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Impact of digital clinical decision support on quality of care and antibiotic stewardship for children under five in South-Central Somalia
Abstract
In the context of protracted conflict, severe droughts and health system constraints, children under-five in Somalia face one of the highest mortality rates in the world. The WHO Integrated Management of Childhood Illness (IMCI) guidance targets the main causes of morbidity and mortality, but adherence is low. We implemented the ALgorithm for the MANAgement of CHildhood illness (ALMANACH), a digital clinical decision support system, with the aim of improving IMCI adherence whilst promoting antibiotic stewardship in South-Central Somalia. Alongside, we evaluated health service delivery and ALMANACH acceptability and impact to inform design and roll-out. A pre-post assessment involving direct observation of consultations with sick children (2–59 months) based on the Demographic and Health Surveys Service Provision Assessment, complemented by exit interviews with caregivers and feedback from healthcare staff and stakeholders. Over 600 consultations were observed in each assessment period, in seven health facilities. ALMANACH had a significant impact on antibiotic prescription (reduction from 58.1% pre- to 16.0% post-implementation). This was particularly pronounced among certain conditions such as upper respiratory tract infections (30-fold reduction, RR = 0.03). Large differences in guideline adherence were observed (danger signs: 1.3% pre- to 99% post-implementation; counselling on follow-up: 12% pre- to 94% post-; and Vitamin A supplementation need checked: 19.9% pre- to 96.1% post-implementation). ALMANACH was found to be acceptable to caregivers, healthcare providers and stakeholders, with reports of positive impact on perceived quality of care. Implementation of ALMANACH in primary healthcare in Somalia significantly improved quality of care and guideline adherence, supporting the use of ALMANACH and similar tools to improve healthcare in fragile and resource-constrained settings.
RESUMEN
En un contexto de conflicto prolongado, sequías severas, y limitaciones en el sistema de salud, los niños menores de 5 años en Somalia sufren una de las tasas de mortalidad más altas del mundo. La estrategia Atención Integrada a las Enfermedades Prevalentes de la Infancia (AIEPI) de la OMS incluye recomendaciones alrededor de las causas principales de morbilidad y mortalidad, pero la adherencia a esta guía es pobre. Implementamos el algoritmo para la gestión de enfermedades de la infancia ALMANACH (ALgorithm for the MANAgement of CHildhood illness), un sistema digital de apoyo para las decisiones clínicas, a fin de mejorar el cumplimiento de la AIEPI durante un esfuerzo de promoción de la correcta administración de antibióticos en el centro-sur de Somalia. De manera paralela, evaluamos la prestación de servicios de salud, y la aceptabilidad e impacto de ALMANACH, para informar su diseño y lanzamiento. Evaluación antes-después de la implementación del algoritmo, derivada de la observación directa de consultas médicas para niños enfermos (de 2 a 59 meses), basada en la Evaluación de Provisión de Servicios (SPA, por sus siglas en inglés) de DHS (Demographic and Health Surveys, Encuestas Demográficas y de Salud), complementada con encuestas de salida a los cuidadores, y retroalimentación del personal de salud y partes interesadas. Se observaron más de 600 consultas en cada periodo de evaluación, en 7 instalaciones de salud. ALMANACH mostró tener un impacto significativo en la prescripción de antibióticos (con una reducción de 58.1% antes de la implementación, a 16.0% después). Esto fue particularmente pronunciado con ciertas condiciones, como las infecciones de vías respiratorias superiores (ocurriendo 30 veces menos, RR = 0.03). Se observaron grandes cambios en la adherencia a las recomendaciones (atención a signos de peligro: de 1.3% antes de la implementación, a 99% después; orientación acerca del seguimiento: de 12%, antes, a 94% después; y prueba de necesidad de vitamina A suplementaria: de 19.9%, antes, a 96.1% después). El ALMANACH le resultó aceptable a los cuidadores, al personal de salud y a las partes interesadas, con reportes de impacto positivo en la calidad percibida del cuidado. La implementación de ALMANACH en la atención primaria de salud en Somalia resultó en una calidad de cuidados y adherencia a las recomendaciones significativamente mayores, favoreciendo el uso de ALMANACH y herramientas semejantes en el mejoramiento del cuidado de la salud en entornos frágiles y de recursos limitados.
RESUMO
No contexto de conflitos prolongados, secas graves e limitações do sistema de saúde, as crianças com menos de cinco anos na Somália enfrentam uma das taxas de mortalidade mais elevadas do mundo. As orientações da OMS sobre a Gestão Integrada das Doenças da Infância (GIDI) visam as principais causas de morbilidade e mortalidade, mas a adesão é baixa. Implementámos o ALgorithm for the MANAgement of CHildhood illness (ALMANACH), um sistema digital de apoio à decisão clínica, com o objetivo de melhorar a adesão à IMCI, promovendo simultaneamente a gestão de antibióticos no centro-sul da Somália. Paralelamente, avaliámos a prestação de serviços de saúde, e a aceitabilidade e o impacto do ALMANACH para informar a sua conceção e implementação. Uma pré/pós-avaliação que envolveu a observação direta de consultas com crianças doentes (2–59 meses) com base na Avaliação da Prestação de Serviços do DHS, complementada por entrevistas à saída com os prestadores de cuidados e feedback dos profissionais de saúde e das partes interessadas. Foram observadas mais de 600 consultas em cada período de avaliação, em 7 unidades de saúde. O ALMANACH teve um impacto significativo na prescrição de antibióticos (redução de 58,1% antes da implementação para 16,0% após a implementação). Este impacto foi particularmente pronunciado em determinadas doenças, como as infeções do trato respiratório superior (redução de 30 vezes, RR = 0,03). Foram observadas grandes diferenças na adesão às directrizes (sinais de perigo: 1,3% antes da implementação para 99% após a implementação; aconselhamento no seguimento: 12% antes para 94% depois; e necessidade de controlo da suplementação com vitamina A: 19,9% antes da implementação para 96,1% após a implementação. O ALMANACH foi considerado aceitável pelos cuidadores, prestadores de cuidados de saúde e partes interessadas, com relatos de um impacto positivo na perceção da qualidade dos cuidados. A implementação do ALMANACH nos cuidados de saúde primários na Somália melhorou significativamente a qualidade dos cuidados e a adesão às directrizes, apoiando a utilização do ALMANACH e de ferramentas semelhantes para melhorar os cuidados de saúde em contextos frágeis e com recursos limitados.
