implementation challenges and realistic evaluation, and c) individual outcomes in the research PHCs: all children under-5 attending IMCI clinics, eligible for PO use will be included with parental consent in a cross-sectional study. Among them, severe IMCI cases will be followed in a prospective cohort to assess their health status at 14 days. We will analyze pathways, patterns of care, and costs of care. DISCUSSION This research will identify challenges to the systematic implementation of PO in IMCI consultations, such as health workers practices, frequent turnover, quality of care, etc. Further research will be needed to fully address key questions such as the best time to introduce PO into the IMCI process, the best SpO2 threshold for deciding on hospital referral, and assessing the cost-effectiveness of PO use. The AIRE research will provide health policy makers in West Africa with sufficient evidence on the context, process and outcomes of using PO integrated into IMCI to promote scale-up in all PHCs. TRIAL REGISTRATION Trial registration number: PACTR202206525204526 retrospectively registered on 06/15/2022.
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Affiliation(s)
| | - Sarah Louart
- ALIMA, Dakar, Senegal
- IRD, CEPED, Paris, France
- University of Lille, CLERSE - Centre Lillois d'Études et de Recherches Sociologiques et Économiques, Lille, France
| | | | - Laura Catala
- Inserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France
| | | | | | | | | | | | - Adama Hema
- Terre des hommes-Lausanne (Tdh), Ouagadougou, Burkina Faso
| | | | | | | | - Lucie Peters-Bokol
- Inserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France
| | - Honorat Agbeci
- Inserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France
| | - Zineb Zair
- Inserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France
| | | | | | | | - Hannatou Abarry
- Ministère de la santé, des populations et des affaires sociales, Niamey, Niger
| | | | | | | | - Valérie Briand
- University of Bordeaux, Inserm UMR 1219, IRD EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | - Désiré Lucien Dahourou
- Inserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France
- Institut de Recherche en Sciences de la Santé/CNRST, Département Biomédical, Santé Publique, Ouagadougou, Burkina Faso
| | - Anthony Cousien
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, IAME, F-75018, Paris, France
| | | | - Valériane Leroy
- Inserm, University Paul Sabatier Toulouse 3, CERPOP, UMR 1295, Toulouse, France.
- Center for Epidemiology and Research in Population Health (CERPOP), UMR 1295, Inserm, University Paul Sabatier Toulouse 3, Toulouse, France.
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16
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Kpoda HBN, Somé SA, Somda MAS, Yara M, Dabone BEA, Ilboudo P, Bakyono R, Ouangraoua S, Sie A, Kabré E, Meda C, Sempore E, Yaro S, Simboro I, Sakana L, Hien A, Bazie H, Badolo H, Ilboudo B, Sanon S, Meda N, Hien H. Evaluation of Adherence of Health-Care Workers to Integrated Management of Childhood Illness Guidelines in the Context of the Free Care Program in Burkina Faso. Am J Trop Med Hyg 2022; 107:tpmd210976. [PMID: 35895336 PMCID: PMC9490671 DOI: 10.4269/ajtmh.21-0976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 02/24/2022] [Indexed: 11/07/2022] Open
Abstract
To reduce child mortality in children younger than 5 years, Burkina Faso has been offering free care to this population of children since 2016. The free care program is aligned with the Integrated Management of Childhood Illness (IMCI) guidelines. Given that the number of studies that evaluated the competence of health-care workers (HCWs) during the free care program was limited, we assessed the adherence level of HCWs to the IMCI guidelines in the context of free care. This was a secondary data analysis. Data were obtained from a cross-sectional study conducted from July to September 2020 in 40 primary health-care centers and two district hospitals in the Hauts-Bassins region in Burkina Faso. Our analysis included 419 children younger than 5 years old who were consulted according to IMCI guidelines. Data were collected through direct observation using a checklist. The overall score of adherence of HCWs to IMCI guidelines was 57.8% (95% CI, 42.6-73.0). The mean adherence score of the evaluation of danger signs was 71.9% (95% CI, 58.7-85.1). The mean adherence score of following IMCI guidelines was significantly greater in boys (54.2%) compared with girls (44.6%; P < 0.001). Adherence scores of the performance of different IMCI tasks were significantly different across HCW categories. The overall adherence of HCWs to IMCI guidelines in the context of free care was greater than the adherence reported before the implementation of free care in Burkina Faso. However, this assessment needs to be performed nationwide to capture the overall adherence of HCWs to IMCI guidelines in the context of the free care program.
