Maintenance Notice

Due to necessary scheduled maintenance, the JMIR Publications website will be unavailable from Wednesday, July 01, 2020 at 8:00 PM to 10:00 PM EST. We apologize in advance for any inconvenience this may cause you.

Who will be affected?


Currently submitted to: Journal of Medical Internet Research

Date Submitted: Nov 15, 2020
Open Peer Review Period: Nov 15, 2020 - Jan 10, 2021
(currently open for review)

Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.

Effectiveness of smartphone-based Community Case Management on urgent referral, re-consultation and hospitalization of children under-5 in Malawi: Results of a cluster-randomized, stepped-wedge trial

  • Griphin Supporting LIFE; 
  • Griphin Baxter Chirambo; 
  • Matthew Thompson; 
  • Victoria Hardy; 
  • Nicole Ide; 
  • Phillip H Hwang; 
  • Kanika Dharmayat; 
  • Nikolaos Mastellos; 
  • Ciara Heavin; 
  • Yvonne O'Connor; 
  • Adamson S Muula; 
  • Bo Andersson; 
  • Sven Carlsson; 
  • Tammy Tran; 
  • Jenny Chen-Ling Hsieh; 
  • Hsin-Yi Lee; 
  • Annette Fitzpatrick; 
  • Joseph Tsung Shu Wu; 
  • John O'Donoghue



Integrated community case management (CCM) has led to reductions in child mortality in Malawi from illnesses such as malaria, pneumonia and diarrhoea. However, adherence to CCM guidelines is often poor, potentially leading to inappropriate clinical decisions and outcomes.


We determined the impact of an electronic version of CCM (eCCM) application on referral, re-consultation and hospitalization rates of children presenting to village clinics in Malawi.


A stepped-wedge cluster-randomized trial compared paper-based CCM (control) with and without use of an eCCM app on smartphones from November 2016 to April 2017.A total of 102 village clinics from two districts in Northern Malawi were assigned to one of six clusters which were randomized to the sequencing of crossover from the control to the intervention phases, as well as the duration of exposure in each phase. Children ≥2 months to <5 years presenting with acute illness were enrolled consecutively by Health Surveillance Assistants (HSAs). The primary outcome of urgent referrals to higher-level facilities was evaluated using multi-level mixed effects models. A logistic regression model with random effect of cluster and fixed effect for each step was fitted. Adjustment for potential confounders included baseline factors, such as patient’s age, sex, and geographical location of village clinics. Calendar time was adjusted for in the analysis.


A total of 6965 children were recruited, 3421 in the control and 3544 in the intervention phase. After adjusting for calendar time, children in the intervention phase were more likely to be urgently referred to a higher-level health facility compared with children in the control phase (OR 2.02, 95% CI 1.27-3.23; p<0.01). Overall, children in the intervention arm had lower odds of attending a repeat HSA consultation (OR 0.45, 95% CI 0.34-0.59; p<0.01) or hospital admission (OR 0.75, 95% CI 0.62-0.90; p<0.01), but after adjusting for time these differences were not significant (p>0.05).


Addition of eCCM decision support led to a greater proportion of children being referred to higher-level facilities, with no apparent increase in hospital admissions or repeat consultations in village clinics. Our findings provide support for the implementation of eCCM tools in Malawi and other Low and Middle Income Countries (LMIC), with a need for ongoing assessment of effectiveness and integration with national digital health strategies. Clinical Trial:; NCT02763345. Registered 3 May 2016


Please cite as:

Supporting LIFE G, Chirambo GB, Thompson M, Hardy V, Ide N, Hwang PH, Dharmayat K, Mastellos N, Heavin C, O'Connor Y, Muula AS, Andersson B, Carlsson S, Tran T, Hsieh JC, Lee H, Fitzpatrick A, Tsung Shu Wu J, O'Donoghue J

Effectiveness of smartphone-based Community Case Management on urgent referral, re-consultation and hospitalization of children under-5 in Malawi: Results of a cluster-randomized, stepped-wedge trial

JMIR Preprints. 15/11/2020:25777

DOI: 10.2196/preprints.25777


Download PDF

Request queued. Please wait while the file is being generated. It may take some time.

© The authors. All rights reserved. This is a privileged document currently under peer-review/community review (or an accepted/rejected manuscript). Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for review and ahead-of-print citation purposes only. While the final peer-reviewed paper may be licensed under a cc-by license on publication, at this stage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.