Fenella Beynon’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.

Background Hypoxemia predicts mortality at all levels of care, and appropriate management can reduce preventable deaths. However, pulse oximetry and oxygen therapy remain inaccessible in many primary care health facilities. We aimed to develop and validate a simple risk score comprising commonly evaluated clinical features to predict hypoxemia in 2-59-month-old children with pneumonia. Methods Data from 7 studies conducted in 5 countries from the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) dataset were included. Readily available clinical features and demographic variables were used to develop a multivariable logistic regression model to predict hypoxemia (SpO 2 <90%) at presentation to care. The adjusted log coefficients were transformed to derive the PREPARE hypoxemia risk score and its diagnostic value was assessed in a held-out, temporal validation dataset. Results We included 14,509 children in the analysis; 9.8% (n=2,515) were hypoxemic at presentation. The multivariable regression model to predict hypoxemia included age, sex, respiratory distress (nasal flaring, grunting and/or head nodding), lower chest indrawing, respiratory rate, body temperature and weight-for-age z-score. The model showed fair discrimination (area under the curve 0.70, 95% CI 0.67 to 0.73) and calibration in the validation dataset. The simplified PREPARE hypoxemia risk score includes 5 variables: age, respiratory distress, lower chest indrawing, respiratory rate and weight-for-age z-score. Conclusion The PREPARE hypoxemia risk score, comprising five easily available characteristics, can be used to identify hypoxemia in children with pneumonia with a fair degree of certainty for use in health facilities without pulse oximetry. Its implementation would require careful consideration to limit inappropriate referrals on patients and the health system. Further external validation in community settings in low-and middle-income countries is required. KEY MESSAGES What is already known on this topic Pulse oximetry is unavailable or underutilized in many resource-limited settings in low- and middle-income countries. Hypoxemia is a good predictor of mortality and its early identification and further management can reduce mortality. What this study adds The PREPARE hypoxemia risk score was developed using one of the largest and most geographically diverse datasets on childhood pneumonia to date. Using age, lower chest indrawing, respiratory rate, respiratory distress and weight-for-age z-score to calculate the PREPARE hypoxemia risk score could help identify children with hypoxemia in settings without pulse oximeters. How this study might affect research, practice or policy This study contributes to the important discussion on how best to identify hypoxemic children in the absence of pulse oximetry. Further research is warranted to validate the findings in community settings Operationalizing and integrating the score within existing clinical management pathways must be tailored to the setting of implementation.

Effective and sustainable strategies are needed to address the burden of preventable deaths among children under-five in resource-constrained settings. The Tools for Integrated Management of Childhood Illness (TIMCI) project aims to support healthcare providers to identify and manage severe illness, whilst promoting resource stewardship, by introducing pulse oximetry and clinical decision support algorithms (CDSAs) to primary care facilities in India, Kenya, Senegal and Tanzania. Health impact is assessed through: a pragmatic parallel group, superiority cluster randomised controlled trial (RCT), with primary care facilities randomly allocated (1:1) in India to pulse oximetry or control, and (1:1:1) in Tanzania to pulse oximetry plus CDSA, pulse oximetry, or control; and through a quasi-experimental pre-post study in Kenya and Senegal. Devices are implemented with guidance and training, mentorship, and community engagement. Sociodemographic and clinical data are collected from caregivers and records of enrolled sick children aged 0-59 months at study facilities, with phone follow-up on Day 7 (and Day 28 in the RCT). The primary outcomes assessed for the RCT are severe complications (mortality and secondary hospitalisations) by Day 7 and primary hospitalisations (within 24 hours and with referral); and, for the pre-post study, referrals and antibiotic. Secondary outcomes on other aspects of health status, hypoxaemia, referral, follow-up and antimicrobial prescription are also evaluated. In all countries, embedded mixed-method studies further evaluate the effects of the intervention on care and care processes, implementation, cost and cost-effectiveness. Pilot and baseline studies started mid-2021, RCT and post-intervention mid-2022, with anticipated completion mid-2023 and first results late-2023. Study approval has been granted by all relevant institutional review boards, national and WHO ethical review committees. Findings will be shared with communities, healthcare providers, Ministries of Health and other local, national and international stakeholders to facilitate evidence-based decision-making on scale-up. Study registration: NCT04910750 and NCT05065320.

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.

Effective, scalable and sustainable strategies to improve quality of care are needed to address the substantial burden of preventable deaths of children under-five in resource-constrained settings. Clinical decision support systems (CDSS), digital tools which generate recommendations for healthcare providers based on patient-specific information, show promise. By strengthening adherence to evidence-based assessment, diagnosis and management and generating high-quality data, CDSS can improve quality care - care that is effective, safe, people-centered, timely, equitable, integrated and efficient. Designing and implementing CDSS that deliver this impact is a complex and iterative process. We advocate for collaboration on developing and evaluating these tools to guide their implementation for maximal impact.

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.

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 its limited scope, usability, and outdated clinical algorithms. 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 skills to easily create the algorithms, and medAL-reader the mobile health (mHealth) app 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.

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.