Effectiveness of smartphone-based community case management on the urgent referral, reconsultation, and hospitalization of children aged under 5 years in Malawi: cluster-randomized, stepped-wedge trial
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Author(s)
Type
Journal Article
Abstract
Background: Integrated community case management (CCM) has led to reductions in child mortality in Malawi from illnesses such as malaria, pneumonia and diarrhoea. However, adherence to CCM guidelines is often poor, potentially leading to inappropriate clinical decisions and poor outcomes. We determined the impact of an electronic version of a smartphone-based CCM (eCCM) application on referral, re-consultation and hospitalization rates of children presenting to village clinics in Malawi.
Methods: A stepped-wedge cluster-randomized trial compared paper-based CCM (control) with and without use of an eCCM app on smartphones from November 2016 to February 2017. A total of 102 village clinics from two districts in Northern Malawi were assigned to one of six clusters which were randomized to the sequencing of crossover from the control to the intervention phases, as well as the duration of exposure in each phase. Children ≥2 months to <5 years presenting with acute illness were enrolled consecutively by Health Surveillance Assistants (HSAs). The primary outcome of urgent referrals to higher-level facilities was evaluated using multi-level mixed effects models. A logistic regression model with random effect of cluster and fixed effect for each step was fitted. Adjustment for potential confounders included baseline factors, such as patient’s age, sex, and geographical location of village clinics. Calendar time was adjusted for in the analysis.
Results: A total of 6965 children were recruited, 3421 in the control and 3544 in the intervention phase. After adjusting for calendar time, children in the intervention phase were more likely to be urgently referred to a higher-level health facility compared with children in the control phase (OR 2.02, 95% CI 1.27-3.23; p<0.01). Overall, children in the intervention arm had lower odds of attending a repeat HSA consultation (OR 0.45, 95% CI 0.34-0.59; p<0.01) or hospital admission (OR 0.75, 95% CI 0.62-0.90; p<0.01), but after adjusting for time these differences were not significant (p>0.05).
Conclusions: Addition of eCCM decision support using smartphones led to a greater proportion of children being referred to higher-level facilities, with no apparent increase in hospital admissions or repeat consultations in village clinics. Our findings provide support for the implementation of eCCM tools in Malawi and other Low and Middle Income Countries (LMIC), with a need for ongoing assessment of effectiveness and integration with national digital health strategies.
Trial registration: ClinicalTrials.gov; NCT02763345. Registered 3 May 2016
Methods: A stepped-wedge cluster-randomized trial compared paper-based CCM (control) with and without use of an eCCM app on smartphones from November 2016 to February 2017. A total of 102 village clinics from two districts in Northern Malawi were assigned to one of six clusters which were randomized to the sequencing of crossover from the control to the intervention phases, as well as the duration of exposure in each phase. Children ≥2 months to <5 years presenting with acute illness were enrolled consecutively by Health Surveillance Assistants (HSAs). The primary outcome of urgent referrals to higher-level facilities was evaluated using multi-level mixed effects models. A logistic regression model with random effect of cluster and fixed effect for each step was fitted. Adjustment for potential confounders included baseline factors, such as patient’s age, sex, and geographical location of village clinics. Calendar time was adjusted for in the analysis.
Results: A total of 6965 children were recruited, 3421 in the control and 3544 in the intervention phase. After adjusting for calendar time, children in the intervention phase were more likely to be urgently referred to a higher-level health facility compared with children in the control phase (OR 2.02, 95% CI 1.27-3.23; p<0.01). Overall, children in the intervention arm had lower odds of attending a repeat HSA consultation (OR 0.45, 95% CI 0.34-0.59; p<0.01) or hospital admission (OR 0.75, 95% CI 0.62-0.90; p<0.01), but after adjusting for time these differences were not significant (p>0.05).
Conclusions: Addition of eCCM decision support using smartphones led to a greater proportion of children being referred to higher-level facilities, with no apparent increase in hospital admissions or repeat consultations in village clinics. Our findings provide support for the implementation of eCCM tools in Malawi and other Low and Middle Income Countries (LMIC), with a need for ongoing assessment of effectiveness and integration with national digital health strategies.
Trial registration: ClinicalTrials.gov; NCT02763345. Registered 3 May 2016
Date Issued
2021-10-20
Date Acceptance
2021-08-11
Citation
Journal of Medical Internet Research, 2021, 23 (10), pp.1-11
ISSN
1438-8871
Publisher
JMIR Publications
Start Page
1
End Page
11
Journal / Book Title
Journal of Medical Internet Research
Volume
23
Issue
10
Copyright Statement
©Griphin Baxter Chirambo, Matthew Thompson, Victoria Hardy, Nicole Ide, Phillip H Hwang, Kanika Dharmayat, Nikolaos
Mastellos, Ciara Heavin, Yvonne O'Connor, Adamson S Muula, Bo Andersson, Sven Carlsson, Tammy Tran, Jenny Chen-Ling
Hsieh, Hsin-Yi Lee, Annette Fitzpatrick, Tsung-Shu Joseph Wu, John O'Donoghue. Originally published in the Journal of Medical
Internet Research (https://www.jmir.org), 20.10.2021. This is an open-access article distributed under the terms of the Creative
Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly
cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright
and license information must be included
Mastellos, Ciara Heavin, Yvonne O'Connor, Adamson S Muula, Bo Andersson, Sven Carlsson, Tammy Tran, Jenny Chen-Ling
Hsieh, Hsin-Yi Lee, Annette Fitzpatrick, Tsung-Shu Joseph Wu, John O'Donoghue. Originally published in the Journal of Medical
Internet Research (https://www.jmir.org), 20.10.2021. This is an open-access article distributed under the terms of the Creative
Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly
cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright
and license information must be included
License URL
Identifier
https://www.jmir.org/2021/10/e25777
Subjects
childhood infection
community case management
mobile health
mobile phone
pediatrics
Case Management
Child
Hospitalization
Humans
Malawi
Referral and Consultation
Smartphone
Medical Informatics
08 Information and Computing Sciences
11 Medical and Health Sciences
17 Psychology and Cognitive Sciences
Publication Status
Published
Date Publish Online
2021-10-20