Community Research and Development Information Service - CORDIS

Periodic Report Summary 2 - SUPPORTING LIFE (Supporting Low-cost Intervention For disEase control)

Project Context and Objectives:
The vast majority of front line health care for children with acute illnesses in sub-Saharan African countries is provided by health care workers who have a basic level of training. In Malawi, these are known as Health Surveillance Assistants (or HSAs). They are a group of trained, outreach workers employed by the Malawian Ministry of Health who serve as frontline health care staff in the battle against largely preventable childhood diseases. To tackle the burden of disease from serious but preventable illnesses such as pneumonia and malaria, the WHO and UNICEF developed the Community Case Management (CCM), now adopted as standard practice in many countries in sub-Saharan Africa, including Malawi. CCM is a paper-based clinical decision tool, utilizing a traffic light triage system enabling first-level health workers, such as HSAs in Malawi, to promptly identify children under-5 requiring urgent referral to higher level facilities, and direct the treatment and advice at the point-of-care for children who can be treated at home.
To support HSAs at the patient point-of-care and larger epidemiological bodies to manage and control diseases, we propose to use low cost technologies through the development of the Supporting Low-cost Intervention For disEase control (Supporting LIFE) project. The overarching objective of the Supporting LIFE project is to assist HSAs in delivering an eHealth intervention to improve and manage disease control, targeting children aged ≥2 months up to 5 years. This project is endeavoring to utilize established technology to circumvent the absent or limited healthcare infrastructure by exploiting the cellular telecommunications network and point of care decision support systems.
According to the 2010 International Telecommunications Union's report, 95% of rural areas in developed countries have a cellular network signal, while 75% of rural areas in developing countries have a similar service (including data services). The expansion of information and communication technologies to low and middle-income countries such as Malawi has offered the potential for CCM to be delivered via e/mHealth solutions. Therefore we have designed and developed a decision support toolkit dedicated to support HSAs with the adherence to and implementation of CCM guidelines. This decision support toolkit, in the form of an Android-based smartphone application (SL eCCM App v5.0 release Dec 2014), leverages existing CCM protocols for disease control as well as help to encourage higher levels of compliance with recommended practices.
From July 2015 to October 2015, we conducted a study to investigate the usability and acceptance of the SL eCCM App to HSAs. Our findings revealed that HSAs had a very positive experience using the SL eCCM App and felt it would improve their ability to assess children. In the summer of 2016, we will conduct a pragmatic stepped-wedge cluster randomized trial to assess the added value of a mobile application of CCM on referral, re-consultation and hospitalization rates of children under-5 in Malawi. Given that no research studies to date have evaluated the effectiveness or acceptability of mobile phone based versions of CCM, the findings and lessons learnt from the Supporting LIFE project will provide the Malawi Ministry of Health with invaluable evidence for their decision-making on CCM and mHealth policies.

Project Results:
The Supporting LIFE consortium has successfully developed a mobile version of community case management (SL eCCM App) to run on Android-based smartphones. The Supporting LIFE team decided to take an incremental approach in the development of the software solution. At present, 5 versions of the SL eCCM App have been released. Each iteration of the App was designed to build up the full capabilities of the software DSS solution in a controlled manner. SL eCCM App mirrors the ‘Sick Child Form,’ the paper-based job aid used by Health Surveillance Assistants (HSAs) for community case management of sick children. The App also features an integrated breath counter, which allows HSAs to measure breathing rate directly within the SL eCCM App.

A feasibility study was conducted to 1) evaluate the acceptability, barriers and facilitators of implementing a mobile version of CCM in village clinics to HSAs and 2) assess the feasibility of following up children in the community to collect information on clinical outcomes (i.e. re-consultation rates and referral rates to higher level health facilities). Upon evaluating methods for measuring adherence to eIMCI/CCM protocols, it was decided that assessing successful follow-up would provide a more direct measure of clinical effectiveness SL eCCM App. The study involved training 12 HSAs to use SL eCCM App, followed by a two-week period of SL eCCM App use in their village clinics. Focus groups and semi-structured interviews were conducted to explore their initial perceptions to the App as well as any barriers and/or facilitators experienced by HSAs. Findings revealed that HSAs preferred SL eCCM App to standard practice (Sick Child Form and Village Clinic Register), as they felt it improved their adherence to CCM protocol. Findings also revealed that follow-up was possible for children, either via telephone or face-to-face encounters.

