Community participation for reproductive, maternal, newborn and child health: insights from the design and implementation of the BornFyne-prenatal management system digital platform in Cameroon.

Introduction: Across communities in low-middle income countries, digital health is currently revolutionizing the delivery of health services, particularly in the field of reproductive, maternal, newborn, and child health (RMNCH) services. While studies have shown the effectiveness of mHealth in delivering RMNCH services, there is little information about factors that enhance mHealth services utilization in low-cost settings including stakeholders' level of influence on the implementation of digital health intervention in sub-Saharan Africa. This paper seeks to describe important lessons on the levels of stakeholders' direct or indirect influence on the design and implementation of the BornFyne-PNMS digital health platform to support RMNCH services. Methods: A participatory research (PR) design approach was employed to explore stakeholders' perspectives of a new initiative, through direct engagement of local priorities and perspectives. The process of introducing the digital application called the BornFyne-PNMS for district health delivery system and the community, and integrating it within the district health delivery system was guided by research-to-action, consistent with the PR approach. To explore stakeholders' perspectives through a PR approach, we conducted a series of stakeholder meetings fashioned after focus group discussions. Results: Issues around male involvement in the program, sensitization and equity concerns arose. Emergent challenges and proposed strategies for implementation from diverse stakeholders evidently enriched the design and implementation process of the project intervention. Stakeholder meetings informed the addition of variables on the mobile application that were otherwise initially omitted, which will further enhance the RMNCH electronic data collection for health information systems strengthening in Cameroon. Discussion: This study charts a direction that is critical in digital health delivery of RMNCH in a rural and low-income community and describes the important iterative stakeholder input throughout the study. The strategy of stakeholders' involvement in the BornFyne PNMS implementation charts a direction for ownership and sustainability in the strengthening of Cameroon's health information system.

Basic or enhanced clinician training to improve adherence to malaria treatment guidelines: a cluster-randomised trial in two areas of Cameroon.

BACKGROUND: The scale-up of malaria rapid diagnostic tests (RDTs) is intended to improve case management of fever and targeting of artemisinin-based combination therapy. Habitual presumptive treatment has hampered these intentions, suggesting a need for strategies to support behaviour change. We aimed to assess the introduction of RDTs when packaged with basic or enhanced clinician training interventions in Cameroon. METHODS: We did a three-arm, stratified, cluster-randomised trial at 46 public and mission health facilities at two study sites in Cameroon to compare three approaches to malaria diagnosis. Facilities were randomly assigned by a computer program in a 9:19:19 ratio to current practice with microscopy (widely available, used as a control group); RDTs with a basic (1 day) clinician training intervention; or RDTs with an enhanced (3 days) clinician training intervention. Patients (or their carers) and fieldworkers who administered surveys to obtain outcome data were masked to study group assignment. The primary outcome was the proportion of patients treated in accordance with WHO malaria treatment guidelines, which is a composite indicator of whether patients were tested for malaria and given appropriate treatment consistent with the test result. All analyses were by intention to treat. This study is registered at ClinicalTrials.gov, number NCT01350752. FINDINGS: The study took place between June 7 and Dec 14, 2011. The analysis included 681 patients from nine facilities in the control group, 1632 patients from 18 facilities in the basic-training group, and 1669 from 19 facilities in the enhanced-training group. The proportion of patients treated in accordance with malaria guidelines did not improve with either intervention; the adjusted risk ratio (RR) for basic training compared with control was 1·04 (95% CI 0·53-2·07; p=0·90), and for enhanced training compared with control was 1·17 (0·61-2·25; p=0·62). Inappropriate use of antimalarial drugs after a negative test was reduced from 84% (201/239) in the control group to 52% (413/796) in the basic-training group (unadjusted RR 0·63, 0·28-1·43; p=0·25) and to 31% (232/759) in the enhanced-training group (0·29, 0·11-0·77; p=0·02). INTERPRETATION: Enhanced clinician training, designed to translate knowledge into prescribing practice and improve quality of care, has the potential to halve overtreatment in public and mission health facilities in Cameroon. Basic training is unlikely to be sufficient to support the behaviour change required for the introduction of RDTs.

Microscopy is more reliable than questionnaire-based methods in the diagnosis of malaria in school children.

The objectives of the study were to determine by the use of a structured questionnaire the prevalence of malaria and its associated symptoms amongst school children and to relate these to the prevalence of malaria determined by microscopic examination. The questionnaire was administered to 840 pupils of classes 3, 5 and 7 (age range 5-16 years) in 17 primary schools of the Kumba Health District of Cameroon. Blood samples were collected from the same individuals for identification of malaria parasites. The prevalence rate by microscopic examination was 41.4% significantly higher (P<0.001) than 23.9% obtained by questionnaire survey. Headache and fever had similar prevalence rates (53.6% and 53.0% respectively) which were significantly higher (P<0.001) than the prevalence rate of malaria by microscopic examination. Other malaria hyphen;related symptoms gave rates which greatly underestimated the prevalence of malaria (P<0.001). There was no significant correlation between the prevalence rates obtained by questionnaire and the rate of malaria by microscopy. The sensitivity and specificity of these screening tests for malaria were all low. The use of the microscope as a malaria diagnostic tool at primary health care unit is strongly recommended.