Description of Project Implementation Stages

The teledermatology project was initiated in Togo in 2018 by SOTODERM with financial support from the Pierre Fabre Foundation.

Type, Period, and Scope of the Study

This was a descriptive, cross-sectional study that took place in July 2023 at the teledermatology sites set up in Togo since the project began in 2018.

The study was conducted on 47 of the 50 teledermatology sites throughout the country. The three centers that were not included in the study were areas declared unsafe by the political authorities due to terrorist attacks recorded there in the months preceding our study or due to accessibility problems.

Inclusion criteria

All health workers present at their posts at the time of the study were included in the study.

Data Collection

Data collection was performed by seven referring dermatologists using survey forms. To limit information bias, the investigators were distributed so that no dermatologist collected data on the sites for which he or she was responsible for responding to requests for expert reports.

In each center, two types of data were collected: data collected from the respondents and data collected from the registers and expertise form.

Data Collected

During a face-to-face interview, data was collected on the quality and response times of the expert.

Data on the ability to diagnose and correctly manage common dermatoses was collected by presenting photographs of common dermatoses and noting the percentage of correct diagnoses evoked by the agent, as well as the therapeutic prescriptions proposed by the agent.

Data collected on expertise sheets and registers:

Data Processing and Statistical Analysis

Data entry was performed using EPI Data software, version 3.1. Data was, then, exported for statistical analysis using STATA, version 15.1. For continuous variables, means and standard deviations were calculated, while categorical variables were presented in absolute frequencies and proportions.

Ethics Statement

All patients seen in our study gave verbal consent.

Health Centers and Agents

Our study involved 47 (94%) of the 50 teledermatology sites set up by the project. A total of 70 (70%) of the 100 agents present at the 50 teledermatology project sites were included in our study, 82.9% of whom were paramedics (nurses, medical assistants, midwives).

The agents’ diagnostic skills were assessed by presenting them with photographs (between 5 and 10) of common dermatoses. In all, 64 (91.4%) of the health-care workers scored above the benchmark for good diagnostic ability (finding more than half the diagnoses in this diagnostic quality assessment exercise). All agents mentioned the non-availability of the majority of prescribed drugs from their centers’ in-house pharmacies.

Activities on the Bogou Platform

During the period from June 2020 to July 2024 (generalization phase), 2231 cases requesting expertise were sent to the Bogou teledermatology platform by agents at the 47 sites included in our study.

The average response time was 40 hours (1.67 days), with a minimum of 2 minutes and a maximum of 1,694 hours (70.6 days). The mean age of the patients was 29 years, and the sex ratio (female-to-male) was 1.2. The average duration of evolution of the dermatoses for which the patients consulted was 17 days. In 15.1% of the cases, no diagnostic hypothesis was suggested by the agents. In 86% of cases, the expert made a definite diagnosis (Table 1). For the 1854 cases where only one diagnosis was made, there was a concordance diagnosis between the expert’s and the agent’s diagnoses in 837 cases (45.1%).

Table 1: Key data from tele-expertise activity on the Bogou platform (n=2231).

Of the 2231 cases of dermatoses referred to the Bogou platform during the study period by the 70 agents evaluated, 90.9% (1958 patients) were managed on site and 9.1% (197 patients) were referred. Of the 1958 patients managed on site, more than half (59.2%; 1,160 patients) were never seen again. Of the 798 patients reviewed, 616 (77.2%) were cured of their dermatosis.

Superficial cutaneous mycoses, pyoderma and contact dermatitis were the top three dermatoses out of the top ten dermatoses for which expert opinion was sought (Table 2).

Table 2: Main dermatoses posted on the Bogou platform in descending order.

Taking into account all types of consultations on the 47 sites (380088 consultations) in our study, dermatosis accounted for 2% (15505) of consultations or visits to these centers.

DISCUSSION

The main strength of our study was that it was not limited to collecting data on the tele-expertise platform, but also enabled us to collect data from the various actors involved in the remote care supply chain, as well as data from consultation registers, in order to put the results obtained into perspective. In addition, one of the original features of this project was the capacity-building of health agents, both upstream through training and the provision of a management guide (with iconography and management algorithms), and downstream through the supervision of these agents by dermatosis referents. Data from this evaluation confirmed the positive impact of tele-expertise on access to dermatological care in resource-limited countries [14–16].

The average response time after a request for expertise in our study was around forty hours. This compares with 22.16 hours during the pilot phase of a Togolese teledermatology project [13], and 32 hours in the pilot phase of a study by Faye et al. in Mali [10]. With the generalization phase, the number of centers has risen from 20 (pilot phase) to 50 centers, with a significant increase in the number of tele-expertise requests. This could explain the increase in response times by dermatologist experts, whose numbers had not changed since the pilot phase.

The ten main dermatoses for which expert reports were requested were, in descending order, superficial cutaneous mycoses, pyoderma, contact eczema, prurigo, erysipelas, scabies, urticaria, chickenpox, atopic dermatitis, acne. The profile of these dermatoses is virtually the same in hospitals in Togo as in other countries in the West African sub-region [10,13,17,18]. This profile confirms the preponderance of infectious dermatoses and the emergence of immunoallergic dermatoses in Africa.

The results obtained in the implementation of this project showed that teledermatology, or tele-expertise, is a good strategy for improving the quality of dermatological care in peripheral care centers, with a significant impact on resolving the problems of geographical accessibility for populations. Yet, the constraints to improving care remain the permanent unavailability of trained agents and dermatological drugs in the country’s peripheral centers.

CONCLUSION

The results obtained in the implementation of the tele-expertise project in dermatology in Togo document the positive impact on the quality of services offered by non-dermatologist health workers on the one hand and the increase in the population’s geographical accessibility to dermatological care on the other. The strategy of tele-expertise in healthcare provision is a good prospect for developing countries suffering from a chronic shortage of quality healthcare personnel. There are still, however, challenges to be overcome in terms of access to dermatological medicine for the population as part of universal access to care.