Camille Renner’s research while affiliated with University of Basel and other places

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.

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.