DIGAMS: Active Digital Community Antimicrobial Stewardship

Leveraging digitized community health workers(CHWs) to actively monitor and inform antimicrobial access, usage and outcomes including resistance in communities with loose antimicrobial supply chain. 

Miiro Chraish

Head of research and PI, Mobiklinic

In low income countries(LICs) like Uganda, proper laboratory investigation before prescription of antibiotics is uncommon, and antibiotics can easily be accessed over the counter from pharmacies. Majority of Ugandans access their antibiotics through prescriptions from poorly equipped public health facilities, self-purchase from drug outlets or lately from community health workers(CHWs) for children under 5. 

This laxity in the antibiotics supply regulation has fueled poor antibiotics usage practices, blowing the antimicrobial resistance burden (AMR) out of proportion. As per WHO, 1.27 million deaths and 4.95 million deaths were attributed to, and associated with AMR respectively in 2019. Sub-Saharan Africa has the highest mortality (23.5/100,000) attributable to AMR and the world bank estimates that AMR will wipe 3.8% off the global economy by 2050. 

It may take decades to get public health systems in LICs ready to optimally implement antimicrobial stewardship practices like AWaRe protocols, and ensure timely access to essential antibiotics to a poor population. Strict enforcement of antimicrobial regulatory frameworks may deny the ordinary folk access to life saving drugs while the laxity is fueling AMR. We are therefore tasked with finding a middle ground between access and abuse, to be able to safeguard current and future lives. 

Our solution is designed to be used by, and to empower CHWs in community antimicrobial access, usage, and outcomes monitoring and guidance . Through the CHWs supported by professionals, the solution will be able to impact the antimicrobial usage practices of ordinary people in towns and last mile rural areas. 

At Mobiklinic, we currently offer digital, logistic and supervisory support to CHWs to extend basic, promotive and preventive health services. Antimicrobial monitoring through the DIGAMS feature is to be part of this buffet of community health services. 

We continuously rely on various community health workers who test use the different features and give us constructive feedback that bodes well with theirs’ and communities' preferences. They are key stakeholders from whom we learn about community health services. 

We conduct system and UX research using tools like user surveys, non-participant observations and user assessment tests among others which inform our incremental development needs and choices. Agile development is a core component of our technology sustainability. 

We deliberately recruit and engage differently abled CHWs to get key perspectives of the unique and different needs of the differently abled communities, anticipate common technology inadequacies and preemptively address them before the technology goes into production. 

Our antimicrobial resistance solution involves training of community health workers, coupled with continuous supportive supervision in antimicrobial access, use, and resistance monitoring, directly transfering knowledge to CHWs and their communities. 

Our solution is part of the Mobiklinic digital health platform that is used by CHWs to extend mostly free basic, promotive and preventive health services including vaccination delivery and maternal and child health services. It also used to in delivery of fairly costed non-communicable disease management packages to last mile communities. 

Through our solution and upon antimicrobial referral and surveillance, we are to provide a free access AMR dashboard to the ministry of health, all public and private health facilities, drug outlets and all health cadres in the communities where the solution will be implemented.

We intend to publish articles of any significant findings regarding AMR in open access, peer reviewed journal. 

Lastly and most importantly, we want this to culminate into a digital community AMR toolkit that will offer guidance for integration of our solution into other systems and similar technologies as part of open sourcing our solution. 

Our existing solutions are currently deployed in last mile, underserved communities where they have demonstrated impact in vaccine delivery, community service provision efficiency and improved healthcare practices. 

These very communities have poor antimicrobial use practices because of limited knowledge or access. With the leadership of CHWs, we shall be able to establish the true extent of antimicrobial access and usage shortcomings, it's impact on antimicrobial resistance and design community tailored solutions through DIGAMS.

With a nuanced understanding of community needs and preference, and incorporating these in our intervention, we shall be able to change antimicrobial usage practices for the better, improve their effectiveness with resultant improvement in treatment outcomes and wellbeing. 

Input

Human resources

Technology 

Smartphones

Internet connectivity

Activities

Training of CHWs 

Software development 

Supportive supervision 

Monitoring and evaluation 

Research 

Output

Knowledge assessment reports 

User satisfaction reports 

Operational DIGAMS feature 

AMR Community dashboard

Community digital AMR toolkit 

Effective AMR AI chatbot 

Outcome 

Adoption of our AMR toolkit by governments and partners 

Improved antimicrobial knowledge. 