RÉSUMÉ
Dans le contexte d’un conflit prolongé, de graves sécheresses et de contraintes du système de santé, les enfants de moins de cinq ans en Somalie sont confrontés à l’un des taux de mortalité les plus élevés au monde. Les lignes directrices de l’OMS sur la prise en charge intégrée des maladies de l’enfant (PCIME) ciblent les principales causes de morbidité et de mortalité, mais leur observance est faible. Nous avons mis en œuvre ALgorithm for the MANAgement of CHildhood illness (ALMANACH), un système numérique d’aide à la décision clinique, dans le but d’améliorer l’observance à la PCIME tout en promouvant la gestion responsable des antibiotiques dans le centre-sud de la Somalie. Parallèlement, nous avons évalué la prestation de services de santé, ainsi que l’acceptabilité et l’impact d’ALMANACH pour éclairer la conception et le déploiement. Une évaluation pré-post impliquant l’observation directe des consultations des enfants malades (2–59 mois) basée sur l’Évaluation des prestations de services de l’EDS, complétée par des entretiens de sortie avec les soignants et les commentaires du personnel de santé et des parties prenantes. Plus de 600 consultations ont été observées au cours de chaque période d’évaluation, dans 7 formations sanitaires. ALMANACH a eu un impact significatif sur la prescription d’antibiotiques (réduction de 58,1% avant la mise en œuvre à 16,0% après la mise en œuvre). Cela était particulièrement prononcé dans certaines affections telles que les infections des voies respiratoires supérieures (réduction de 30 fois, RR = 0,03). De grandes différences dans le respect des lignes directrices ont été observées (signes de danger: 1,3% avant à 99% après la mise en œuvre; conseils sur le suivi: 12% avant à 94% après la mise en œuvre; et vérification du besoin de supplémentation en vitamine A: 19,9% avant 96,1% après la mise en œuvre). ALMANACH s’est avéré acceptable pour les soignants, les prestataires de soins de santé et les parties prenantes, avec des rapports faisant état d’un impact positif sur la qualité perçue des soins. La mise en œuvre d’ALMANACH dans les soins de santé primaires en Somalie a considérablement amélioré la qualité des soins et le respect des lignes directrices, encourageant l’utilisation d’ALMANACH et d’outils similaires pour améliorer les soins de santé dans des contextes fragiles et aux ressources limitées.
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Background
Globally, pneumonia is the leading infectious cause of under-five mortality, and this can be reduced by prompt healthcare seeking. Data on factors associated with delays in seeking care for children with pneumonia in Uganda is scarce.
Objectives
The study aimed to determine the prevalence, factors associated with delay, barriers, and facilitators of prompt healthcare seeking for children under five years of age with severe pneumonia attending Mulago National Referral Hospital (MNRH) Uganda.
Methods
A mixed methods cross-sectional study was conducted among 384 caregivers of children with severe pneumonia at MNRH. Quantitative data was collected using interviewer-administered structured questionnaires and qualitative data through focus group discussions with caregivers. Descriptive statistics were used to determine the prevalence of delay in care seeking. Logistic regression analysis was used to determine the factors that were independently associated with delay in seeking healthcare. Content thematic analysis was used to analyze for barriers and facilitators of prompt healthcare seeking.
Results
The prevalence of delay in seeking healthcare was 53.6% (95% CI: 48.6–58.6). Long distance to a hospital (AOR = 1.94, 95% CI 1.22–3.01, p value = 0.003), first seeking care elsewhere (AOR = 3.33, 95% CI 1.85–6.01, p value = 0.001), and monthly income ≤100,000 UGX (28 USD) (AOR = 2.27,95% CI 1.33–3.86, p value = 0.003) were independently associated with delay in seeking healthcare. Limited knowledge of symptoms, delayed referrals, self-medication, and low level of education were barriers to prompt healthcare seeking while recognition of symptoms of severe illness in the child, support from spouses, and availability of money for transport were key facilitators of early healthcare seeking.
Conclusion
This study showed that more than half of the caregivers delayed seeking healthcare for their children with pneumonia symptoms. Caregivers who first sought care elsewhere, lived more than 5 km from the hospital, and earned less than 28 USD per month were more likely to delay seeking healthcare for their children with severe pneumonia. Limited knowledge of symptoms of pneumonia, self-medication, and delayed referral hindered prompt care-seeking. Key facilitators of prompt care-seeking were accessibility to health workers, support from spouses, and recognition of symptoms of severe illness in children. There is a need for programs that educate caregivers about pneumonia symptoms, in children less than five years.
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.
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.
In 2015, we conducted a randomized controlled trial (RCT) in primary care to evaluate if posters and pamphlets dispensed in general practice waiting rooms enhanced vaccination uptake for seasonal influenza. Unexpectedly, vaccination uptake rose in both arms of the RCT whereas public health data indicated a decrease. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear if stated. Our objectives were to refine a definition of the HE for primary care, to evaluate its size, and to draw consequences for primary care research. We designed a Preferred Reporting Items for Systematic reviews and Meta-Analyses review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analyzed to evaluate odds ratios (ORs) in primary care. The search led to 180 records, reduced on review to 74 for definition and 15 for quantification. Our definition of HE is “an aware or unconscious complex behavior change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias.” Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect, and regression to the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: [1.13; 1.75]; I2 = 97%), but the significance of the HE disappears in well-designed studies. We conclude that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research, but its size can considerably be reduced by refining study designs.
Background: In contrast to most developed countries, antimicrobial resistance (AMR) has continued to be a serious challenge to public health in the majority of resource-limited countries in Africa. Materials and method: A comprehensive review of all available literature reporting on antimicrobial resistance patterns, antimicrobial drug usage in both human and animals, as well as national AMR regulations in Somalia was undertaken. Results: The review observed that successful AMR control and surveillance among resource-poor nations are affected by a lack of infrastructural and institutional capacities, poor investment in human and material resources, as well as non-adherence to available policies. The humanitarian crisis affecting Somalia has persisted for too long, leading to loss of lives, productivity and dilapidation of public health infrastructures. Somalia like most countries has adopted the One Health approach in developing their soon-to-be gazetted National Action Plan on AMR, which covers both human health, animal health and the environment. Although
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.
Background
The Integrated eDiagnosis Approach (IeDA), centred on an electronic Clinical Decision Support System (eCDSS) developed in line with national Integrated Management of Childhood Illness (IMCI) guidelines, was implemented in primary health facilities of two regions of Burkina Faso. An evaluation was performed using a stepped-wedge cluster randomised design with the aim of determining whether the IeDA intervention increased Health Care Workers’ (HCW) adherence to the IMCI guidelines.
Methods
Ten randomly selected facilities per district were visited at each step by two trained nurses: One observed under-five consultations and the second conducted a repeat consultation. The primary outcomes were: overall adherence to clinical assessment tasks; overall correct classification ignoring the severity of the classifications; and overall correct prescription according to HCWs’ classifications. Statistical comparisons between trial arms were performed on cluster/step-level summaries.
Results
On average, 54 and 79% of clinical assessment tasks were observed to be completed by HCWs in the control and intervention districts respectively (cluster-level mean difference = 29.9%; P -value = 0.002). The proportion of children for whom the validation nurses and the HCWs recorded the same classifications (ignoring the severity) was 73 and 79% in the control and intervention districts respectively (cluster-level mean difference = 10.1%; P -value = 0.004). The proportion of children who received correct prescriptions in accordance with HCWs’ classifications were similar across arms, 78% in the control arm and 77% in the intervention arm (cluster-level mean difference = − 1.1%; P -value = 0.788).
Conclusion
The IeDA intervention improved substantially HCWs’ adherence to IMCI’s clinical assessment tasks, leading to some overall increase in correct classifications but to no overall improvement in correct prescriptions. The largest improvements tended to be observed for less common conditions. For more common conditions, HCWs in the control districts performed relatively well, thus limiting the scope to detect an overall impact.
Trial registration
ClinicalTrials.gov NCT02341469 ; First submitted August 272,014, posted January 19, 2015.
