Using rubber stamps and mobile phones to help understand and change antibiotic prescribing behaviour in private sector primary healthcare clinics in Kenya

Abstract

BackgroundAntibiotic use in primary care can drive antimicrobial resistance (AMR) in the community. However, our understanding of antibiotic prescribing in low- and middle-income countries (LMICs) stems mostly from hospital-based studies or prescription/sales records, with little information available on routine primary care practices. We used an innovative, paper-to-digital documentation approach to deliver routine data and understand antibiotic use for common infections in low-resource primary healthcare clinics (PHCs).MethodsRubber stamps were introduced in nine private sector PHCs serving Nairobi’s informal settlements to ‘print-on-demand’ clinical documentation templates into paper charts. The intervention included one mobile phone per PHC to take and share images of filled templates, guideline compilation booklets and monthly continuing medical education (CME) sessions. Templates for upper respiratory tract (URTI), urinary tract (UTI), sexually transmitted (STI) and gastrointestinal infection (GI) management were used in eight PHCs. Information in templates from 889 patient encounters was digitised from smartphone images, analysed, and fed back to clinicians during monthly CME sessions. UTI charts (n=130 and 96, respectively) were audited preintervention and postintervention for quality of clinical documentation and management.ResultsAntibiotics were prescribed in 94.3%±1.6% of all patient encounters (97.3% in URTI, 94.2% in UTI, 91.6% in STI and 91.3% in GI), with 1.4±0.4 antibiotics prescribed per encounter. Clinicians considered antibiotic use appropriate in only 58.6% of URTI and 47.2% of GI cases. While feedback did not affect the number of antibiotics prescribed for UTIs, the use of nitrofurantoin, an appropriate, narrow-spectrum antibiotic, increased (9.2% to 29.9%; p<0.0001) and use of broad spectrum quinolones decreased (30.0% to 16.1%; p<0.05).ConclusionAntibiotic use for common infections is high in private sector PHCs in Kenya, with both knowledge and ‘know-do’ gaps contributing to inappropriate prescription. Paper-based templates in combination with smartphone technologies can sustainably deliver routine primary care case management data to support the battle against AMR.

Tackling antimicrobial resistance in low-income and middle-income countries

“…Driven by the desire to get well soon and at minimal cost (again, a quick fix), patients often demand treatment regardless of the type of infection (bacterial or viral) and avoid necessary investigations during consultations 7. For instance, in Kenya, patient expectations were often felt as pressure by healthcare practitioners to prescribe antibiotics 17…”

Digital ≠ paperless: novel interfaces needed to address global health challenges

“…Recent work demonstrates the combination of paper-based clinical documentation templates containing OMR fields, with a computer vision algorithm on smartphones to automatically digitise patient records. 12 In this case, templates are printed using rubber stamps, a widely available and low-cost solution for printing on demand, and the algorithm generates digital data from a smartphone picture of the template (figure 1). The approach has demonstrated improvements in both clinical documentation 13 and care quality 12 with minimal infrastructure or training.…”

“…12 In this case, templates are printed using rubber stamps, a widely available and low-cost solution for printing on demand, and the algorithm generates digital data from a smartphone picture of the template (figure 1). The approach has demonstrated improvements in both clinical documentation 13 and care quality 12 with minimal infrastructure or training. While useful for capturing structured data, the approach does not support capture of narrative information, or continuous variables like heart rate.…”

Behavioural interventions to address rational use of antibiotics in outpatient settings of low‐income and lower‐middle‐income countries

“…None of the included studies examined purely persuasive interventions, although similar components were included as part of a bundle intervention in nine studies [26,28,30,32,[34][35][36][37][38]. Two studies were classified as enabling interventions that relied on continued medical education, other forms of education or guidelines for antibiotic use [27,29].…”

“…The majority of these 29 studies were excluded due to misclassification as an LMIC: for instance, several studies were from China, which the World Bank currently classifies as an upper-middle-income country. 13 studies were included after full-text review [26][27][28][29][30][31][32][33][34][35][36][37][38]. Given the heterogeneity in interventions and study designs, we present our results using a narrative synthesis approach without a meta-analysis.…”