The Effect of Mobile Phone Text Message Reminders on Health Workers' Adherence to Malaria and Other Disease Case Management Guidelines in Malawi

Background Mobile health, or m-health includes the use of portable devices, such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices to support medical and public health practice. Mobile phones are widespread in Asia and Africa, and dissemination of health-related messages via mobile phones is an inexpensive way to reach geographically dispersed recipients. Evidence from developing countries, is scarce, particularly for improving health service delivery. Only one rigorously designed study, a randomized controlled trial in Kenya, assessed the use of mobile phone text messaging to improve health worker case management practices, showing that sending daily text message reminders to health workers over six months led to a 24-percentage-point improvement in correct management of uncomplicated malaria.

Malaria is endemic throughout Malawi and poses a significant burden for the health system. Malawi changed its malaria case management guidelines in 2011 to require diagnostic confirmation with microscopy or a malaria rapid diagnostic test (RDT) prior to treatment. A health facility survey in 2011 prior to the rollout of RDTs found that only 67% of patients with malaria were correctly treated, primarily due to a missed diagnosis of malaria. Although more recent assessments are lacking, it is likely that Malawi faces similar problems documented in other sub-Saharan African countries: non-systematic diagnostic testing of febrile patients for malaria, poor adherence to negative test results, failure to administer the first dose of antimalarial therapy during the consultation, and gaps in patient counseling. Furthermore, additional assessments have pointed to deficiencies in quality of care for other common illnesses in Malawi, such as pneumonia and diarrhea, which are similar to some of the widespread quality problems found in other developing countries.

Study design and objectives

This study is a trial of text message reminders to health workers in Malawi to improve case management of malaria and other common illnesses. The study will employ a cluster-randomized, controlled trial design with pre- and post-intervention measures, with health facilities as the cluster and unit of randomization. In several districts of Malawi, health facilities will be randomized to one of three arms:

1. Text messages to health facility-based health workers on the correct management of malaria (patients of all ages)
2. Text messages to health facility-based health workers on the correct management of malaria (patients of all ages) and other common illnesses, per Integrated Management of Childhood Illness guidelines (patients < 5 years)
3. Control health facilities where health workers receive no study intervention (only routine supervision and supports from supervisors and district health management team, which will occur in text message arms as well)