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Affiliation(s)
- Hervé B. N. Kpoda
- Centre Muraz de Bobo-Dioulasso, Institut National de Santé Publique, Burkina Faso
| | - Satouro Arsène Somé
- Centre Muraz de Bobo-Dioulasso, Institut National de Santé Publique, Burkina Faso
| | - Manituo Aymar Serge Somda
- Centre Muraz de Bobo-Dioulasso, Institut National de Santé Publique, Burkina Faso
- Unite de Formation et de Recherche Sciences et Technique/Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Mimbouré Yara
- Observatoire National de la Santé de la Population, Institut National de Santé Publique, Burkina Faso
| | | | | | - Richard Bakyono
- Observatoire National de la Santé de la Population, Institut National de Santé Publique, Burkina Faso
| | - Soumeya Ouangraoua
- Centre Muraz de Bobo-Dioulasso, Institut National de Santé Publique, Burkina Faso
| | - Ali Sie
- Centre de Recherche en Santé de Nouna, Institut National de Santé Publique, Burkina Faso
| | - Elie Kabré
- Laboratoire National de Santé Publique, Ouagadougou, Burkina Faso
| | - Clément Meda
- Unite de Formation et de Recherche Sciences et Technique/Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Emmanuelle Sempore
- Centre Muraz de Bobo-Dioulasso, Institut National de Santé Publique, Burkina Faso
| | - Seydou Yaro
- Centre Muraz de Bobo-Dioulasso, Institut National de Santé Publique, Burkina Faso
| | - Imelda Simboro
- Observatoire National de la Santé de la Population, Institut National de Santé Publique, Burkina Faso
| | - Leticia Sakana
- Centre National de Recherche et de Formation sur le Paludisme, Institut National de Sante Publique, Burkina Faso
| | - Alain Hien
- Centre Muraz de Bobo-Dioulasso, Institut National de Santé Publique, Burkina Faso
| | - Herman Bazie
- Observatoire National de la Santé de la Population, Institut National de Santé Publique, Burkina Faso
| | - Hermamn Badolo
- Observatoire National de la Santé de la Population, Institut National de Santé Publique, Burkina Faso
| | - Bernard Ilboudo
- Centre Muraz de Bobo-Dioulasso, Institut National de Santé Publique, Burkina Faso
| | - Souleymane Sanon
- Centre National de Recherche et de Formation sur le Paludisme, Institut National de Sante Publique, Burkina Faso
| | - Nicolas Meda
- Unite de Formation et de Recherche Sciences de la Santé/Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Hervé Hien
- Centre Muraz de Bobo-Dioulasso, Institut National de Santé Publique, Burkina Faso
- Institut de Recherche en Science de la Santé/Centre National de la Recherche Scientifique et Technologique, Ouagadougou, Burkina Faso
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17
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Schmitz T, Beynon F, Musard C, Kwiatkowski M, Landi M, Ishaya D, Zira J, Muazu M, Renner C, Emmanuel E, Bulus SG, Rossi R. Effectiveness of an electronic clinical decision support system in improving the management of childhood illness in primary care in rural Nigeria: an observational study. BMJ Open 2022; 12:e055315. [PMID: 35863838 PMCID: PMC9310162 DOI: 10.1136/bmjopen-2021-055315] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/01/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To evaluate the impact of ALgorithm for the MANAgement of CHildhood illness ('ALMANACH'), a digital clinical decision support system (CDSS) based on the Integrated Management of Childhood Illness, on health and quality of care outcomes for sick children attending primary healthcare (PHC) facilities. DESIGN Observational study, comparing outcomes of children attending facilities implementing ALMANACH with control facilities not yet implementing ALMANACH. SETTING PHC facilities in Adamawa State, North-Eastern Nigeria. PARTICIPANTS Children 2-59 months presenting with an acute illness. Children attending for routine care or nutrition visits (eg, immunisation, growth monitoring), physical trauma or mental health problems were excluded. INTERVENTIONS The ALMANACH intervention package (CDSS implementation with training, mentorship and data feedback) was rolled out across Adamawa's PHC facilities by the Adamawa State Primary Health Care Development Agency, in partnership with the International Committee of the Red Cross and the Swiss Tropical and Public Health Institute. Tablets were donated, but no additional support or incentives were provided. Intervention and control facilities received supportive supervision based on the national supervision protocol. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was caregiver-reported recovery at day 7, collected over the phone. Secondary outcomes were antibiotic and antimalarial prescription, referral, and communication of diagnosis and follow-up advice, assessed at day 0 exit interview. RESULTS We recruited 1929 children, of which 1021 (53%) attended ALMANACH facilities, between March and September 2020. Caregiver-reported recovery was significantly higher among children attending ALMANACH facilities (adjusted OR=2·63, 95% CI 1·60 to 4·32). We observed higher parenteral and lower oral antimicrobial prescription rates (adjusted OR=2·42 (1·00 to 5·85) and adjusted OR=0·40 (0·22 to 0·73), respectively) in ALMANACH facilities as well as markedly higher rates for referral, communication of diagnosis, and follow-up advice. CONCLUSION Implementation of digital CDSS with training, mentorship and feedback in primary care can improve quality of care and recovery of sick children in resource-constrained settings, likely mediated by better guideline adherence. These findings support the use of CDSS for health systems strengthening to progress towards universal health coverage.