Objectives:
The objective of this study was to address the knowledge gap regarding antibiotic use in Medecins Sans Frontiéres (MSF) projects located in Africa by exploring antibiotic prescription and consumption habits and their drivers at different healthcare levels.
Design:
This study used an exploratory study design through thematic analysis of semistructured, in-depth interviews, focus group discussions (FGDs) and field observations in order to understand the main drivers influencing current antibiotics prescription habits and consumption habits of patients in different geographical settings.
Setting:
The study took place in MSF centres and towns across four countries: Guinea-Bissau, Central African Republic (CAR), Democratic Republic of Congo (DRC) and Sudan.
Participants:
384 respondents participated in the study, which includes project staff, prescribers, community members, patients, among other groups.
Results:
Treatment protocols were physically present in all countries except DRC, but compliance to protocols varied across contexts. A failing health system and barriers to accessing healthcare were perceived as major drivers of overuse and inconsistent prescription practices. Patient demands influenced prescription decisions, and self-medication was commonly reported in the context of failing health systems. Additionally, there was a strong demand for quick cures and communities preferred injections over pills. Patients tended to stop antibiotic treatment once symptoms abated and had major gaps in understanding antibiotic intake instructions and functions.
Conclusions:
While there were specific findings in each context, the larger trend from these four MSF projects in Africa indicates widespread use of antibiotics based on unclear assumptions, which are often influenced by patient demands. There needs to be a broader focus on the balance between access and excess, especially in such fragile contexts where access to healthcare is a real challenge.
Background:
Integrated Management of Childhood Illnesses (IMCI) is a strategy developed by the World Health Organization (WHO) and UNICEF in 1992. It was deployed as an integrated approach to improve children's health in the world. This strategy is divided into three components: organizational, clinical, and communitarian. If the Integrated Management of Childhood Illnesses implementation-related factors in low- and middle-income countries are known, the likelihood of decreasing infant morbidity and mortality rates could be increased. This work aimed to identify, from the clinical component of the strategy, the implementation-related factors to Integrated Management of Childhood Illnesses at 18 Colombian cities.
Methods:
A quantitative cross-sectional study was performed with a secondary analysis of databases of a study conducted in Colombia by the Public Health group of Universidad de Los Andes in 2016. An Integrated Care Index was calculated as a dependent variable and descriptive bivariate and multivariate analyses to find the relationship between this index and the relevant variables from literature.
Results:
Information was obtained from 165 medical appointments made by nurses, general practitioners, and pediatricians. Health access is given mainly in the urban area, in the first level care and outpatient context. Essential medicines availability, necessary supplies, second-level care, medical appointment periods longer than 30 min, and care to the child under 30 months are often related to higher rates of Integrated Care Index.
Conclusion:
Health care provided to children under five remains incomplete because it does not present the basic minimums for the adequate IMCI's implementation in the country. It is necessary to provide integrated care that provides medicine availability and essential supplies that reduce access barriers and improve the system's fragmentation.
Introduction:
Several studies suggest increasing rates of antibiotic resistance among adult populations with Urinary tract infections (UTI). Escherichia coli (E. coli), is the predominant bacterium both in the community and in hospital environments causing uropathogenic infections. This study aimed to estimate the common uropathogen bacteria that cause UTI among outpatients as well as to determine the antibiotic resistance pattern of E. coli isolates among outpatients with UTI infections at Shaafi hospital, Mogadishu, Somalia.
Methodology:
A cross-sectional study was conducted at Shaafi Hospital, Mogadishu, Somalia. A total of 128 samples were collected from outpatients suspected of UTI and tested through bacteriological investigations and antimicrobial susceptibility tests following the Kirby-Bauer agar disc diffusion method.
Results:
E. coli was isolated in 34 (41%) out of the total 83 samples that showed growth followed by Staphylococcus aureus 22 (26.5%), Pseudomonas aeruginosa, 13 (15.7%), Klebsiella pneumoniae 8 (9.6 %) and Proteus spp. 6 (7.2%). E. coli was highly sensitive to nitrofurantoin, 29 (85.3%), and ciprofloxacin (n = 23, 67.6%), and had the highest resistance rate of ceftriaxone, 33 (97.1%). The odds of having UTI were higher in patients with a history of UTI (Odds ratio OR = 0.211, 95% confidence interval CI: 0.080, 0.553) and history of antibiotic use (OR = 0.322, 95% CI: 0.113, 0.917). Increased resistance rate of E. coli against cephalosporins could be due to its excessive use as empirical therapy.
Conclusion:
The study indicates that outpatients with UTI could be at high risk of antibiotic resistance, suggesting regular surveillance and monitoring of antibiotics.
Background:
Mobile health (mHealth), refers to healthcare practices supported by mobile devices, such as mobile phones and tablets. Within primary care, health workers often use mobile devices to register clients, track their health, and make decisions about care, as well as to communicate with clients and other health workers. An understanding of how health workers relate to, and experience mHealth, can help in its implementation.
Objectives:
To synthesise qualitative research evidence on health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services, and to develop hypotheses about why some technologies are more effective than others.
Search methods:
We searched MEDLINE, Embase, CINAHL, Science Citation Index and Social Sciences Citation Index in January 2018. We searched Global Health in December 2015. We screened the reference lists of included studies and key references and searched seven sources for grey literature (16 February to 5 March 2018). We re-ran the search strategies in February 2020. We screened these records and any studies that we identified as potentially relevant are awaiting classification.
Selection criteria:
We included studies that used qualitative data collection and analysis methods. We included studies of mHealth programmes that were part of primary healthcare services. These services could be implemented in public or private primary healthcare facilities, community and workplace, or the homes of clients. We included all categories of health workers, as well as those persons who supported the delivery and management of the mHealth programmes. We excluded participants identified as technical staff who developed and maintained the mHealth technology, without otherwise being involved in the programme delivery. We included studies conducted in any country.
Data collection and analysis:
We assessed abstracts, titles and full-text papers according to the inclusion criteria. We found 53 studies that met the inclusion criteria and sampled 43 of these for our analysis. For the 43 sampled studies, we extracted information, such as country, health worker category, and the mHealth technology. We used a thematic analysis process. We used GRADE-CERQual to assess our confidence in the findings.
