Perceived Improvement in Integrated Management of Childhood Illness Implementation through Use of Mobile Technology: Qualitative Evidence From a Pilot Study in Tanzania

This journal article shares findings of a study examining health care provider (HCP) and caretaker perceptions of electronic Integrated Management of Childhood Illness (eIMCI) in diagnosing and treating childhood illnesses. According to the article, providers expressed positive opinions of eIMCI, noting that the personal digital assistants were faster and easier to use than were the paper forms and encouraged adherence to IMCI procedures. Caretakers also held a positive view of eIMCI, noting improved service from providers, more thorough examination of their child, and a perception that providers who used the personal digital assistants were more knowledgeable. The authors conclude that eIMCI represents a promising method for improving health care delivery because it improves health care provider and caretaker perception of the clinical encounter.

The article explains that Integrated Management of Childhood Illness (IMCI) is a standardised strategy developed by the World Health Organization and UNICEF to reduce mortality and morbidity among children younger than 5 years of age. To address low provider adherence to IMCI, a research study exploring the use of electronic IMCI (eIMCI) was conducted. An electronic handheld device, or personal digital assistant (PDA), was programmed to guide the HCPs step by step through the IMCI protocols. The authors conducted semi-structured interviews among 20 caretakers and 11 health care providers in the Pwani region of Tanzania.

Overall, HCPs described using the personal digital assistants (PDAs) as a positive experience. All stated that they preferred the PDA method over the paper method for administering IMCI. All HCPs stated that the PDA simplified or reduced the work required during the IMCI appointment. HCPs cited flipping through pages for information, using multiple charts and booklets, and looking up correct treatment dosages among the reasons that the conventional paper method was time consuming. All HCPs believed that the PDA was as fast (18%) or faster (82%) to use than the paper forms. Nine (82%) HCPs noted that the PDA provided guidance through the IMCI protocol, showing them what questions to ask and what procedures to follow, and often reminding them what to do next.

Most HCPs (10 out of 11) felt the PDA assisted with decision making by calculating dosages, freeing them from memorising dosage charts, searching for charts in paper form, and making calculations by hand, which can lead to mistakes. Eight HCPs (73%) believed the PDA enabled them to adhere more closely to IMCI guidelines than when they used the conventional paper method. In addition, because the PDA reduced the amount of time required to go through the IMCI protocol, it allowed HCPs to complete the entire protocol. In contrast, the use of paper methods often led to an incomplete assessment because of a lack of time or difficulty finding information. The two most common suggestions made by HCPs were to expand information in the IMCI protocol (including adding diagnoses such as HIV/AIDS, skin rashes, and urinary tract infection, removing medications no longer used at the hospital, and adding a wider array of symptoms) and to use the PDA at the hospital as well as the health centres. In general, HCPs wanted the PDA to simplify their work, although three HCPs mentioned that discontinuing the use of the PDA caused problems with new and returning patients who expected to see it during their appointments. Four HCPs (36%) requested additional training in using the PDA.

A total of 18 caretakers (90%) noted that the provider carried out a closer examination of their child, and 13 (65%) remarked that they were asked more or different questions than in previous appointments. HCPs asked caretakers specific questions about their child's health, and probed for more information when they suspected some had been left out. Twelve caretakers (60%) observed improvements in the providers' physical examination of the child, such as carrying out a chest exam or temperature reading, or simply touching the child, which was often something caretakers had not observed in previous appointments. Eleven caretakers (55%) described feeling more engaged in the appointment as a result of increased questioning. Caretakers felt that they were listened to more carefully, were treated "nicely", and made to feel that their input was important. Many of the caretakers (62%) believed that HCPs were able to better diagnose and/or treat their child's disease by using the PDA. In some instances, the caretakers had an overly inflated confidence in the abilities of the PDA.

Overall the study found that, while the sample size was small, there was a preference for the electronic tool for supporting IMCI care over the paper tool. Providers found eIMCI faster and simpler, valued the decision support and guidance, and believed that caretakers were more confident in their ability to deliver care. Caretakers were more confident in the assessment and diagnosis, noted an increased thoroughness in examination, and felt more engaged in the assessment. These positive endorsements of the eIMCI system show promise for the potential to scale to more sites. Providers did voice concerns about limiting critical thinking during the evaluation using eIMCI and the sustainability of the technology. The initial instructions to the HCPs were to use their judgment in treating patients even with the PDA tool, but they still vocalised concerns about how prescriptive the PDA-based protocols were.

The article concludes that participants communicated a clear message regarding HCPs' difficulty with paper-based IMCI and caretakers' dissatisfaction with previous examination methods. Given existing research revealing problems with provider non-adherence to IMCI guidelines, these observations indicate that a more efficient and user-friendly method for implementing IMCI is necessary. The introduction of the PDA for IMCI implementation represents a creative use of technology in improving health care delivery, and further investigation into the many uses of this method is warranted. The demonstrated ability of electronic systems to improve adherence to and usability of medical protocols extends beyond the IMCI protocol and has important implications for the role of clinical decision support.