Performance of Health Workers Using an Electronic Algorithm for the Management of Childhood Illness in Tanzania: A Pilot Implementation Study

Abstract

In low-resource settings, where qualified health workers (HWs) are scarce and childhood mortality high, rational antimicrobial prescription for childhood illnesses is a challenge. To assess whether smartphones running guidelines, as compared with paper support, improve consultation process and rational use of medicines for children, a pilot cluster-randomized controlled study was conducted in Tanzania. Nine primary health-care facilities (HFs) were randomized into three arms: 1) paper algorithm, 2) electronic algorithm on a smartphone, and 3) control. All HWs attending children aged 2-59 months for acute illness in intervention HFs were trained on a new clinical algorithm for management of childhood illness (ALMANACH) either on 1) paper or 2) electronic support; 4 months after training, consultations were observed. An expert consultation was the reference for classification and treatment. Main outcomes were proportion of children checked for danger signs, and antibiotics prescription rate. A total of 504 consultations (166, 171, and 167 in control, paper, and phone arms, respectively) were observed. The use of smartphones versus paper was associated with a significant increase in children checked for danger signs (41% versus 74%, P = 0.04). Antibiotic prescriptions rate dropped from 70% in the control to 26%, and 25% in paper and electronic arms. The HWs-expert agreement on pneumonia classification remained low (expert's pneumonia identified by HWs in 26%, 30%, and 39% of patients, respectively).Mobile technology in low-income countries is implementable and has a potential to improve HWs' performance. Additional point-of-care diagnostic tests are needed to ensure appropriate management. Improving the rational use of antimicrobial is a challenge that ALMANACH can help to take up.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

“…CURRENT MEDICAL RESEARCH AND OPINION 311 appreciable reduction in the number of medicines prescribed 337 . Mobile technologies with clinical algorithms can also improve the management of childhood illness leading to an appreciable reduction in antibiotic utilisation 338 . This is a potential approach for the future in LMICs given the wide use of mobile technologies across countries 339,340 .…”

Digital Technology and the Future of Health Systems

“…This can be in the form of checklists for routine care such as antenatal visits, decision support for diagnosis of illness, and video or graphic counseling messages from the provider directly to the client. Numerous studies have shown the advantage of using decision support, 10,11 video counseling, 12 and digital supervision strategies 13 to improve quality. Though many of these strategies are in their infancy, they are increasingly being adopted by countries as core components of their health strategies.…”

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

“…Similar structural barriers have been reported by HWs using mHealth interventions in other low-income settings, such as an IMCI-based software on tablets and smartphones in Tanzania, 36 even when results have shown improvements in case management. 37 Two of the lowest indicators at baseline that did not improve-measuring respiratory rate and dispensing the first dose of medications at the facility-are also two of the most time-consuming tasks. The Tanzania study that used an adapted IMCI algorithm on smartphones and tablets found that although respiratory rate measurements did improve significantly, HWs still only did these about half the time.…”

“…The Tanzania study that used an adapted IMCI algorithm on smartphones and tablets found that although respiratory rate measurements did improve significantly, HWs still only did these about half the time. 37 Respiratory rates have relatively poor sensitivity for predicting pneumonia, 38 and it is possible HWs did not think the extra time to do them was warranted. Directly observing the first dose of medications requires HW time at overcrowded HFs in Malawi (the median number of daily visits per OPD at baseline was 98); furthermore, HWs and patients in Malawi have previously been taught that AL should be given with food, milk, or a milk-containing drink, and some HWs might have been afraid to give AL if they thought a patient had not eaten.…”

“…mHealth interventions using tablets or smartphones with programmed clinical algorithms that more directly guide case management practices might be more effective and have shown promising results in similar settings. 37,39 Even more promising might be electronically programmed clinical algorithms that integrate additional point-of-care tests, which have shown improved child health outcomes than electronic algorithms alone. 40 Other alternative strategies to consider for improving HW performance include adding a small financial incentive to the text message intervention for participation, which resulted in good participation rates in an SMS-based drug stock reporting system in Tanzania, 41 and more systematic supervision to reinforce case-management practices, with or without text messages.…”