Usability and feasibility of a tablet-based Decision-Support and Integrated Record-keeping (DESIRE) tool in the nurse management of hypertension in rural western Kenya

How Is Telehealth Currently Being Utilized to Help in Hypertension Management within Primary Healthcare Settings? A Scoping Review

Telehealth has improved patient access to healthcare services and has been shown to have a positive impact in various healthcare settings. In any case, little is understood regarding the utilization of telehealth in hypertension management in primary healthcare (PHC) settings. This study aimed to identify and classify information about the types of interventions and types of telehealth technology in hypertension management in primary healthcare. A scoping review based on PRISMA-ScR was used in this study. We searched for articles in four databases: Pubmed, Scopus, Science Direct, and Embase in English. The selected articles were published in 2013-2023. The data were extracted, categorized, and analyzed using thematic analysis. There were 1142 articles identified and 42 articles included in this study. Regarding the proportions of studies showing varying trends in the last ten years, most studies came from the United States (US) (23.8%), were conducted in urban locations (33.3%), and had a quantitative study approach (69%). Telehealth interventions in hypertension management are dominated by telemonitoring followed by teleconsultation. Asynchronous telehealth is becoming the most widely used technology in managing hypertension in primary care settings. Telehealth in primary care hypertension management involves the use of telecommunications technology to monitor and manage blood pressure and provide medical advice and counselling remotely.

Acceptability and use of the electronic community health information system and its determinants among health extension workers in Ethiopia: a retrospective cross-sectional observational study

BACKGROUND

The electronic community health information system has been increasingly developed and deployed to quantify and support quality health service delivery by community health workers in Ethiopia. However, the success and failure of the electronic community health information system depend on the acceptability and use by its users. This study assessed the acceptability and use of the electronic community health information system and its determinants among health extension workers in Ethiopia.

METHODS

A retrospective cross-sectional observational study was conducted among 587 randomly selected health extension workers from six regions of Ethiopia. The Revised Technology Acceptance Model was used as a theoretical framework for the study. Descriptive statistics, structural equation modeling, and principal component analysis techniques were used to analyze the data. For all significance tests, multiple comparison adjustments were made using the Bonferroni Correction Method.

RESULTS

There was near universal acceptance of the electronic community health information system, ranging from 94.4 to 97.4% among health extension workers. However, actual use of the system was considerably lower, at 50%. Perceived usefulness of the electronic community health information system had a direct and positive effect on acceptability (β3 = 0.415, p < 0.001). Perceived ease of use had both direct and indirect positive effects on electronic community health information system acceptability (β2 = 0.340, p < 0.001 and β1*β3 = 0.289, p < 0.001, respectively), while acceptability had a direct and positive effect on the use of the electronic community health information system (β3 = 0.297, p < 0.001).

CONCLUSIONS

Despite the very high acceptability of the electronic community health information system among health extension workers, actual use of the system is considerably lower. Hence, an integrated and coordinated approach is required to close the acceptance-use gap.

The Vinyasa Tool for mHealth Solutions: Supporting Human-Centered Design in Nascent Digital Health Ecosystems

BACKGROUND

mHealth (mobile health) systems have been deployed widely in low- and middle-income countries (LMICs) for health system strengthening, requiring considerable resource allocation. However, most solutions have not achieved scale or sustainability. Poor usability and failure to address perceived needs are among the principal reasons mHealth systems fail to achieve acceptance and adoption by health care workers. A human-centered design approach to improving mHealth system use requires an exploration of users' perceptions of mHealth systems, including the environmental, user-related, and technological aspects of a system. At present, there is a dearth of contextually intelligent tools available to mHealth developers that can guide such exploration before full-scale development and deployment.

OBJECTIVE

To develop a tool to aid optimization of mHealth solutions in LMICs to facilitate human-centered design and, consequently, successful adoption.

METHODS

We collated findings and themes from key qualitative studies on mHealth deployment in LMICs. We then used the Informatics Stack framework by Lehmann to label, sort, and collate findings and themes into a list of questions that explore the environment, users, artifacts, information governance, and interoperability of mHealth systems deployed in LMICs.

RESULTS

We developed the Vinyasa Tool to aid qualitative research about the need and usability of mHealth solutions in LMICs. The tool is a guide for focus group discussions and key informant interviews with community-based health care workers and primary care medical personnel who use or are expected to use proposed mHealth solutions. The tool consists of 71 questions organized in 11 sections that unpack and explore multiple aspects of mHealth systems from the perspectives of their users. These include the wider world and organization in which an mHealth solution is deployed; the roles, functions, workflow, and adoption behavior of a system's users; the security, privacy, and interoperability afforded by a system; and the artifacts of an information system-the data, information, knowledge, algorithms, and technology that constitute the system. The tool can be deployed in whole or in part, depending on the context of the study.

