Abstract
Background: Integrated community case management (CCM) has led to reductions in child mortality in Malawi from illnesses such as malaria, pneumonia and diarrhoea. However, adherence to CCM guidelines is often poor, potentially leading to inappropriate clinical decisions and outcomes. We determined the impact of an electronic version of CCM (eCCM) application on referral, re-consultation and hospitalization rates of children presenting to village clinics in Malawi. Methods: A stepped-wedge cluster-randomized trial compared paper-based CCM (control) with and without use of an eCCM app on smartphones from November 2016 to April 2017.A total of 102 village clinics from two districts in Northern Malawi were assigned to one of six clusters which were randomized to the sequencing of crossover from the control to the intervention phases, as well as the duration of exposure in each phase. Children ≥2 months to <5 years presenting with acute illness were enrolled consecutively by Health Surveillance Assistants (HSAs). The primary outcome of urgent referrals to higher-level facilities was evaluated using multi-level mixed effects models. A logistic regression model with random effect of cluster and fixed effect for each step was fitted. Adjustment for potential confounders included baseline factors, such as patient’s age, sex, and geographical location of village clinics. Calendar time was adjusted for in the analysis. Results: A total of 6965 children were recruited, 3421 in the control and 3544 in the intervention phase. After adjusting for calendar time, children in the intervention phase were more likely to be urgently referred to a higher-level health facility compared with children in the control phase (OR 2.02, 95% CI 1.27-3.23; p 0.05). Conclusions: Addition of eCCM decision support led to a greater proportion of children being referred to higher-level facilities, with no apparent increase in hospital admissions or repeat consultations in village clinics. Our findings provide support for the implementation of eCCM tools in Malawi and other Low and Middle Income Countries (LMIC), with a need for ongoing assessment of effectiveness and integration with national digital health strategies. Trial Registration: ClinicalTrials.gov; NCT02763345. Registered 3 May 2016 Funding Statement: This work was supported by the European Union’s Seventh Framework Programme for research, technological development and demonstration (grant agreement no 305292). Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: Ethics approval and consent to participate: The study received ethical approval from the University of Washington Human Subjects Division in Seattle USA (#51750), Imperial College of London Research Ethics Committee (16IC3396) in London UK and the College of Medicine Research and Ethics Committee (COMREC) in Blantyre Malawi (P.07/16/1984). National and community-level permissions were also obtained prior to the conduct of this study. Consent for
Highlights
Malawi has one of the world’s lowest doctor-to-patient ratios [1], with ≤1 doctor per 50,000 people [2,3,4,5], which is considerably lower than the World Health Organization’s recommendation of 1 doctor per 5000 people
The addition of e-community case management (CCM) decision support by using smartphones led to a greater proportion of children being referred to higher-level facilities, with no apparent increase in hospital admissions or repeat consultations in village clinics
Our findings provide support for the implementation of electronic version of a smartphone-based CCM (e-CCM) tools in Malawi and other low- and middle-income countries with a need for ongoing assessments of effectiveness and integration with national digital health strategies
Summary
Malawi has one of the world’s lowest doctor-to-patient ratios [1], with ≤1 doctor per 50,000 people [2,3,4,5], which is considerably lower than the World Health Organization’s recommendation of 1 doctor per 5000 people. HSAs are allocated to hard-to-reach areas, each serving a population of approximately 1000 [7] They have several duties they are expected to carry out (eg, family planning, environmental health, and HIV counseling), of which community case management (CCM) is integral [8]. CCM uses simple signs and symptoms to help HSAs identify self-limiting conditions that can be managed in the community and more serious illnesses that require medical attention from clinically trained health personnel (eg, nurses) at higher-level health care facilities or hospitals. The introduction of this strategy has provided access to basic health care that many children would otherwise have been denied [10]. We determined the impact of an e-CCM app on the referral, reconsultation, and hospitalization rates of children presenting to village clinics in Malawi
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