Acceptability and uptake of an electronic decision-making tool to support the implementation of IMCI in primary healthcare facilities in KwaZulu-Natal, South Africa

ABSTRACT

Background: Despite progress in reducing child mortality, preventable child deaths remain a challenge in South Africa. Poor implementation of Integrated Management of Childhood Illness (IMCI) guidelines has been well described, and the reported barriers to implementation include a lack of user-friendly implementation tools.

Aim: To investigate whether an electronic decision support tool to strengthen IMCI implementation is acceptable to nurses, clinic managers and caregivers at primary care facilities in KwaZulu-Natal, South Africa.

Methods: The electronic IMCI (eIMCI) software was tested in 15 health facilities in uMgungundlovu district from May to July 2018. System use was tracked and qualitative data obtained from three user groups. IMCI practitioners participated in questionnaires and focus groups, operational managers in in-depth interviews and caregivers in exit interviews.

Results: Thirty-two IMCI practitioners, six operational managers and 30 caregivers were included. Acceptance was high among caregivers and operational managers, albeit less conclusive among IMCI practitioners whose eIMCI uptake indicated higher variability in acceptance than the qualitative reports. Despite suboptimal staff deployment after training and low baseline computer literacy levels, 3626 eIMCI records were captured across 12 sites over 14 weeks, with a median of 19 records per facility per week. Practitioners’ indicators of self-efficacy improved significantly (p < 0.05) post-implementation compared to baseline. Seventy-six percent of caregivers reported a marked difference in experience compared to previous consultations, emphasising the comprehensiveness and efficiency of care.

Conclusion: Uptake was promising and acceptance was good, with themes converging across participant groups to highlight improved comprehensiveness and efficiency of service. Limited computer literacy was the principal barrier to uptake. The next steps include incremental scale-up with stronger mentoring and supervision components and evaluations to assess the feasibility, effectiveness and cost-effectiveness of eIMCI implementation.

Abbreviations: CDSS: clinical decision support system; CHCs: community health centres; DoH: Department of Health; eIMCI: electronic IMCI; eHealth: electronic health; EHR: electronic health records; ICT: information and communication technology; IMCI: Integrated Management of Childhood Illness; OM: operational managers; PHCs: primary healthcare clinics; SA: South Africa; SSA: sub-Saharan Africa.

KEYWORDS:

• Integrated Management of Childhood Illness
• electronic health
• clinical decision support systems
• sub-Saharan Africa
• South Africa
• acceptability
• uptake

Disclosure statement

No potential conflict of interest was reported by the authors.

Appendix

Additional information

Funding

The work was supported by the ELMA Foundation under the ‘Unfinished Business’ grant, addressing paediatric components of the UNAIDS 90-90-90 strategy for HIV, TB and malnutrition. The funding organisation had no role in the design, implementation, interpretation or publication of the study.

Notes on contributors

Cecilie Jensen

Cecilie Jensen received her medical degree from the University of Bergen, Norway. Currently working at Health Systems Trust in South Africa, she is collaborating with the KwaZulu-Natal Department of Health to strengthen systems for child health at primary care level. Interests include primary healthcare, infectious diseases, child health and health systems.

Neil H. McKerrow

Neil H. McKerrow is the Provincial Paediatrician and head of Paediatrics and Child Health for KwaZulu-Natal responsible for health services for children across the province; chair of the Ministerial Committee on Morbidity and Mortality in Under under-5 years (CoMMiC); co-chair of the WHO Technical Advisory Group on Child Health Accountability and Tracking (CHAT); and honorary lecturer in the Departments of Paediatrics and Child Health of the Universities of Cape Town and KwaZulu-Natal. Interests include child health, health systems and social paediatrics.

Gabrielle Wills is an economist with Research on Socio-Economic Policy in the Department of Economics at Stellenbosch University. Her current research interest is public service delivery reform, particularly in the education sector. Her research experience is predominantly quantitative, conducting analyses using large-scale administrative data, household survey data or data collected through randomised control trials.