The feasibility and ongoing use of electronic decision support to strengthen the implementation of IMCI in KwaZulu-Natal, South Africa.

BACKGROUND: Continued efforts are required to reduce preventable child deaths. User-friendly Integrated Management of Childhood Illness (IMCI) implementation tools and supervision systems are needed to strengthen the quality of child health services in South Africa. A 2018 pilot implementation of electronic IMCI case management algorithms in KwaZulu-Natal demonstrated good uptake and acceptance at primary care clinics. We aimed to investigate whether ongoing electronic IMCI implementation is feasible within the existing Department of Health infrastructure and resources. METHODS: In a mixed methods descriptive study, the electronic IMCI (eIMCI) implementation was extended to 22 health facilities in uMgungundlovu district from November 2019 to February 2021. Training, mentoring, supervision and IT support were provided by a dedicated project team. Programme use was tracked, quarterly assessments of the service delivery platform were undertaken and in-depth interviews were conducted with facility managers. RESULTS: From December 2019 - January 2021, 9 684 eIMCI records were completed across 20 facilities, with a median uptake of 29 records per clinic per month and a mean (range) proportion of child consultations using eIMCI of 15% (1-46%). The local COVID-19-related movement restrictions and epidemic peaks coincided with declines in the monthly eIMCI uptake. Substantial inter- and intra-facility variations in use were observed, with the use being positively associated with the allocation of an eIMCI trained nurse (p < 0.001) and the clinician workload (p = 0.032). CONCLUSION: The ongoing eIMCI uptake was sporadic and the implementation undermined by barriers such as low post-training deployment of nurses; poor capacity in the DoH for IT support; and COVID-19-related disruptions in service delivery. Scaling eIMCI in South Africa would rely on resolving these challenges.

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

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.

Safety and efficacy of zinc supplementation for children with HIV-1 infection in South Africa: a randomised double-blind placebo-controlled trial.

BACKGROUND: Zinc deficiency is associated with impaired immune function and an increased risk of infection. Supplementation can decrease the incidence of diarrhoea and pneumonia in children in resource-poor countries. However, in children with HIV-1 infection, the safety of zinc supplementation is uncertain. We aimed to assess the role of zinc in HIV-1 replication before mass zinc supplementation is recommended in regions of high HIV-1 prevalence. METHODS: We did a randomised double-blind placebo-controlled equivalence trial of zinc supplementation at Grey's Hospital in Pietermaritzburg, South Africa. 96 children with HIV-1 infection were randomly assigned to receive 10 mg of elemental zinc as sulphate or placebo daily for 6 months. Baseline measurements of plasma HIV-1 viral load and the percentage of CD4+ T lymphocytes were established at two study visits before randomisation, and measurements were repeated 3, 6, and 9 months after the start of supplementation. The primary outcome measure was plasma HIV-1 viral load. Analysis was per protocol. FINDINGS: The mean log(10) HIV-1 viral load was 5.4 (SD 0.61) for the placebo group and 5.4 (SD 0.66) for the zinc-supplemented group 6 months after supplementation began (difference 0.0002, 95% CI -0.27 to 0.27). 3 months after supplementation ended, the corresponding values were 5.5 (SD 0.77) and 5.4 (SD 0.61), a difference of 0.05 (-0.24 to 0.35). The mean percentage of CD4+ T lymphocytes and median haemoglobin concentrations were also similar between the two groups after zinc supplementation. Two deaths occurred in the zinc supplementation group and seven in the placebo group (p=0.1). Children given zinc supplementation were less likely to get watery diarrhoea than those given placebo. Watery diarrhoea was diagnosed at 30 (7.4%) of 407 clinic visits in the zinc-supplemented group versus 65 (14.5%) of 447 visits in the placebo group (p=0.001). INTERPRETATION: Zinc supplementation of HIV-1-infected children does not result in an increase in plasma HIV-1 viral load and could reduce morbidity caused by diarrhoea. RELEVANCE TO PRACTICE: Programmes to enhance zinc intake in deficient populations with a high prevalence of HIV-1 infection can be implemented without concern for adverse effects on HIV-1 replication. In view of the reductions in diarrhoea and pneumonia morbidity, zinc supplementation should be used as adjunct therapy for children with HIV-1 infection.