In 2019, the global under-5 mortality rate (U5MR) was 37·7 deaths per 1000 live births, with an estimated 5·2 million deaths, a majority of which could have been prevented with accurate clinical assessments and appropriate delivery of basic primary healthcare. Nearly half of these deaths (49%) occurred in 5 countries: Nigeria, India, Pakistan, Democratic Republic of the Congo, and Ethiopia. Across Nigeria the U5MR was 117·2 deaths per 1000 live births, a statistic that was significantly higher in the Kano State region, where U5MR was 203 per 1000 live births.1,2 Keeping with these global trends, an estimated 48·1 million under-5 deaths are projected to occur between 2020 and 2030, of which almost 23% (11 million) are preventable.1
The leading cause of under-5 deaths are neonatal disorders followed by respiratory infections, diarrheal diseases, congenital birth defects, and malaria.3 In 1995, the World Health Organization (WHO) and UNICEF (United Nations Children's Fund) developed Integrated Management of Childhood Illness (IMCI), a comprehensive clinical strategy that focuses on addressing the top causes of morbidity and mortality in under-5s in low and middle-income countries (LMIC). Moving away from a single clinical diseases or conditions approach, IMCI uses an integrated approach comprising four components: 1) improving case management skills of all health-care staff 2) improving overall health systems, 3) improving clinical healthcare capacity and 4) improving family and community health practices.
IMCI has been shown to improve health worker practices and quality of care when appropriately implemented.4 A 2016 Cochrane review found that effective implementation of IMCI reduced child mortality by up to 15%.5, 18 Despite the benefits, comprehensive IMCI programming has been slow to scale and challenging to implement. As of 2017, only 44 of 94 countries had implemented all three IMCI components in more than 90% of districts.6 Lack of political support, limited human and material resources, the time commitment required of health workers, including the time and expense taken for complex training that results in absence from other duties, and inadequate funding for the required training are often cited as challenges to being able to scale and operationalize IMCI globally.7,8
Nigeria, which adopted IMCI in 1997, faces similar barriers to implementation. National uptake remains low, with less than 25% of first-level facilities having trained staff on IMCI. Kano state, one of the first six states where the IMCI program was rolled out, has experienced poor adherence and compliance to IMCI protocols, primarily because of inadequate training and monitoring.9 The consequence of such poor training is continuation of poor quality of care, leading to low utilization of services. A study conducted on awareness and implementation of IMCI among pediatric nurses in Southwest Nigeria revealed that while over 50% of the respondents had fair knowledge and implementation of IMCI completion and proper use of the guidelines was limited.10 Nurses cited lack of training and the time required for implementation as primary challenges. In the absence of professional implementation aids (walls charts, booklets), nurses had to improvise when assessing and treating patients.
To circumvent the training challenges, countries have shortened the original IMCI training,11 which is designed as an 11-day in-service course that combines theoretical and hands-on clinical sessions.12 Standard implementation is guided by an IMCI chart booklet, a large paper register that prompts health workers to follow a step-by-step algorithm to help diagnose, triage, and treat illness. The booklet also serves the dual purpose of capturing data that can be used for the monitoring and supervision of IMCI programs. Although the booklets are simple, following this process for each case can be labor and time intensive and serves as a deterrent to proper compliance and quality of care.
In this study, we tested whether the introduction of THINKMD - an IMCI compliant digital CDS platform - can lead to meaningful improvement to adherence to IMCI guidelines and acquisition of data points that identify key danger signs. We also evaluated the acceptability and usability of the platform among community health workers (CHWs) performing clinical risk assessments of children 2–59 months of age. The study also documented whether introduction of a digital platform can help ease the burden of training, monitoring, and supervision that are necessary for IMCI adoption, sustainability, and health outcome impact. Other pilot projects have reported on the importance and challenges associated with introducing digital technologies to assist with primary health care implementation13.
The digital CDS platform used in this study was developed by THINKMD.14 The platform is a clinical decision support platform that guides users through a comprehensive assessment in which key IMCI based clinical data elements are acquired and then analyzed utilizing physician-based Bayesian logic to generate integrated clinical risk and severity assessments, triage recommendations, treatment options15. The platform interprets 42 key clinical data points based on WHO IMCI and Integrated Community Case Management (iCCM) guidelines and protocols, as well as other evidence-based data points that allow for additional evaluations. Initial clinical validation studies of this platform demonstrated an 85–95% correlation between integrated clinical assessments and triage recommendations generated by CHWs to that of local physicians independently evaluating the same child.14