The Effect of Text Message Reminders to Health Workers on Quality of Care for Malaria, Pneumonia, and Diarrhea in Malawi: A Cluster-Randomized, Controlled Trial

Digital Solutions for Community and Primary Health Workers: Lessons From Implementations in Africa

The agenda for Universal Health Coverage has driven the exploration of various innovative approaches to expanding health services to the general population. As more African countries have adopted digital health tools as part of the strategic approach to expanding health services, there is a need for defining a standard framework for implementation across board. Therefore, there is a need to review and employ an evidence-based approach to inform managing challenges, adopting best approaches, and implement informed recommendations. We reviewed a variety of digital health tools applied to different health conditions in primary care settings and highlighted the challenges faced, approaches that worked and relevant recommendations. These include limited coverage and network connectivity, lack of technological competence, lack of power supply, limited mobile phone usage and application design challenges. Despite these challenges, this review suggests that mHealth solutions could attain effective usage when healthcare workers receive adequate onsite training, deploying applications designed in an intuitive and easy to understand approach in a manner that fits into the users existing workflows, and involvement of the stakeholders at all levels in the design, planning, and implementation stages of the interventions.

Ter Kuile F, Blomberg B, Phiri KS. Adherence to community versus facility-based delivery of monthly malaria chemoprevention with dihydroartemisinin-piperaquine for the post-discharge management of severe anemia in Malawian children: A cluster randomized trial

Background

The provision of post-discharge malaria chemoprevention (PMC) in children recently admitted with severe anemia reduces the risk of death and re-admissions in malaria endemic countries. The main objective of this trial was to identify the most effective method of delivering dihydroartemesinin-piperaquine to children recovering from severe anemia.

Methods

This was a 5-arm, cluster-randomized trial among under-5 children hospitalized with severe anemia at Zomba Central Hospital in Southern Malawi. Children were randomized to receive three day treatment doses of dihydroartemesinin-piperaquine monthly either; 1) in the community without a short text reminder; 2) in the community with a short message reminder; 3) in the community with a community health worker reminder; 4) at the facility without a short text reminder; or 5) at the facility with a short message reminder. The primary outcome measure was adherence to all treatment doses of dihydroartemesinin-piperaquine and this was assessed by pill-counts done by field workers during home visits. Poisson regression was utilized for analysis.

Results

Between March 2016 and October 2018, 1460 clusters were randomized. A total of 667 children were screened and 375 from 329 clusters were eligible and enrolled from the hospital. Adherence was higher in all three community-based compared to the two facility-based delivery (156/221 [70·6%] vs. 78/150 [52·0%], IRR = 1·24,95%CI 1·06–1·44, p = 0·006). This was observed in both the SMS group (IRR = 1·41,1·21–1·64, p<0·001) and in the non-SMS group (IRR = 1·37,1·18–1·61, p<0·001). Although adherence was higher among SMS recipients (98/148 66·2%] vs. non-SMS 82/144 (56·9%), there was no statistical evidence that SMS reminders resulted in greater adherence ([IRR = 1·03,0·88–1·21, p = 0·68). When compared to the facility-based non-SMS arm (control arm), community-based delivery utilizing CHWs resulted in higher adherence [39/76 (51·3%) vs. 54/79 (68·4%), IRR = 1·32, 1·14–1·54, p<0·001].

Interpretation

Community-based delivery of dihydroartemesinin-piperaquine for post-discharge malaria chemoprevention in children recovering from severe anemia resulted in higher adherence compared to facility-based methods.

Trial registration

NCT02721420; ClinicalTrials.gov.