Results from one-year use of an electronic Clinical Decision Support System in a post-conflict context: An implementation research

Autoři: Andrea Bernasconi aff001;  Francois Crabbé aff002;  Ajibola Margret Adedeji aff004;  Attahiru Bello aff005;  Torsten Schmitz aff002;  Marco Landi aff004;  Rodolfo Rossi aff006
Působiště autorů: ICRC, Kyaing Tong, Myanmar aff001;  HTTU, Swiss TPH, Basel, Switzerland aff002;  University of Basel, Basel, Switzerland aff003;  ICRC, Yola, Nigeria aff004;  Adamawa State Primary Healthcare Development Agency, Adamawa, Nigeria aff005;  PHC programs, ICRC, Genève, Switzerland aff006
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article



In 2017, the Adamawa State Primary Healthcare Development Agency introduced ALMANACH, an electronic clinical decision support system based on a modified version of IMCI. The target area was the Federal State of Adamawa (Nigeria), a region recovering after the Boko Haram insurgency. The aim of this implementation research was to assess the improvement in terms of quality care offered after one year of utilization of the tool.


We carried out two cross-sectional studies in six Primary Health Care Centres to assess the improvements in comparison with the baseline carried out before the implementation. One survey was carried out inside the consultation room and was based on the direct observation of 235 consultations of children aged from 2 to 59 months old. The second survey questioned 189 caregivers outside the health facility for their opinion about the consultation carried out through using the tablet, the prescriptions and medications given.


In comparison with the baseline, more children were checked for danger signs (60.0% vs. 37.1% at baseline) and in addition, children were actually weighed (61.1% vs. 27.7%) during consultation. Malnutrition screening was performed in 35.1% of children (vs. 12.1%). Through ALMANACH, also performance of preventive measures was significantly improved (p<0.01): vaccination status was checked in 39.8% of cases (vs. 10.6% at baseline), and deworming and vitamin A prescription was increased to 46.5% (vs. 0.7%) and 48.3% (vs. 2.8%) respectively. Furthermore, children received a complete physical examination (58.3% vs. 45.5%, p<0.01) and correct treatment (48.4% vs. 29.5%, p<0.01). Regarding antibiotic prescription, 69.3% patients received at least one antibiotic (baseline 77.7%, p<0.05).


Our findings highlight major improvements in terms of quality of care despite many questions still pending to be answered in relation to a full integration of the tool in the Adamawa health system.

Klíčová slova:

Antibiotics – Clinical decision support systems – Fevers – Malaria – Quality of care – Social systems – Vaccination and immunization – Vitamin A


1. WHO, UNICEF. Integrated Management of Childhood Illness (IMCI). A joint WHO/UNICEF initiative. Geneva, World Health Organization/United Nations Children's Fund, 1997.

2. Lambrechts T, Bahl R, Robinson D, Aboubaker S, Picazo O. The analytic review of the Integrated Management of Childhood Illness strategy. Geneva: WHO. URL: (Accessed 24 April 2017).

3. WHO. Integrated Management of Childhood Illness (IMCI). Chart Booklet. Geneva: WHO 2014.

4. Gera T, Shah D, Garner P, Richardson M, Sachdev HS. Integrated management of childhood illness (IMCI) strategy for children under five. Cochrane Database Syst Rev. 2016;6.

5. WHO. Towards a Grand Convergence for child survival and health: a strategic review of options for the future building on lessons learnt from IMNCI. Geneva: WHO 2016. Online at, accessed on 11 April 2019.

6. Bryce J, Victora CG, Habicht JP, Vaughan JP, Black RE. The multi-country evaluation of the integrated management of childhood illness strategy: lessons for the evaluation of public health interventions. Am J Public Health. 2004; 94.

7. WHO, UNICEF, DFID, USAID. The Analytic Review of Integrated Management of Childhood Illness Strategy. Geneva: WHO 2003.

8. Ahmed HM, Mitchell M, Hedt B. National implementation of Integrated Management of Childhood Illness (IMCI): policy constraints and strategies. Health Policy. 2010; 96.

9. Pandya H, Slemming W, Saloojee H. Health system factors affecting implementation of integrated management of childhood illness (IMCI): qualitative insights from a South African province. Health Policy Plan. 2018; 33.

10. Walter ND, Lyimo T, Skarbinski J, Metta E, Kahigwa E, Flannery B, et al. Why first-level health workers fail to follow guidelines for managing severe disease in children in the coast region, the United Republic of Tanzania. Bull World Health Organ. 2009; 87.

11. Mitchell M, Hedt-Gauthier BL, Msellemu D, Nkaka M, Lesh N. Using electronic technology to improve clinical care—results from a before-after cluster trial to evaluate assessment and classification of sick children according to Integrated Management of Childhood Illness (IMCI) protocol in Tanzania. BMC Med Inform Decis Mak. 2013; 27.

12. Lange S, Mwisongo A, Mæstad O. Why don't clinicians adhere more consistently to guidelines for the Integrated Management of Childhood Illness (IMCI)? Soc Sci Med. 2014; 104.

13. Rambaud-Althaus C, Shao AF, Kahama-Maro J, Genton B, d'Acremont V. Managing the Sick Child in the Era of Declining Malaria Transmission: Development of ALMANACH, an Electronic Algorithm for Appropriate Use of Antimicrobials. PLoS One. 2015; 10.

14. Bernasconi A, Crabbé F, Rossi R, Qani I, Vanobberghen A, Raab M, et al. The ALMANACH Project: Preliminary results and potentiality from Afghanistan. Int J Med Inform. 2017

15. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005; 765.

16. Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review. JAMA 2005, 293.

17. DeRenzi B, Lesh N, Parikh TS, Sims C, Maokola W, Chemba M, et al. (2008, April). E-IMCI: improving paediatric health care in low-income countries. ACM Conference on Computer-Human Interaction (CHI).