Main results:
Most of the 43 included sample studies were from low- or middle-income countries. In many of the studies, the mobile devices had decision support software loaded onto them, which showed the steps the health workers had to follow when they provided health care. Other uses included in-person and/or text message communication, and recording clients' health information. Almost half of the studies looked at health workers' use of mobile devices for mother, child, and newborn health. We have moderate or high confidence in the following findings. mHealth changed how health workers worked with each other: health workers appreciated being more connected to colleagues, and thought that this improved co-ordination and quality of care. However, some described problems when senior colleagues did not respond or responded in anger. Some preferred face-to-face connection with colleagues. Some believed that mHealth improved their reporting, while others compared it to "big brother watching". mHealth changed how health workers delivered care: health workers appreciated how mHealth let them take on new tasks, work flexibly, and reach clients in difficult-to-reach areas. They appreciated mHealth when it improved feedback, speed and workflow, but not when it was slow or time consuming. Some health workers found decision support software useful; others thought it threatened their clinical skills. Most health workers saw mHealth as better than paper, but some preferred paper. Some health workers saw mHealth as creating more work. mHealth led to new forms of engagement and relationships with clients and communities: health workers felt that communicating with clients by mobile phone improved care and their relationships with clients, but felt that some clients needed face-to-face contact. Health workers were aware of the importance of protecting confidential client information when using mobile devices. Some health workers did not mind being contacted by clients outside working hours, while others wanted boundaries. Health workers described how some community members trusted health workers that used mHealth while others were sceptical. Health workers pointed to problems when clients needed to own their own phones. Health workers' use and perceptions of mHealth could be influenced by factors tied to costs, the health worker, the technology, the health system and society, poor network access, and poor access to electricity: some health workers did not mind covering extra costs. Others complained that phone credit was not delivered on time. Health workers who were accustomed to using mobile phones were sometimes more positive towards mHealth. Others with less experience, were sometimes embarrassed about making mistakes in front of clients or worried about job security. Health workers wanted training, technical support, user-friendly devices, and systems that were integrated into existing electronic health systems. The main challenges health workers experienced were poor network connections, access to electricity, and the cost of recharging phones. Other problems included damaged phones. Factors outside the health system also influenced how health workers experienced mHealth, including language, gender, and poverty issues. Health workers felt that their commitment to clients helped them cope with these challenges.
Authors' conclusions:
Our findings propose a nuanced view about mHealth programmes. The complexities of healthcare delivery and human interactions defy simplistic conclusions on how health workers will perceive and experience their use of mHealth. Perceptions reflect the interplay between the technology, contexts, and human attributes. Detailed descriptions of the programme, implementation processes and contexts, alongside effectiveness studies, will help to unravel this interplay to formulate hypotheses regarding the effectiveness of mHealth.
Background
In 2017, the Adamawa State Primary Healthcare Development Agency introduced ALMANACH, an electronic clinical decision support system based on a modified version of IMCI. The target area was the Federal State of Adamawa (Nigeria), a region recovering after the Boko Haram insurgency. The aim of this implementation research was to assess the improvement in terms of quality care offered after one year of utilization of the tool.
Methods
We carried out two cross-sectional studies in six Primary Health Care Centres to assess the improvements in comparison with the baseline carried out before the implementation. One survey was carried out inside the consultation room and was based on the direct observation of 235 consultations of children aged from 2 to 59 months old. The second survey questioned 189 caregivers outside the health facility for their opinion about the consultation carried out through using the tablet, the prescriptions and medications given.
Results
In comparison with the baseline, more children were checked for danger signs (60.0% vs. 37.1% at baseline) and in addition, children were actually weighed (61.1% vs. 27.7%) during consultation. Malnutrition screening was performed in 35.1% of children (vs. 12.1%). Through ALMANACH, also performance of preventive measures was significantly improved (p<0.01): vaccination status was checked in 39.8% of cases (vs. 10.6% at baseline), and deworming and vitamin A prescription was increased to 46.5% (vs. 0.7%) and 48.3% (vs. 2.8%) respectively. Furthermore, children received a complete physical examination (58.3% vs. 45.5%, p<0.01) and correct treatment (48.4% vs. 29.5%, p<0.01). Regarding antibiotic prescription, 69.3% patients received at least one antibiotic (baseline 77.7%, p<0.05).
Conclusions
Our findings highlight major improvements in terms of quality of care despite many questions still pending to be answered in relation to a full integration of the tool in the Adamawa health system.
Purpose of Review
The purpose of this article is to perform a systematic review over the past 5 years on the role and effectiveness of clinical decision support systems (CDSSs) on antibiotic stewardship.
Recent Findings
CDDS interventions found a significant impact on multiple outcomes relevant to antibiotic stewardship. There are various types of CDSS implementations, both active and passive (provider initiated). Passive interventions were associated with more significant outcomes; however, both interventions appeared effective. In the reviewed literature, CDSSs were consistently associated with decreasing antibiotic consumption and narrowing the spectrum of antibiotic usage. Generally, guideline adherence was improved with CDSS, although this was not universal. The effect on other outcomes, such as mortality, Clostridiodes difficile infections, length of stay, and cost, inconsistently showed a significant difference.
Summary
Overall, CDDS implementation has effectively decreased antibiotic consumption and improved guideline adherence across the various types of CDSS. Other positive outcomes were noted in certain settings, but were not universal. When creating a new intervention, it is important to identify the optimal structure and deployment of a CDSS for a specific setting.
Background
Quality of care is a difficult parameter to measure. With the introduction of digital algorithms based on the Integrated Management of Childhood Illness (IMCI), we are interested to understand if the adherence to the guidelines improved for a better quality of care for children under 5 years old.
Methods
More than one year after the introduction of digital algorithms, we carried out two cross sectional studies to assess the improvements in comparison with the situation prior to the implementation of the project, in two Basic Health Centres in Kabul province. One survey was carried out inside the consultation room and was based on the direct observation of 181 consultations of children aged 2 months to 5 years old, using a checklist completed by a senior physicians. The second survey queried 181 caretakers of children outside the health facility for their opinion about the consultation carried out through the tablet and prescriptions and medications given.
Results
We measured the quality of care as adherence to the IMCI’s guidelines. The study evaluated the quality of the physical examination and the therapies prescribed with a special attention to antibiotic prescription. We noticed a dramatic improvement (p<0.05) of several indicators following the introduction of digital algorithms. The baseline physical examination was appropriate only for 23.8% [IC% 19.9–28.1] of the patients, 34.5% [IC% 30.0–39.2] received a correct treatment and 86.1% [IC% 82.4–89.2] received at least one antibiotic. With the introduction of digital algorithms, these indicators statistically improved respectively to 84.0% [IC% 77.9–88.6], >85% and less than 30%.
Conclusions
Our findings suggest that digital algorithms improve quality of care by applying the guidelines more effectively. Our experience should encourage to test this tool in different settings and to scale up its use at province/state level.
Background:
Integrated Management of Childhood Illness (IMCI) is regarded as a standard public health approach to lowering child mortality in developing countries. However, little is known about how health workers adhere to the guidelines at the national level in sub-Saharan African countries.
Methods:
Data from the Service Provision Assessment surveys of Namibia (NA) (survey year: 2009), Kenya (KE) (2010), Tanzania (TZ) (2006) and Uganda (UG) (2007) were analysed for adherence to the IMCI guidelines by health workers. Potential influencing factors included the survey country, patient's age, the different levels of the national health system, the training level of the health care provider (physician, non-physician clinician, nurse-midwife, auxiliary staff), and the status of re-training in IMCI.
Results:
In total, 6856 children (NA: 1495; KE: 1890; TZ: 2469; UG: 1002 / male 51.2-53.5%) aged 2-73 months (2-24 months, 65.3%; median NA: 19 months; KE: 18 months; TZ: 16 months; UG: 15 months) were clinically assessed by 2006 health workers during the surveys. Less than 33% of the workers carried out assessment of all three IMCI danger signs, namely inability to eat/drink, vomiting everything, and febrile convulsions (NA: 11%; KE: 11%; TZ: 14%; UG: 31%) while the rate for assessing all three of the IMCI main symptoms of cough/difficult breathing, diarrhoea, and fever was < 60% (NA: 48%; KE: 34%; TZ: 50%; UG: 57%). Physical examination rates for fever (temperature) (NA: 97%; KE: 87%; TZ: 73%; UG: 90%), pneumonia (respiration rate/auscultation) (NA: 43%; KE: 24%; TZ: 25%; UG: 20%) and diarrhoea (dehydration status) (NA: 29%; KE: 19%; TZ: 20%; UG: 39%) varied widely and were highest when assessing children with the actual diagnosis of pneumonia and diarrhoea. Adherence rates tended to be higher in children ≤ 24 months, at hospitals, among higher-qualified staff (physician/non-physician clinician) and among those with recent IMCI re-training.