Improved antimicrobial usage practices.  

Improved antimicrobial prescribing patterns. 

Improved antimicrobial usage outcomes

Impact. 

Reduction in AMR morbidity and mortality.  

Reduction in cost for managing antibiotics

Reduction in AMR associated DALYs. 

Improved well being of communities 

We plan to scale this solution in the following ways.

Internally: Integrate DIGAMS into our training, technology and implementation standards and procedures across all our digital platforms in rural and urban areas. This will involve creating a digital training module that will be uploaded onto our digital learning platform, and incorporating a module into our routine CHW curriculum. All our supported CHWs in Uganda and Kenya will be implementing this solution in the next 6 months. 

Knowledge dissemination: We intend to produce open peer reviewed journals to disseminate the impact of DIGAMS and a toolkit to guide on it implementation. 

Government ownership: Through the learnings generated, we shall implement a build, implement, transfer model with governments that will want to incorporate our solution in community health platforms. We shall offer assistance in technology integration and implementation support, by allocating and facilitating technical personnel to join digital health working groups under the ministries of health.

Open sourcing: Lastly, DIGAMS is meant to be a public good by design, and the source code will be open sourced to all a wider health tech developer community interact with and improve it. 

We shall conduct a baseline, and endline review of key performance metrics/indicators and do longitudinal comparison of both. 

Indicators to be monitored and tools to be used. 

• Knowledge of antimicrobial use, disposal and resistance among CHWs and the community. 

We shall use a knowledge assessment form that will be part of the baseline, post training, routine quarterly user survey and the endline survey questionnaires. 

• Knowledge of digital tools for antimicrobial monitoring and reporting. 

Technology acceptance and readiness assessment, User assessment testing tool post training, routine quarterly user survey tool.

• Number of CHWs trained, and actively using DIGAMS

User data in the back end. 

• Number of individuals and homesteads monitored for AMR. 

Backend data on a monitoring dashboard

• Number of suspected AMR cases identified and reported. 

Backend data on a monitoring dashboard

• Number of antimicrobial usage remote consultations made by CHWs

CHW user logs, displayed on a monitoring dashboard

• Number of health facilities, drug outlets and healthcare professionals using our AMR dashboard.

AMR dashboard user data

• Prevalence of antimicrobial resistance

Analysis of AMR surveillance data from referred AMR cases. 

Given that our solution relies on technology, barriers to technology acceptance, usage and adoption that are usually prominent in last mile communities may potentially impact our goals. 

1. A good number of CHWs are not currently digitized because they cannot afford smartphones. We intend to offer free smartphones to CHWs in last mile communities, and linking others to our asset financing partners for digitization. 

2. Digital illiteracy: Some CHWs may lack digital skills including basic functionalities of smartphones. We intend to train them on basic functionalities of the smartphone, and usage of our digital health solutions.

3.Internet connectivity: Despite the offline functionalities, there is always a need of routine data synchronization. To enable convenient internet access, we are in advanced discussions with a leading telecom service provider to allow free internet access for our platforms. 

4. Community resistance: Given that most new development solutions are met with a certain degree of community skepticism, we anticipate the same in implementation of our DIGAMS AMR solution. To overcome this, we shall liaise with community leaders to conduct community sensitization and engagement to allay fears of community members. CHWs are also respected community members and any solution advanced by them is highly accepted. 

We seek funding for technology development.

We seek funding to digitize at least 1000 CHWs to be able to use our solution: This will involve antimicrobial and digital knowledge and skills transfer, procurement of smartphones, internet support and continued supportive supervision. 

We seek funding for community engagement, regarding the new concepts of antimicrobial monitoring in community health service provision. 

The Oxford Institute for Antimicrobial Research and the Institute for Health Metrics and Evaluation: Structuring and comprehensive analysis of generated data, and translation of the same into practical toolkits for antimicrobial stewardship. 

Meta: To support software development and integration in REACT including practical open sourcing that will involve dedicated updating. 

We also well seek partnership in studying user data to train a competent AI chatbot, to guide CHWs on anti-microbial use, in different local languages.