18. Mitchell M, Getchell M, Nkaka M, Msellemu D, Van Esch J, Hedt-Gauthier B. Perceived improvement in integrated management of childhood illness implementation through use of mobile technology: qualitative evidence from a pilot study in Tanzania. J Health Commun. 2012;17.

19. Terre des Hommes. IeDA—A digital solution to save children's lives. Available at accessed on 28 September 2019.

20. Geneva Health Forum, 7th edition. MSFeCARE (Electronic Clinical Algorithm and REcommendation). Available at accessed on 28 September 2019.

21. Keitel K, Kagoro F, Samaka J, Masimba J, Said Z, Temba H, et al. A novel electronic algorithm using host biomarker point-of-care tests for the management of febrile illnesses in Tanzanian children (e-POCT): A randomized, controlled non-inferiority trial. PLoS Med. 2017; 14

22. Keitel K, D'Acremont V. Electronic clinical decision algorithms for the integrated primary care management of febrile children in low-resource settings: review of existing tools. Clin Microbiol Infect. 2018;24.

23. D’Acremont V, Kilowoko M, Kyungu E, Philipina S, Sangu W, Kahama-Maro J, et al. Beyond Malaria—Causes of Fever in Outpatient Tanzanian Children. N Engl J Med. 2014; 370.

24. Bernasconi A, Crabbé F, Raab M, Rossi R. Can the use of digital algorithms improve quality care? An example from Afghanistan. PLoS One. 2018; 13.

25. Shao AF, Rambaud-Althaus C, Swai N, Kahama-Maro J, Genton B, D’Acremont V, et al. Can smartphones and tablets improve the management of childhood illness in Tanzania? A qualitative study from a primary health care worker’s perspective. BMC Health Serv Res. 2015;15.

26. Shao AF, Rambaud-Althaus C, Samaka J, Faustine AF, Perri-Moore S, Swai N, et al: New Algorithm for Managing Childhood Illness Using Mobile Technology (ALMANACH): A Controlled Non-Inferiority Study on Clinical Outcome and Antibiotic Use in Tanzania. PLoS One. 2015; 10.

27. Peters DH, Adam T, Alonge O, Agyepong IA, Tran N. Implementation research: what it is and how to do it. BMJ 2013;347.

28. Ohanu ME, Mbah AU, Okonkwo PO, Nwagbo FS. Interference by malaria in the diagnosis of typhoid using Widal test alone. West Afr J Med. 2003;22.

29. Samal KK, Sahu CS. Malaria and Widal reaction. J Assoc Physicians India. 1991;39.

30. Leonard KL, Masatu MC. Professionalism and the know-do gap: exploring intrinsic motivation among health workers in Tanzania. Health Econ 2009, 19.

31. Berner ES: Testing system accuracy. In: Berner ES, editor. Clinical decision support systems: Theory and practice. New York: Springer-Verlag New York, Inc.; 1999.

32. Maestad O, Torsvik G, Aakvik A. Overworked? On the relationship between workload and health worker performance. J Health Econ. 2010;29(5):686–98. doi: 10.1016/j.jhealeco.2010.05.006 20633940

33. Paul F. Health Worker Motivation and the Role of Performance Based Finance System in Africa: A Qualitative Study on Health Worker Motivation and the Rwandan Performance Basel Finance Initiative in District Hospitals. LSE Department of International Development (ID), London, United Kingdom. 2009;2008

34. Leshabari MT, Muhondwa EPY, Mwangu MA, Mbembati NAA. Motivation of health care workers in Tanzania: a case study of Muhimbili National Hospital. East African Journal of Public Health. 2008;5.

35. Wyber R, Vaillancourt S, Perry W, Mannava P, Folaranmi T, Celi LA. Big data in global health: improving health in low- and middle-income countries. Bull World Health Organ. 2015;93.

36. World Health Organization. WHO informal consultation in fever management in peripheral health care setting: a global review of evidence and practice. 2013. Available at:, accessed on 11 April 2019.

37. Elfving K, Shakely D, Andersson M, Baltzell K, Ali AS, Bachelard M, et al. Acute uncomplicated febrile illness in children aged 2–59 months in Zanzibarda—etiologies, antibiotic treatment and outcome. PLoS One 2016;11.

38. Risk R, Naismith H, Burnett A, Moore SE, Cham M, Unger S. Rational prescribing in paediatrics in a resource-limited setting. Arch Dis Child. 2013;98.

39. Okeke IN, Laxminarayan R, Bhutta ZA, Duse AG, Jenkins P, O'Brien TF, et al. Antimicrobial resistance in developing countries. Part I: recent trends and current status. Lancet Infect Dis. 2005;5.

40. Founou RC, Founou LL, Essack SY. Clinical and economic impact of antibiotic resistance in developing countries: A systematic review and meta-analysis. PLoS One. 2017;12

41. Chokshi A, Sifri Z, Cennimo D, Horng H. Global Contributors to Antibiotic Resistance. J Glob Infect Dis. 2019;11

42. Alividza V, Mariano V, Ahmad R, Charani E, Rawson TM, Holmes AH, et al. Investigating the impact of poverty on colonization and infection with drug-resistant organisms in humans: a systematic review. Infect Dis Poverty. 2018;7.

43. Zhang Y, Dai Y, Zhang S. Impact of implementation of Integrated Management of Childhood Illness on improvement of health system in China. J Paediatr Child Health. 2007;43

44. Taneja S, Bahl S, Mazumder S, Martines J, Bhandari N, Bhan MK. Impact on inequities in health indicators: Effect of implementing the integrated management of neonatal and childhood illness programme in Haryana, India. J Glob Health. 2015 Jun;5

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