Conclusion:
Despite nationwide training in IMCI the adherence rates for assessment and physical examination remained low in all four countries. IMCI training should continue to be provided to all health staff, particularly nurses, midwives, and auxiliary staff, with periodic re-training and an emphasis to equally target children of all age groups.
Background
The management of childhood infections remains inadequate in resource-limited countries, resulting in high mortality and irrational use of antimicrobials. Current disease management tools, such as the Integrated Management of Childhood Illness (IMCI) algorithm, rely solely on clinical signs and have not made use of available point-of-care tests (POCTs) that can help to identify children with severe infections and children in need of antibiotic treatment. e-POCT is a novel electronic algorithm based on current evidence; it guides clinicians through the entire consultation and recommends treatment based on a few clinical signs and POCT results, some performed in all patients (malaria rapid diagnostic test, hemoglobin, oximeter) and others in selected subgroups only (C-reactive protein, procalcitonin, glucometer). The objective of this trial was to determine whether the clinical outcome of febrile children managed by the e-POCT tool was non-inferior to that of febrile children managed by a validated electronic algorithm derived from IMCI (ALMANACH), while reducing the proportion with antibiotic prescription.
Methods and findings
We performed a randomized (at patient level, blocks of 4), controlled non-inferiority study among children aged 2–59 months presenting with acute febrile illness to 9 outpatient clinics in Dar es Salaam, Tanzania. In parallel, routine care was documented in 2 health centers. The primary outcome was the proportion of clinical failures (development of severe symptoms, clinical pneumonia on/after day 3, or persistent symptoms at day 7) by day 7 of follow-up. Non-inferiority would be declared if the proportion of clinical failures with e-POCT was no worse than the proportion of clinical failures with ALMANACH, within statistical variability, by a margin of 3%. The secondary outcomes included the proportion with antibiotics prescribed on day 0, primary referrals, and severe adverse events by day 30 (secondary hospitalizations and deaths). We enrolled 3,192 patients between December 2014 and February 2016 into the randomized study; 3,169 patients (e-POCT: 1,586; control [ALMANACH]: 1,583) completed the intervention and day 7 follow-up. Using e-POCT, in the per-protocol population, the absolute proportion of clinical failures was 2.3% (37/1,586), as compared with 4.1% (65/1,583) in the ALMANACH arm (risk difference of clinical failure −1.7, 95% CI −3.0, −0.5), meeting the prespecified criterion for non-inferiority. In a non-prespecified superiority analysis, we observed a 43% reduction in the relative risk of clinical failure when using e-POCT compared to ALMANACH (risk ratio [RR] 0.57, 95% CI 0.38, 0.85, p = 0.005). The proportion of severe adverse events was 0.6% in the e-POCT arm compared with 1.5% in the ALMANACH arm (RR 0.42, 95% CI 0.20, 0.87, p = 0.02). The proportion of antibiotic prescriptions was substantially lower, 11.5% compared to 29.7% (RR 0.39, 95% CI 0.33, 0.45, p < 0.001). Using e-POCT, the most common indication for antibiotic prescription was severe disease (57%, 103/182 prescriptions), while it was non-severe respiratory infections using the control algorithm (ALMANACH) (70%, 330/470 prescriptions). The proportion of clinical failures among the 544 children in the routine care cohort was 4.6% (25/544); 94.9% (516/544) of patients received antibiotics on day 0, and 1.1% (6/544) experienced severe adverse events. e-POCT achieved a 49% reduction in the relative risk of clinical failure compared to routine care (RR 0.51, 95% CI 0.31, 0.84, p = 0.007) and lowered antibiotic prescriptions to 11.5% from 94.9% (p < 0.001). Though this safety study was an important first step to evaluate e-POCT, its true utility should be evaluated through future implementation studies since adherence to the algorithm will be an important factor in making use of e-POCT’s advantages in terms of clinical outcome and antibiotic prescription.
Conclusions
e-POCT, an innovative electronic algorithm using host biomarker POCTs, including C-reactive protein and procalcitonin, has the potential to improve the clinical outcome of children with febrile illnesses while reducing antibiotic use through improved identification of children with severe infections, and better targeting of children in need of antibiotic prescription.
Trial registration
ClinicalTrials.gov NCT02225769
Objectives
To determine the extent of provider communication, predictors of good communication and the association between provider communication and patient outcomes, such as patient satisfaction, in seven sub-Saharan African countries.
Design
Cross-sectional, multicountry study.
Setting
Data from recent Service Provision Assessment (SPA) surveys from seven countries in sub-Saharan Africa. SPA surveys include assessment of facility inputs and processes as well as interviews with caretakers of sick children. These data included 3898 facilities and 4627 providers.
Participants
16 352 caregivers visiting the facility for their sick children.
Primary and secondary outcome measures
We developed an index of four recommended provider communication items for a sick child assessment based on WHO guidelines. We assessed potential predictors of provider communication and considered whether better provider communication was associated with intent to return to the facility for care.
Results
The average score of the composite indicator of provider communication was low, at 35% (SD 26.9). Fifty-four per cent of caregivers reported that they were told the child’s diagnosis, and only 10% reported that they were counselled on feeding for the child. Caregivers’ educational attainment and provider preservice education and training in integrated management of childhood illness were associated with better communication. Private facilities and facilities with better infrastructure received higher communication scores. Caretakers reporting better communication were significantly more likely to state intent to return to the facility (relative risk: 1.19, 95% CI 1.16 to 1.22).
Conclusions
There are major deficiencies in communication during sick child visits. These are associated with lower provider education as well as less well-equipped facilities. Poor communication, in turn, is linked to lower satisfaction and intention to return to facility among caregivers of sick children. Countries should test strategies for enhancing quality of communication in their efforts to improve health outcomes and patient experience.
Background:
More than 7.5 million children younger than age five living in low- and middle-income countries die every year. The World Health Organization (WHO) developed the integrated management of childhood illness (IMCI) strategy to reduce mortality and morbidity and to improve quality of care by improving the delivery of a variety of curative and preventive medical and behavioral interventions at health facilities, at home, and in the community.
Objectives:
To evaluate the effects of programs that implement the IMCI strategy in terms of death, nutritional status, quality of care, coverage with IMCI deliverables, and satisfaction of beneficiaries.
Search methods:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE; EMBASE, Ovid; the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EbscoHost; the Latin American Caribbean Health Sciences Literature (LILACS), Virtual Health Library (VHL); the WHO Library & Information Networks for Knowledge Database (WHOLIS); the Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Science; Population Information Online (POPLINE); the WHO International Clinical Trials Registry Platform (WHO ICTRP); and the Global Health, Ovid and Health Management, ProQuest database. We performed searches until 30 June 2015 and supplemented these by searching revised bibliographies and by contacting experts to identify ongoing and unpublished studies.