Following the feasibility study, further development of the SL eCCM App had commenced in order to ensure its compliance with newly-updated CCM guidelines. The consortium has since been preparing to run a larger stepped-wedge cluster randomized trial in the summer of 2016. This trial will aim to evaluate the added value of SL eCCM App on HAS referral practices and parent/caregiver health seeking behavior in Malawi.

Continued engagement with stakeholders has been a key priority for the Supporting LIFE project. Project partners have met with a number of stakeholders from Ministry of Health, World Health Organization, Baobab Health Trust and local Malawi universities. Stakeholder views on the current landscapes of mHealth and information quality in Malawi have guided the development and implementation of SL eCCM App and subsequent field research. Stakeholder interviews particularly guided the initial development of design guidelines for national disease surveillance in Malawi, including data mapping and information flow.

Dissemination of Supporting LIFE project outputs has also been progressing well. Supporting LIFE consortium members have presented the project at numerous conferences on mHealth, Health Information Systems and Global Health.
In parallel with public engagement a number of academic papers have been successfully published (selected papers):
Fleming, S., Gill, P., Jones, C., Taylor, J., Van den Bruel, A., Heneghan, C., Roberts, N. and Thompson, M. (2015). The Diagnostic Value of Capillary Refill Time for Detecting Serious Illness in Children: A Systematic Review and Meta-Analysis. PLOS ONE, 10(9), p.e0138155.
O'Connor, Y., Heavin, C. and O'Donoghue, J. (2015). Review of Key Stakeholders for an mHealth Pilot Study in Malawi Motivations and Expectations. International Journal of Reliable and Quality E-Healthcare, 4(2), pp.51-66.
O’Connor, Y., Heavin, C. and O’Donoghue, J. (2016). First impressions are lasting impressions: intention to participate in mobile health projects within developing countries. Journal of Decision Systems, 25(2), pp.173-190.

Potential Impact:
The Supporting LIFE project aims to utilize low-cost technologies to improve healthcare delivery in resource poor settings by assisting unskilled front-line health workers, Health Surveillance Assistants (HSAs), manage cases of common childhood illness in Malawi. The Supporting LIFE Community Case Management Application (SL eCCM App) mobile application will enable HSAs more accurately diagnose and treat children under the age of 5 years with common uncomplicated illnesses (e.g. pneumonia, malaria).

The evaluation of this prototype of CCM will provide invaluable insight on the potential of mHelath solutions to reduce morbidity and mortality in young children in rural communities. Improved adherence to CCM protocols would result in more appropriate referrals to higher-level health facilities. Improvement in appropriate referrals may result in an increase in uptake of health services, which would pose an added strain on the Malawi health system. However understanding the facilitators and barriers of such uptake of health services would inform the Malawi Ministry of Health on the needs of its paediatric population.

The Supporting LIFE project aims to build research capacity in Malawi, particularly within Mzuzu University. Faculty members and students will have active roles in Supporting LIFE research activities, including assisting in the development of study design to data collection. Supporting LIFE will additionally facilitate the development of links between African and European institutions, thereby improving visibility of certain Malawian organizations.

Furthermore, the outputs from WP5 (Disease Control Surveillance) will facilitate national epidemiological data for the monitoring and management of disease control. Therefore, the evidence generated from Supporting LIFE will likely be valuble to Malawi Ministry of Health, as it will provide policy makers with data relating to the potential effectiveness of mobile platforms for CCM, thereby justifying the decision to implement these strategies at the country-level.
The Supporting LIFE project is expected to also have a number of long term indirect benefits such as the 1) creation of skills in project management in the Mzuzu area, 2) collaboration of community organisations, NGOs, and Malawian universities, 3) extension of expertise to rural communities and 4) development of sustainable industries in Malawi regarding mobile phones, programming, power supplies.

List of Websites:

Reported by

United Kingdom
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