The impact of pulse oximetry and Integrated Management of Childhood Illness (IMCI) training on antibiotic prescribing practices in rural Malawi: A mixed-methods study

Abstract

Background: The misdiagnosis of non-malarial fever in sub-Saharan Africa has contributed to the significant burden of pediatric pneumonia and the inappropriate use of antibiotics in this region. This study aims to assess the impact of 1) portable pulse oximeters and 2) Integrated Management of Childhood Illness (IMCI) continued education training on the diagnosis and treatment of non-malarial fever amongst pediatric patients being treated by the Global AIDS Interfaith Alliance (GAIA) in rural Malawi.

Methods: This study involved a logbook review to compare treatment patterns between five GAIA mobile clinics in Mulanje, Malawi during April-June 2019. An intervention study design was employed with four study groups: 1) 2016 control, 2) 2019 control, 3) IMCI-only, and 4) IMCI and pulse oximeter. A total of 3,504 patient logbook records were included based on these inclusion criteria: age under five years, febrile, malaria-negative, and treated during the dry season. A qualitative questionnaire was distributed to the participating GAIA providers. Fisher's Exact Testing and odds ratios were calculated to compare the prescriptive practices between each study group and reported with 95% confidence intervals.

Results: The pre- and post-exam scores for the providers who participated in the IMCI training showed an increase in content knowledge and understanding (p<0.001). The antibiotic prescription rates in each study group were 75% (2016 control), 85% (2019 control), 84% (IMCI only), and 42% (IMCI + pulse oximeter) (p<0.001). An increase in pneumonia diagnoses was detected for patients who received pulse oximeter evaluation with an oxygen saturation <95% (p<0.001). No significant changes in antibiotic prescribing practices were detected in the IMCI-only group (p>0.001). However, provider responses to the qualitative questionnaires indicated alternative benefits of the training including improved illness classification and increased provider confidence.

Conclusion: Clinics that implemented both the IMCI course and pulse oximeters exhibited a significant decrease in antibiotic prescription rates, thus highlighting the potential of this tool in combatting antibiotic overconsumption in low-resource settings. Enhanced detection of hypoxia in pediatric patients was regarded by clinicians as helpful for identifying pneumonia cases. GAIA staff appreciated the IMCI continued education training, however it did not appear to significantly impact antibiotic prescription rates and/or pneumonia diagnosis.

Fig 1. Average pre- and post- exam scores for the 15 GAIA providers who participated in either the first or second IMCI continued education training course (March 4–8 or April 1–5 respectively) categorized by clinical position as either nurse or clinical officer, shown with standard deviation.

Fig 2. Percentage of U-5 NMF patients prescribed antibiotics per clinic site within each study group: Control 2016, control 2019, IMCI-only, and IMCI/Pulse Oximeter (PO).

Fig 3. Percentage of U-5 NMF patients evaluated with a pulse oximeter in clinic sites 4 and 5 over the six-week study period.

Fig 4

(Left) Most common diagnoses for patients that received pulse oximeter evaluation with a resulting oxygen saturation ≥95%. (Right) Most common diagnoses for patients that received pulse oximeter evaluation with a resulting oxygen saturation <95%. ARI = Acute Respiratory Infection; URTI = Upper Respiratory Infection; LRTI = Lower Respiratory Infection.

Fig 5. Key themes from qualitative interviews held with GAIA providers regarding their opinions of the IMCI continued education course training and the pulse oximeter.