Can smartphones and tablets improve the management of childhood illness in Tanzania? A qualitative study from a primary health care worker’s perspective

The impact of the Integrated Management of Childhood Illness (IMCI) strategy has been less than anticipated because of poor uptake. Electronic algorithms have the potential to improve quality of health care in children. However, feasibility studies about the use of electronic protocols on mobile devices over time are limited. This study investigated constraining as well as facilitating factors that influence the uptake of a new electronic Algorithm for Management of Childhood Illness (ALMANACH) among primary health workers in Dar es Salaam, Tanzania.; A qualitative approach was applied using in-depth interviews and focus group discussions with altogether 40 primary health care workers from 6 public primary health facilities in the three municipalities of Dar es Salaam, Tanzania. Health worker's perceptions related to factors facilitating or constraining the uptake of the electronic ALMANACH were identified.; In general, the ALMANACH was assessed positively. The majority of the respondents felt comfortable to use the devices and stated that patient's trust was not affected. Most health workers said that the ALMANACH simplified their work, reduced antibiotic prescription and gave correct classification and treatment for common causes of childhood illnesses. Few HWs reported technical challenges using the devices and complained about having had difficulties in typing. Majority of the respondents stated that the devices increased the consultation duration compared to routine practice. In addition, health system barriers such as lack of staff, lack of medicine and lack of financial motivation were identified as key reasons for the low uptake of the devices.; The ALMANACH built on electronic devices was perceived to be a powerful and useful tool. However, health system challenges influenced the uptake of the devices in the selected health facilities

Structured literature reviews: search strategy.

<p>Structured literature reviews: search strategy.</p

Flow diagrams of study selection process in the structured literature reviews.

<p>Flow diagrams of study selection process in the structured literature reviews.</p

Samples of ALMANACH in electronic format.

<p>Samples of ALMANACH in electronic format.</p

Overview of ALMANACH's structure.

<p>mRDT: malaria rapid diagnostic test. UTI: urinary tract infection.</p

New Algorithm for Managing Childhood Illness Using Mobile Technology (ALMANACH): A Controlled Non-Inferiority Study on Clinical Outcome and Antibiotic Use in Tanzania

Introduction: 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. Methods: 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. Results: 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. Conclusion: 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. Trial Registration Pan African Clinical Trials Registry PACTR20101100026221

Characteristics of the 19 patients who received antibiotics during re-attendance in the ALMANACH arm.

<p>*Out of working hours, the patient was evaluated and managed by a routine clinician of the HF rather than the study clinician.</p><p>^&This patient is the same as patient n°22 in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0132316#pone.0132316.t004" target="_blank">Table 4</a>.</p><p>Characteristics of the 19 patients who received antibiotics during re-attendance in the ALMANACH arm.</p

Distribution of diagnoses at inclusion in the ALMANACH (A) and standard practice (B) arms.

<p>* Diagnosis given by clinicians when they do not classify further the respiratory infection.</p

Key differences between the IMCI and the new ALgorithm for the MANAgement of Childhood illness (ALMANACH) (section dedicated to the management of acute conditions in children aged 2 months to 5 years).

<p>^a 50 breaths/min for children aged 2 to 12 months, 40 breaths/min for children aged 12 months to 5 years.</p><p>^b 50 breaths/min for all children (aged 2 months to 5 years).</p><p>^c No cough or difficult breathing, no diarrhea, no ear problem, no measles, no infected skin lesion or lump.</p><p>Key differences between the IMCI and the new ALgorithm for the MANAgement of Childhood illness (ALMANACH) (section dedicated to the management of acute conditions in children aged 2 months to 5 years).</p