Selection criteria:
We sought to include randomised controlled trials (RCTs) and controlled before-after (CBA) studies with at least two intervention and two control sites evaluating the generic IMCI strategy or its adaptation in children younger than age five, and including at minimum efforts to improve health care worker skills for case management. We excluded studies in which IMCI was accompanied by other interventions including conditional cash transfers, food supplementation, and employment. The comparison group received usual health services without provision of IMCI.
Data collection and analysis:
Two review authors independently screened searches, selected trials, and extracted, analysed and tabulated data. We used inverse variance for cluster trials and an intracluster co-efficient of 0.01 when adjustment had not been made in the primary study. We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach to assess the certainty of evidence.
Main results:
Two cluster-randomised trials (India and Bangladesh) and two controlled before-after studies (Tanzania and India) met our inclusion criteria. Strategies included training of health care staff, management strengthening of health care systems (all four studies), and home visiting (two studies). The two studies from India included care packages targeting the neonatal period.One trial in Bangladesh estimated that child mortality may be 13% lower with IMCI, but the confidence interval (CI) included no effect (risk ratio (RR) 0.87, 95% CI 0.68 to 1.10; 5090 participants; low-certainty evidence). One CBA study in Tanzania gave almost identical estimates (RR 0.87, 95% CI 0.72 to 1.05; 1932 participants).One trial in India examined infant and neonatal mortality by implementing the integrated management of neonatal and childhood illness (IMNCI) strategy including post-natal home visits. Neonatal and infant mortality may be lower in the IMNCI group compared with the control group (infant mortality hazard ratio (HR) 0.85, 95% CI 0.77 to 0.94; neonatal mortality HR 0.91, 95% CI 0.80 to 1.03; one trial, 60,480 participants; low-certainty evidence).We estimated the effect of IMCI on any mortality measured by combining infant and child mortality in the one IMCI and the one IMNCI trial. Mortality may be reduced by IMCI (RR 0.85, 95% CI 0.78 to 0.93; two trials, 65,570 participants; low-certainty evidence).Two trials (India, Bangladesh) evaluated nutritional status and noted that there may be little or no effect on stunting (RR 0.94, 95% CI 0.84 to 1.06; 5242 participants, two trials; low-certainty evidence) and there is probably little or no effect on wasting (RR 1.04, 95% CI 0.87 to 1.25; two trials, 4288 participants; moderate-certainty evidence).The Tanzania CBA study showed similar results.Investigators measured quality of care by observing prescribing for common illnesses at health facilities (727 observations, two studies; very low-certainty evidence) and by observing prescribing by lay health care workers (1051 observations, three studies; very low-certainty evidence). We could not confirm a consistent effect on prescribing at health facilities or by lay health care workers, as certainty of the evidence was very low.For coverage of IMCI deliverables, we examined vaccine and vitamin A coverage, appropriate care seeking, and exclusive breast feeding. Two trials (India, Bangladesh) estimated vaccine coverage for measles and reported that there is probably little or no effect on measles vaccine coverage (RR 0.92, 95% CI 0.80 to 1.05; two trials, 4895 participants; moderate-certainty evidence), with similar effects seen in the Tanzania CBA study. Two studies measured the third dose of diphtheria, pertussis, and tetanus vaccine; and two measured vitamin A coverage, all providing little or no evidence of increased coverage with IMCI.Four studies (2 from India, and 1 each from Tanzania and Bangladesh) reported appropriate care seeking and derived information from careful questioning of mothers about recent illness. Some studies on effects of IMCI may report better care seeking behavior, but others do not report this.All four studies recorded maternal responses on exclusive breast feeding. They provided mixed results and very low-certainty evidence. Therefore, we do not know whether IMCI impacts exclusive breast feeding.No studies reported on the satisfaction of mothers and service users.
Authors' conclusions:
The mix of interventions examined in research studies evaluating the IMCI strategy varies, and some studies include specific inputs to improve neonatal health. Most studies were conducted in South Asia. Implementing the integrated management of childhood illness strategy may reduce child mortality, and packages that include interventions for the neonatal period may reduce infant mortality. IMCI may have little or no effect on nutritional status and probably has little or no effect on vaccine coverage. Maternal care seeking behavior may be more appropriate with IMCI, but study results have been mixed, providing evidence of very low certainty about whether IMCI has effects on adherence to exclusive breast feeding.
The decline of malaria and scale-up of rapid diagnostic tests calls for a revision of IMCI. A new algorithm (ALMANACH) running on mobile technology was developed based on the latest evidence. The objective was to ensure that ALMANACH was safe, while keeping a low rate of antibiotic prescription.
Consecutive children aged 2-59 months with acute illness were managed using ALMANACH (2 intervention facilities), or standard practice (2 control facilities) in Tanzania. Primary outcomes were proportion of children cured at day 7 and who received antibiotics on day 0.
130/842 (15∙4%) in ALMANACH and 241/623 (38∙7%) in control arm were diagnosed with an infection in need for antibiotic, while 3∙8% and 9∙6% had malaria. 815/838 (97∙3%;96∙1-98.4%) were cured at D7 using ALMANACH versus 573/623 (92∙0%;89∙8-94∙1%) using standard practice (p<0∙001). Of 23 children not cured at D7 using ALMANACH, 44% had skin problems, 30% pneumonia, 26% upper respiratory infection and 13% likely viral infection at D0. Secondary hospitalization occurred for one child using ALMANACH and one who eventually died using standard practice. At D0, antibiotics were prescribed to 15∙4% (12∙9-17∙9%) using ALMANACH versus 84∙3% (81∙4-87∙1%) using standard practice (p<0∙001). 2∙3% (1∙3-3.3) versus 3∙2% (1∙8-4∙6%) received an antibiotic secondarily.
Management of children using ALMANACH improve clinical outcome and reduce antibiotic prescription by 80%. This was achieved through more accurate diagnoses and hence better identification of children in need of antibiotic treatment or not. The building on mobile technology allows easy access and rapid update of the decision chart.
Pan African Clinical Trials Registry PACTR201011000262218.
To review the available knowledge on epidemiology and diagnoses of acute infections in children aged 2 to 59 months in primary care setting and develop an electronic algorithm for the Integrated Management of Childhood Illness to reach optimal clinical outcome and rational use of medicines.
A structured literature review in Medline, Embase and the Cochrane Database of Systematic Review (CDRS) looked for available estimations of diseases prevalence in outpatients aged 2-59 months, and for available evidence on i) accuracy of clinical predictors, and ii) performance of point-of-care tests for targeted diseases. A new algorithm for the management of childhood illness (ALMANACH) was designed based on evidence retrieved and results of a study on etiologies of fever in Tanzanian children outpatients.
The major changes in ALMANACH compared to IMCI (2008 version) are the following: i) assessment of 10 danger signs, ii) classification of non-severe children into febrile and non-febrile illness, the latter receiving no antibiotics, iii) classification of pneumonia based on a respiratory rate threshold of 50 assessed twice for febrile children 12-59 months; iv) malaria rapid diagnostic test performed for all febrile children. In the absence of identified source of fever at the end of the assessment, v) urine dipstick performed for febrile children <2years to consider urinary tract infection, vi) classification of 'possible typhoid' for febrile children >2 years with abdominal tenderness; and lastly vii) classification of 'likely viral infection' in case of negative results.
