This application addresses broad Challenge Area (01) Behavior, Behavioral Change and Prevention and Specific Challenge Topic 01-TW-102 Improving health through ICT/mobile technologies: enhancing patient compliance. The Priority topic is implementation research on the use of ICT to adopt and integrate evidence based health interventions and change practice patterns within specific settings to enhance patient compliance/adherence. The Integrated Management of Childhood Illness (IMCI) protocols have been adapted and deployed in over 100 countries. A vast body of evidence indicates that millions of preventable deaths from diseases such as diarrhea, pneumonia, and malaria could be averted if these protocols were more widely applied and correctly followed. We currently study the use of electronic protocols at the point of care to improve provider diagnosis and treatment adherence to the IMCI protocols in Tanzania. Our software runs on PDAS or phones and guides providers step by step through the IMCI protocols to help avoid skipping steps or arriving at the wrong diagnosis or treatments. Our preliminary evidence suggests the use of these electronic protocols can substantially improve the diagnosis/treatment adherence by the provider to IMCI. We propose to now investigate how ICT can be used at the point of care to improve patient adherence to IMCI recommendations through provider and patient actions. This broadly includes the quality and frequency of the treatment and follow-up instructions given by the provider, the patient's ability to understand these instructions, whether the patient adheres to instructions, and the patients'follow-up actions and future care seeking behavior. ICT has the potential to address many of the challenges connected to these elements of patient adherence including the provider's reluctance to consult paper guidelines in front of patients, the difficulty of supervising health workers in remote clinics, and the lack of information needed for refining protocols and program management. However, while there is anecdotal evidence for these benefits of mobile technology, there has been little careful investigation of these claims, and even less that focuses on the patients'experience of ICT-supported encounters. The study will be carried out in clinics run by the Evangelical Lutheran Church of Tanzania (ELCT), who runs more than 180 health care institutions corresponding to about 15% of health services in Tanzania. These health facilities are currently using paper based IMCI protocols for the treatment of children, as mandated by the National Policy of Tanzania. This research will extend and assess our current system, e-IMCI, for guiding clinicians step by step through the IMCI protocols with an additional module for patient adherence. The research will include three phases. During the first phase, we will assess and improve e-IMCI through a rapid iterative prototyping methodology in which ideas are quickly implemented, tested, and either accepted, rejected or improved. During this time, we will observe how e-IMCI impacts provider-patient interaction and solicit feedback from the caregivers of the patients after the interactions. During Phase II, we will field test the improved version of e-IMCI in one clinic using paper IMCI serving as a control to prepare for the study in the next phase, ensuring that the systems and data collection instruments work efficiently. Finally, in our third phase we will conduct a cluster-randomized control trial in 20 clinics (10 using ICT, 10 using paper IMCI) with follow up of patients 1 week following their clinic visit. We will investigate the link between improved adherence by the patient/caregiver to health outcomes. We will also do a cost study and qualitative survey of perceptions of providers and patients to ICT supported clinical care.

Public Health Relevance

This research has high relevance to public health in its potential to improve health outcomes in children who are seen in clinics for acute illness. Our hypothesis is that the use of ICT can improve adherence by the caretaker to treatment instructions and advice given by the provider and improve adherence to the IMCI algorithms by the provider and that improved adherence by the provider and caretaker will lead to improved health outcomes. This is based on previous research by the PI and his team that concluded that ICT can improve assessment and correct classification and treatment of the child. Further, since these illnesses are the leading cause of mortality in children in low income countries, this research has the potential to significantly improve child mortality in these countries.

National Institute of Health (NIH)
Fogarty International Center (FIC)
NIH Challenge Grants and Partnerships Program (RC1)
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Special Emphasis Panel (ZRG1-BDA-A (58))
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Razak, Myat Htoo
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Harvard University
Public Health & Prev Medicine
Schools of Public Health
United States
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Perri-Moore, Seneca; Routen, Thomas; Shao, Amani Flexson et al. (2015) Using an eIMCI-Derived Decision Support Protocol to Improve Provider-Caretaker Communication for Treatment of Children Under 5 in Tanzania. Glob Health Commun 1:41-47