Abstract
BackgroundThere is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities. Integrating a digitized version of paper-based methods of Community Case Management (CCM) could strengthen delivery, increasing urgent referral rates and preventing unnecessary re-consultations and hospital admissions. This trial aims to evaluate the added value of the Supporting LIFE electronic Community Case Management Application (SL eCCM App) compared to paper-based CCM on urgent referral, re-consultation and hospitalization rates, in two districts in Northern Malawi.Methods/designThis is a pragmatic, stepped-wedge cluster-randomized trial assessing the added value of the SL eCCM App on urgent referral, re-consultation and hospitalization rates of children aged 2 months and older to up to 5 years, within 7 days of the index visit. One hundred and two health surveillance assistants (HSAs) were stratified into six clusters based on geographical location, and clusters randomized to the timing of crossover to the intervention using simple, computer-generated randomization. Training workshops were conducted prior to the control (paper-CCM) and intervention (paper-CCM + SL eCCM App) in assigned clusters. Neither participants nor study personnel were blinded to allocation. Outcome measures were determined by abstraction of clinical data from patient records 2 weeks after recruitment. A nested qualitative study explored perceptions of adherence to urgent referral recommendations and a cost evaluation determined the financial and time-related costs to caregivers of subsequent health care utilization. The trial was conducted between July 2016 and February 2017.DiscussionThis is the first large-scale trial evaluating the value of adding a mobile application of CCM to the assessment of children aged under 5 years. The trial will generate evidence on the potential use of mobile health for CCM in Malawi, and more widely in other low- and middle-income countries.Trial registrationClinicalTrials.gov, ID: NCT02763345. Registered on 3 May 2016.
Highlights
There is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities
The strategy was developed by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) to reduce the burden of morbidity and mortality from leading causes of disease among children aged under 5 years in low- and middle-income countries (LMICs) [1,2,3]
This trial will provide important data regarding the impact of digitizing Community Case Management (CCM) on health surveillance assistants (HSAs) urgent referral practices and factors influencing health service utilization in Malawi
Summary
There is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities. Integrating a digitized version of paper-based methods of Community Case Management (CCM) could strengthen delivery, increasing urgent referral rates and preventing unnecessary reconsultations and hospital admissions. Depending on the manifestation of “sick” and “danger” signs, which are recorded by hand in a village clinic register, children are given medicine or managed at home Those children who are severely unwell and outside the scope of CHWs’ practice [6] are urgently referred to the nearest higher-level health facility for more comprehensive clinical management (which can be primary- or secondary-care facilities including health centers, community/rural or district hospitals), with advice given to caregivers about the reason for the referral and the location of the nearest facility [7]
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