This smartphone-run algorithm based on new evidence and two point-of-care tests should improve the quality of care of <5 year children and lead to more rational use of antimicrobials.
This paper outlines some of the key political and socio-economic drivers to instability in Somalia and the challenges faced in delivering healthcare in a country where neither economic support nor stability of the healthcare workforce can be assured. We will describe the scope of international assistance and explore key priorities for healthcare system strengthening in the future.
Poor adherence to the Integrated Management of Childhood Illness (IMCI) protocol reduces the potential impact on under-five morbidity and mortality. Electronic technology could improve adherence; however there are few studies demonstrating the benefits of such technology in a resource-poor settings. This study estimates the impact of electronic technology on adherence to the IMCI protocols as compared to the current paper-based protocols in Tanzania.
In four districts in Tanzania, 18 clinics were randomly selected for inclusion. At each site, observers documented critical parts of the clinical assessment of children aged 2 months to 5 years. The first set of observations occurred during examination of children using paper-based IMCI (pIMCI) and the next set of observations occurred during examination using the electronic IMCI (eIMCI). Children were re-examined by an IMCI expert and the diagnoses were compared. A total of 1221 children (671 paper, 550 electronic) were observed.
For all ten critical IMCI items included in both systems, adherence to the protocol was greater for eIMCI than for pIMCI. The proportion assessed under pIMCI ranged from 61% to 98% compared to 92% to 100% under eIMCI (p < 0.05 for each of the ten assessment items).
Use of electronic systems improved the completeness of assessment of children with acute illness in Tanzania. With the before-after nature of the design, potential for temporal confounding is the primary limitation. However, the data collection for both phases occurred over a short period (one month) and so temporal confounding was expected to be minimal. The results suggest that the use of electronic IMCI protocols can improve the completeness and consistency of clinical assessments and future studies will examine the long-term health and health systems impact of eIMCI.
Background
The global public health crisis of antibiotic resistance is being driven in part by over prescription of antibiotics. We aimed to assess the relative weight of patient expectations, clinical uncertainty, and past behaviour on hospital-based physicians’ antibiotic prescribing decisions.
Methods
A discrete choice experiment was administered among hospital-based physicians in Tuscany, Italy. Respondents were asked to choose in which of two clinical scenarios they would be more likely prescribe to antibiotics, with the two cases differing in levels of clinical uncertainty, patient expectations, and the physician's past behaviour. We fitted a conditional logistic regression.
Results
Respondents included 1,436 hospital-based physicians. Results show that the odds of prescribing antibiotics decrease when a patient requests it (OR=0.80, 95%CI [0.72,0.89]) and increase when the physician has prescribed antibiotics to a patient under similar circumstances previously (OR=1.15, 95%CI [1.03,1.27]). We found no significant effect of clinical uncertainty on the odds of prescribing antibiotics (OR=0.96, 95%CI [0.87, 1.07]).
Conclusions
We show that patient expectation has a significant negative association with antibiotic prescribing among hospital-based physicians. Our findings speak to the importance of cultural context in shaping the physician's disposition when confronted with patient expectations. We suggest shared decision-making to improve prudent prescribing without compromising on patient satisfaction.
Background:
Estimates of the total cumulative exposure to antibiotics of children in low-resource settings, and the source of these treatments, are limited.
Methods:
We estimated the average number of antibiotic treatments children received in the first five years of life in 45 low- and middle-income countries (LMICs) using Demographic and Health Survey (DHS) data. The two-week point prevalence of fever, diarrhea or cough and antibiotic treatment for these illnesses were estimated for ages 0-59 months and aggregated to estimate cumulative illness and antibiotic treatment for each country. We estimated treatment rates and contribution to total antibiotic use attributable to medical care, informal care, and self-medication.
Results:
Forty-five countries contributed 438,140 child-observations. The proportion of illness episodes treated with antibiotics ranged from 10% (95% CI: 9-12) (Niger) to 72% (95% CI: 69-75) (Jordan). A mean of 42·7% (95% CI: 42.1-43.3) of febrile and 32.9% of non-febrile illness (95% CI: 32.4-33.5) episodes received antibiotics. In their first five years, we estimate children received 18.5 antibiotics treatments on average (IQR: 11.6-24.6) in LMICs. Cumulative antibiotic exposure ranged from 3.7 treatments in Niger (95% CI: 2.8-4.6) to 38·6 treatments in DR Congo (95% CI: 34.7-42.4). A median of 9.0% of antibiotic treatment was attributable to informal care (IQR: 5.9-21.2), and 16.9% to self-medication (IQR: 9.5-26.2).
Conclusions:
Childhood antibiotic exposure is high in some LMICs, with considerable variability. While access to antibiotics for children is still not universal, important opportunities for reducing excess use also exist, particularly with respect to the informal care sector and self-medication.
Background:
Antibiotic resistance is a major threat to global health. Although detailed information about antibiotic use in high-income countries is available, little is known regarding the use of antibiotics and cumulative exposure to antibiotics in low-income and middle-income countries (LMICs). We aimed to quantify antibiotic exposure in children younger than 5 years in LMICs.
Methods:
We did a cross-sectional study in sick children younger than 5 years who attended a health-care facility in eight LMICs (Haiti, Kenya, Malawi, Namibia, Nepal, Senegal, Tanzania, and Uganda) between May, 2006, and December, 2016. Demographic and Health Surveys were used to estimate the cumulative number of illnesses related to a fever or cough and the cumulative number of visits to a health-care facility because of these illnesses for each country. We also used clinical observation data from nationally representative health-care facility-based Service Provision Assessment (SPA) surveys to estimate the proportion of children who were prescribed an antibiotic during a visit to a health-care facility and the number of antibiotic prescriptions issued that were unrelated to fever or respiratory problems. By combining these estimates, and using bootstrap analysis to compute uncertainty intervals, we estimated cumulative antibiotic exposure in children from birth up to age 5 years in each LMIC.
Findings:
From SPA surveys, we identified 22 519 clinical observations of children younger than 5 years who visited a health-care facility because of an illness between July, 2007, and December, 2016. From DHS surveys, we identified 68 826 children younger than 5 years who visited a health-care facility between May, 2006, and November, 2016. 85·4% of health-care facility visits were related to either a fever or cough. Antibiotics were prescribed to 80·5% of children diagnosed with respiratory illness, 50·1% with diarrhoea, and 28·3% with malaria. The mean number of antibiotic prescriptions issued to children between birth and age 5 years across the eight LMICs was 24·5 (95% CI 22·6-26·7), ranging from 7·1 (6·3-7·9) in Senegal to 59·1 (54·1-64·6) in Uganda.
Interpretation:
Between birth and age 5 years, children in LMICs are prescribed a remarkably high number of antibiotics. A large proportion of these prescriptions appear to be unnecessary. National and local efforts to reduce unnecessary prescription of antibiotics to children would likely improve both patient wellbeing (in terms of preventing side-effects) and reduce the global threat of antimicrobial resistance.
Funding:
None.
Introduction: Antibiotics have saved and are still saving countless human lives from the burden of infectious diseases. However, as with all other drugs, they can cause adverse events. Generally, these are uncommon, mild and spontaneously resolving. However, in some cases, they can cause relevant clinical problems. Compared with adults, children, particularly in the first years of life, have a higher risk of antibiotic-related adverse events for several reasons.
