Applying the ADAPT guidance to implement a telemedicine and medication delivery service in a malaria-endemic setting: A prospective cohort study

Background: The ADAPT guidance proposes a process model for adapting evidence-informed interventions to novel contexts. Herein, we leveraged this guidance to adapt a paediatric nighttime telemedicine and medication delivery service from Haiti, a setting with low malaria prevalence, to Ghana, where malaria is a leading cause of paediatric mortality. Methods: Core components of the intervention were defined and conserved. Discretionary components were identified and considered for adaptation. The service was defined by a workflow involving a call from a guardian of a sick child, a telemedicine assessment, referral of severe cases, and medication delivery/in-person assessments for non-severe cases. Key adaptations related to partner organisation (private to public/government), clinician type (nurse to emergency medical technician), user fees (sliding scale to none), and point-of-care testing (none to malaria rapid diagnostic testing). The adapted model was implemented in Jamestown and Usshertown, Ghana, on 16 November 2022 as part of a 12-month study to evaluate implementation outcomes and the role of the telemedicine assessment. Empiric thresholds for safety and feasibility were set a priori and served as benchmarks for this study and points of iteration for future studies. Results: In the first year of implementation, 517 cases were enrolled; 492 were included in the analysis, 96% of which were reached at 10-day follow-up. Safety and feasibility thresholds were met. 98% of febrile cases received rapid diagnostic testing for malaria; 4% tested positive. At 10 days, 97% of cases were improving/well, and no severe adverse events were reported. The median lengths of the telemedicine assessment, time to delivery, and in-person assessments were 9, 49, and 43 min, respectively. 99% of participants expressed interest in using the service again. There was fair congruence between paired telemedicine and in-person assessments for vital sign assessments and mild/moderate triage decisions. Conclusions: A nighttime paediatric telemedicine and medication delivery service adapted and implemented per the ADAPT Guidance met a priori-defined safety and feasibility metrics in the malaria-endemic country of Ghana. The role of telemedicine in assessing vital signs and informing mild versus moderate triage decisions may be limited. Trial Registration: This study was registered on Clinicaltrials.gov on 8/17/2022 (NCT05506683).