TIMCI – Tools for Integrated Management of Childhood Illness

Background

Hypoxia, a major fatal complication of pneumonia, occurs in an estimated 13% of children with pneumonia (equivalent to 1.9 million cases per year). It is one of the strongest predictors of mortality in children under five with pneumonia and other diseases. Pulse oximetry is a cheap and non-invasive method of detecting hypoxia, and its implementation, along with access to oxygen, can reduce childhood pneumonia mortality. Yet very few primary healthcare facilities in low- and middle-income countries have access to pulse oximetry and consequently have limited capacity to appropriately detect and manage children with hypoxia. In addition to the problem of missing hypoxaemia when relying on clinical signs alone,  digital tools which can guide health workers through consultations by making recommendations on assessment and management based on individual patient characteristics – have been recommended by WHO to support the implementation of guidelines such as IMCI.

Aims and methods

To evaluate the impact, cost-effectiveness and operational requirements for the introduction of pulse oximetry, supported by clinical decision support algorithms (CDSAs), to primary healthcare facilities in four countries: Kenya, Senegal, Tanzania and the Indian state of Uttar Pradesh (UP).

The TIMCI study is a mixed-method evaluation, with pragmatic cluster randomised controlled trials (RCTs) in India and Tanzania (NCT04910750), and quasi-experimental pre-post studies in Kenya and Senegal (NCT05065320), complemented by embedded mixed-method studies in all countries.

Expected Impact

If the intervention is successful, we expect that healthcare providers equipped with pulse oximetry are better able to identify children with hypoxaemia, provide urgent pre-referral treatment and refer them to a higher level of care for further treatment and supportive care, resulting in improved clinical outcomes. Alongside this, we anticipate that healthcare providers equipped with CDSAs better adhere to IMCI and other relevant child health guidelines, thus improving both detection and management of severe and non-severe illness, leading to improved outcomes and antimicrobial and other resource stewardship.

Through stakeholder engagement and consultation with the project’s International Advisory Group, we therefore selected two primary outcomes for the RCT: (i) Severe complications by Day 7 (mortality and ‘secondary hospitalisations’ i.e. delayed ≥24 hours from the Day 0 consultation, or without referral), expected to be reduced as a result of the intervention; (ii) ‘Primary’ hospitalisations (within 24 h of the Day 0 consultation and with referral), expected to increase as a result of the intervention