Areas covered: In this paper, the conditions that can contribute to the elevated risk of antibiotic-related adverse events in children are discussed.
Expert opinion: Antibiotic stewardship can be a solution to limit antibiotic abuse and misuse and consequently the incidence of antibiotic-related adverse events in children. Moreover, most of the antibiotic-associated adverse events can be avoided with more extensive pre-marketing medicine investigations, improved postmarket safety surveillance system, increased transparency throughout the clinical research enterprise, increased training of clinical pharmacologists and paediatric researchers, expanded pool of paediatric patients, and providing additional funding and incentives for paediatric drug development.
To identify factors precipitating antibiotic misuse and discuss how to promote safe antibiotics use and curb antibiotic resistance. Antibiotic misuse is a significant problem globally, leading to increased antibiotic resistance. Many socio-cultural factors facilitate antibiotic misuse: patient and provider beliefs about antibiotics, inadequate regulation, poor health literacy, inadequate healthcare provider training, and sub-optimal diagnostic capability. This study investigates the influence of such factors on antibiotic use and community health in rural Uganda. Attention was paid to patient-provider dynamics, providers’ concerns, and the role of drug shops in the communities and how these situations exacerbate antibiotic misuse. Using a grounded ethnographic approach, interviews, focus groups, and observations were conducted over six weeks. Five salient themes emerged from data analysis. Based on the study results and a review of past literature on antibiotic resistance, there is need for improved health literacy and education, continued focus on efficiency and affordability in healthcare, and recognition of the role of stewardship and government in providing better healthcare. The problem of antibiotic misuse is multifactorial. Proposed solutions must target multiple contributing factors and must ultimately modify the culture and beliefs surrounding antibiotic use and encourage proper use. Such a multi-pronged approach would be most effective and would decrease rates of antibiotic resistance.
Background:
The lack of effective, integrated diagnostic tools pose a major challenge to the primary care management of febrile childhood illnesses. These limitations are especially evident in low-resource settings and are often inappropriately compensated by antimicrobial over-prescription. Interactive electronic decision trees (IEDTs) have the potential to close these gaps: guiding antibiotic use and better identifying serious disease.
Aims:
This narrative review summarizes existing IEDTs, to provide an overview of their degree of validation, as well as to identify gaps in current knowledge and prospects for future innovation.
Sources:
Structured literature review in PubMed and Embase complemented by google search and contact with developers.
Content:
Six integrated IEDTs were identified: three (eIMCI, REC, and Bangladesh digital IMCI) based on Integrated Management of Childhood Illnesses (IMCI); four (SL eCCM, MEDSINC, e-iCCM, and D-Tree eCCM) on Integrated Community Case Management (iCCM); two (ALMANACH, MSFeCARE) with a modified IMCI content; and one (ePOCT) that integrates novel content with biomarker testing. The types of publications and evaluation studies varied greatly: the content and evidence-base was published for two (ALMANACH and ePOCT), ALMANACH and ePOCT were validated in efficacy studies. Other types of evaluations, such as compliance, acceptability were available for D-Tree eCCM, eIMCI, ALMANACH. Several evaluations are still ongoing. Future prospects include conducting effectiveness and impact studies using data gathered through larger studies to adapt the medical content to local epidemiology, improving the software and sensors, and Assessing factors that influence compliance and scale-up.
Implications:
IEDTs are valuable tools that have the potential to improve management of febrile children in primary care and increase the rational use of diagnostics and antimicrobials. Next steps in the evidence pathway should be larger effectiveness and impact studies (including cost analysis) and continuous integration of clinically useful diagnostic and treatment innovations.
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: The objective of this review is to assess the effect of digital, clinical decision-support tools, accessible via mobile devices by primary healthcare providers in the context of primary care settings, on providers' adherence to recommended practices, time taken for appropriate management, providers' and patients' acceptability and satisfaction, health status, and resource use.
Context Annual rates of antimicrobial prescribing for children by office-based
physicians increased from 1980 through 1992. The development of antimicrobial
resistance, which increased for many organisms during the 1990s, is associated
with antimicrobial use. To combat development of antimicrobial resistance,
professional and public health organizations undertook efforts to promote
appropriate antimicrobial prescribing.
Objective To assess changes in antimicrobial prescribing rates overall and for
respiratory tract infections for children and adolescents younger than 15
years.
Design, Setting, and Participants National Ambulatory Medical Care Survey data provided by 2500 to 3500
office-based physicians for 6500 to 13 600 pediatric visits during 2-year
periods from 1989-1990 through 1999-2000.
Main Outcome Measures Population- and visit-based antimicrobial prescribing rates overall
and for respiratory tract infections (otitis media, pharyngitis, bronchitis,
sinusitis, and upper respiratory tract infection) among children and adolescents
younger than 15 years.
Results The average population-based annual rate of overall antimicrobial prescriptions
per 1000 children and adolescents younger than 15 years decreased from 838
(95% confidence interval [CI], 711-966) in 1989-1990 to 503 (95% CI, 419-588)
in 1999-2000 (P for slope <.001). The visit-based
rate decreased from 330 antimicrobial prescriptions per 1000 office visits
(95% CI, 305-355) to 234 (95% CI, 210-257; P for
slope <.001). For the 5 respiratory tract infections, the population-based
prescribing rate decreased from 674 (95% CI, 568-781) to 379 (95% CI, 311-447; P for slope <.001) and the visit-based prescribing rate
decreased from 715 (95% CI, 682-748) to 613 (95% CI, 570-657; P for slope <.001). Both population- and visit-based prescribing
rates decreased for pharyngitis and upper respiratory tract infection; however,
for otitis media and bronchitis, declines were only observed in the population-based
rate. Prescribing rates for sinusitis remained stable.
Conclusion The rate of antimicrobial prescribing overall and for respiratory tract
infections by office-based physicians for children and adolescents younger
than 15 years decreased significantly between 1989-1990 and 1999-2000.
Information on how health workers spend their time can help programme managers determine whether it is possible to add new services or activities to their schedules and at what cost. One set of interventions with the potential to reduce under-five mortality is training of facility-based health workers according to the guidelines for Integrated Management of Childhood Illness (IMCI), along with improvements to supervision, procurement and information systems that are part of the IMCI strategy. Although it has been shown that IMCI is associated with improved quality of care, it is important to determine if it also requires additional consultation time. To investigate the amount of time required to provide clinical care to children under 5 years based on IMCI compared with routine care, a time and motion study was conducted in Northeast Brazil. IMCI-trained providers spent 1 minute and 26 seconds longer per consultation with under-fives than untrained providers, holding confounding factors constant at the mean levels observed in the sample. The difference was greater when patient load was low, and decreased as the number of patients a provider saw per day increased. This has three implications. First, the ability of the system to absorb new technologies depends on current capacity utilization. Secondly, the cost of treating a child also depends on the level of capacity utilization, at least in terms of provider time. Thirdly, where patient loads are high it is important to determine if the quality of care required for IMCI can be maintained.
So much to do: expected duration of initial consultations for sick children in low- and middle-income countries using the integrated management of childhood illness clinical algorithm (preprint)
- Carter