Using an eIMCI-Derived Decision Support Protocol to Improve Provider-Caretaker Communication for Treatment of Children Under 5 in Tanzania

"Although counseling is a critical component of health care, it is seldom done effectively. This is a particular concern when the counseling involves how to provide treatment to sick children since misunderstanding of what is required at home leads to ineffective treatment adherence and poorer health outcomes. This study indicates that the use of mobile technology can be an important aide in increasing both the delivery and recall of counseling messages."

This study examines whether the use of mobile technology can leverage a standardised treatment protocol to improve the effect of counseling for children's caretakers and result in better understanding of what needs to be done at home after the clinical visit. The World Health Organization (WHO)'s Integrated Management of Childhood Illness (IMCI) approach, which is the official government policy in Tanzania, has contributed to reduction in under-5 mortality in the country. However, even if a child is prescribed the correct treatment as per IMCI, often it will not be correctly given to the child due to insufficient counseling and thus lack of understanding by the caretaker. Cultural norms and poor health literacy rates may contribute to a lack of communication between providers and caretakers.

Building on previous studies in Tanzania in which an electronic version of the IMCI decision support protocol, the eIMCI, was shown to improve the quality of health service delivery in paediatric patients by improving provider adherence to the IMCI protocol, the researchers carried out a randomised cluster design in which clinics in Dar es Salaam, Tanzania were assigned to a test group or a control group, and all providers at the clinic and all patients seen at a specific clinic were then treated using either electronic (test) protocols or paper (control) protocols (paper IMCI-derived protocol, or pIMCI). Six municipal health clinics were selected and randomly assigned to intervention arm, with 3 facilities implementing the pIMCI protocol (provider n = 25) and 3 facilities implementing the eIMCI protocol (provider n = 41). The caretaker sample included caretakers seeking care for children ages 2–59 months at the participating clinics (pIMCI arm n = 180, eIMCI arm n = 172).

The communication that occurred between the provider and the child's caretaker was evaluated in terms of (a) what the provider said to the caretaker during the visit and (b) what the caretaker recalled of what they were told by the provider. The test arm of the study (electronic arm) included a 25-second video formatted for the mobile phone aimed at educating caretakers on relevant health information, embedded prompts within the protocol containing key messages for caretakers, and a customised summary screen compiling the results of the clinical encounter. The control arm (paper arm) provided equivalent information in written text. Participating providers were trained over the course of 2 sessions. The first sessions were 2-day group workshops in which both arms received training on the rationale for updating the WHO IMCI protocol and overview protocol training over the course of 1.5 days; participants were divided for the remaining half day to focus on learning how to deliver the protocol using their respective platforms. The second sessions consisted of face-to-face training, allowing for designated time to practice and familiarise the providers with their respective platforms for protocol delivery.

In summary, providers using the eIMCI protocol (a) were shown to counsel the mother on the child's problem significantly more frequently than were providers using the pIMCI protocol, (b) gave significantly more advice when to return in case of worsening illness or nonimprovement than were providers in the pIMCI group, and (c) verbalised significantly more information regarding medications including type of medication, frequency to administer, and duration to administer (p < .05). For example, providers in the pIMCI arm did not verbalise the child's problem in 22.2% of cases (compared with 1% in the eIMCI arm). Providers in the pIMCI arm did not mention any signs of worsening condition in 7.8% of cases (compared with 3.5% of cases in the eIMCI arm). Providers in the pIMCI arm were more likely to fail to say when to return to the clinic (number of days), although both groups failed to mention this information for more than one-third of the children. Providers in the pIMCI arm did not verbalise the medication name in 19.2% of cases, medication frequency was not explained in 20.8% of cases, and mediation duration was not explained in 13.1% of cases. Far fewer eIMCI arm providers failed to communicate the medication name (3.0% of cases), 6.8% did not verbalise medication frequency, and 7.4% did not verbalise medication duration.

Caretakers receiving care by providers using the eIMCI protocol recalled significantly more diagnoses or problems than did providers using the pIMCI protocol, recalled significantly more advice when to return in case of worsening illness or nonimprovement than did caretakers in the pIMCI group, and recalled significantly more types of medications prescribed (p < .05). For example, caretaker recall of the days to return to the clinic was incorrectly reported (did not match what the provider stated) in 22.9% of eIMCI cases, compared with 50.0% of pIMCI cases (p = .010). Caretakers in the eIMCI arm did not know any medications in 21.5% of cases for which medication names were verbalised by the provider, and for 42.2% of pIMCI cases (p = .001).

"The electronic intervention was therefore considered to be effective by both measures of provider and caretaker components of the communication encounter. While significant improvements were observed from eIMCI use, deficits in provider verbalization of key information points and caretaker recall of information verbalized remained, indicating a need for further improvement in provider-caretaker communication. Long-standing societal patterns likely influenced these deficits, as it has been a well-established norm for providers to abstain from teaching this information, and for caretakers to accept an insufficient level of communication and health related teaching."