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Affiliation(s)
- Torsten Schmitz
- University of Basel, Basel, Switzerland
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Fenella Beynon
- University of Basel, Basel, Switzerland
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Capucine Musard
- University of Basel, Basel, Switzerland
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Marek Kwiatkowski
- University of Basel, Basel, Switzerland
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Marco Landi
- Regional Delegation Nigeria, International Committee of the Red Cross, Jimeta Yola, Nigeria
| | - Daniel Ishaya
- Adamawa State Primary Health Care Development Agency, Jimeta Yola, Nigeria
| | - Jeremiah Zira
- Adamawa State Primary Health Care Development Agency, Jimeta Yola, Nigeria
| | - Muazu Muazu
- Adamawa State Primary Health Care Development Agency, Jimeta Yola, Nigeria
| | - Camille Renner
- University of Basel, Basel, Switzerland
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Edwin Emmanuel
- Regional Delegation Nigeria, International Committee of the Red Cross, Jimeta Yola, Nigeria
| | | | - Rodolfo Rossi
- Health Unit, International Committee of the Red Cross, Geneve, Switzerland
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18
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Jensen C, McKerrow NH. The feasibility and ongoing use of electronic decision support to strengthen the implementation of IMCI in KwaZulu-Natal, South Africa. BMC Pediatr 2022; 22:80. [PMID: 35130847 PMCID: PMC8818499 DOI: 10.1186/s12887-022-03147-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/31/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Continued efforts are required to reduce preventable child deaths. User-friendly Integrated Management of Childhood Illness (IMCI) implementation tools and supervision systems are needed to strengthen the quality of child health services in South Africa. A 2018 pilot implementation of electronic IMCI case management algorithms in KwaZulu-Natal demonstrated good uptake and acceptance at primary care clinics. We aimed to investigate whether ongoing electronic IMCI implementation is feasible within the existing Department of Health infrastructure and resources. METHODS In a mixed methods descriptive study, the electronic IMCI (eIMCI) implementation was extended to 22 health facilities in uMgungundlovu district from November 2019 to February 2021. Training, mentoring, supervision and IT support were provided by a dedicated project team. Programme use was tracked, quarterly assessments of the service delivery platform were undertaken and in-depth interviews were conducted with facility managers. RESULTS From December 2019 - January 2021, 9 684 eIMCI records were completed across 20 facilities, with a median uptake of 29 records per clinic per month and a mean (range) proportion of child consultations using eIMCI of 15% (1-46%). The local COVID-19-related movement restrictions and epidemic peaks coincided with declines in the monthly eIMCI uptake. Substantial inter- and intra-facility variations in use were observed, with the use being positively associated with the allocation of an eIMCI trained nurse (p < 0.001) and the clinician workload (p = 0.032). CONCLUSION The ongoing eIMCI uptake was sporadic and the implementation undermined by barriers such as low post-training deployment of nurses; poor capacity in the DoH for IT support; and COVID-19-related disruptions in service delivery. Scaling eIMCI in South Africa would rely on resolving these challenges.
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Affiliation(s)
- Cecilie Jensen
- Health Systems Strengthening Unit, Health Systems Trust, Durban, South Africa.
| | - Neil H McKerrow
- KwaZulu-Natal Department of Health, Paediatrics and Child Health, Pietermaritzburg, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
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19
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Lampariello R, Ancellin-Panzani S. Mastering stakeholders' engagement to reach national scale, sustainability and wide adoption of digital health initiatives: lessons learnt from Burkina Faso. Fam Med Community Health 2021; 9:e000959. [PMID: 34144970 PMCID: PMC8215243 DOI: 10.1136/fmch-2021-000959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/18/2021] [Indexed: 11/10/2022] Open
Abstract
Although low-income countries have recently seen an exponential flourishing of digital health initiatives, the landscape is characterised by a myriad of small pilots that rarely reach scaling, sustainability and wide adoption. The case of Burkina Faso represents an exception where a digital health initiative initially conceived to improve the diagnosis of sick children under 5 has supported millions of consultations. Technical aspects such as interoperability, standardisation, and adaptation to the existing infrastructure were considered as they are prerequisites for scaling; so was the demonstration of the health impact and affordability of the initiative. Beyond those factors which are largely documented in the literature, the experience in Burkina Faso showed that the positive outcome was also determined by the support of numerous stakeholders. A vast network of stakeholders from the Ministry of Health to child caregivers is involved and each of them could have either blocked or promoted the digital health initiative. Thanks to an extensive, time-consuming and tailored stakeholder strategy, it was possible to avoid potential blockages from multiple actors and gain their engagement.
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Affiliation(s)
| | - Sonia Ancellin-Panzani
- Scaling Up Nutrition Movement Secretariat, Country Liaison Team, United Nations Office for Project Services, Geneva, Switzerland
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