CONCLUSIONS

The Vinyasa Tool is the first such comprehensive qualitative research instrument incorporating questions contextualized to the LMIC setting. We expect it to find wide application among mHealth developers, health system administrators, and researchers developing and deploying mHealth tools for use by patients, providers, and administrators. The tool is expected to guide users toward human-centered design with the goal of improving relevance, usability, and, therefore, adoption.

Community engagement to inform development of strategies to improve referral for hypertension: perspectives of patients, providers and local community members in western Kenya

BACKGROUND

Hypertension is the leading cause of death and disability. Clinical care for patients with hypertension in Kenya leverages referral networks to provide basic and specialized healthcare services. However, referrals are characterized by non-adherence and delays in completion. An integrated health information technology (HIT) and peer-based support strategy to improve adherence to referrals and blood pressure control was proposed. A formative assessment gathered perspectives on barriers to referral completion and garnered thoughts on the proposed intervention.

METHODS

We conducted a qualitative study in Kitale, Webuye, Kocholya, Turbo, Mosoriot and Burnt Forest areas of Western Kenya. We utilized the PRECEDE-PROCEED framework to understand the behavioral, environmental and ecological factors that would influence uptake and success of our intervention. We conducted four mabaraza (customary heterogenous community assemblies), eighteen key informant interviews, and twelve focus group discussions among clinicians, patients and community members. The data obtained was audio recorded alongside field note taking. Audio recordings were transcribed and translated for onward coding and thematic analysis using NVivo 12.

RESULTS

Specific supply-side and demand-side barriers influenced completion of referral for hypertension. Key demand-side barriers included lack of money for care and inadequate referral knowledge. On the supply-side, long distance to health facilities, low availability of services, unaffordable services, and poor referral management were reported. All participants felt that the proposed strategies could improve delivery of care and expressed much enthusiasm for them. Participants appreciated benefits of the peer component, saying it would motivate positive patient behavior, and provide health education, psychosocial support, and assistance in navigating care. The HIT component was seen as reducing paper work, easing communication between providers, and facilitating tracking of patient information. Participants also shared concerns that could influence implementation of the two strategies including consent, confidentiality, and reduction in patient-provider interaction.

CONCLUSIONS

Appreciation of local realities and patients' experiences is critical to development and implementation of sustainable strategies to improve effectiveness of hypertension referral networks. Incorporating concerns from patients, health care workers, and local leaders facilitates adaptation of interventions to respond to real needs. This approach is ethical and also allows research teams to harness benefits of participatory community-involved research.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03543787, Registered June 1, 2018. https://clinicaltrials.gov/ct2/show/NCT03543787.

Barriers, facilitators and motivators of electronic community health information system use among health workers in Ethiopia

Background

The electronic community health information system (eCHIS) has been implemented in Ethiopia to support health services delivered by community health workers. Despite the many benefits of digitizing community health information systems, the implementation of the eCHIS is challenged by many barriers resulting in low uptake. This study assessed the barriers, facilitators, and motivators of eCHIS use among health workers with focus on health extension workers (HEWs) in Ethiopia.

Methods

Phenomenological approach was used to assess the barriers, facilitators and motivators of eCHIS use in Amhara, Harari, Oromia, Sidama, South West Ethiopia and Southern Nation Nationalities and People's regions of Ethiopia. Data were collected from 15-29 May 2022. A total of 54 face-to-face in-depth interviews were conducted among HEWs, HEW supervisors, health information technicians and managers. The interviews were audiotaped using Open Data Kit, transcribed verbatim and translated into English. OpenCode 4.03 software was used for coding and categorizing the data. Thematic analysis was used to analyze the data.

Results

The HEWs and other eCHIS users reported lack of infrastructure and resources; poor quality of training, follow-up, and supervision; parallel recording using the manual and electronic system; and HEWs' workload as barriers hindering eCHIS use. Data quality, retrievability, and traceability; tablet portability; encouragement from supervisors; and positive image in the community resulting from HEWs using tablets in their routine activities were the main facilitators of eCHIS use.

Conclusion

The study identified various barriers that adversely affect the use of eCHIS. An integrated and coordinated approach to eCHIS implementation that encompasses removing the barriers, and reinforcing facilitators is required.

Scoping review of health information technology usability methods leveraged in Africa

OBJECTIVE

The aim of this study was to explore the state of health information technology (HIT) usability evaluation in Africa.

MATERIALS AND METHODS

We searched three electronic databases: PubMed, Embase, and Association for Computing Machinery. We categorized the stage of evaluations, the type of interactions assessed, and methods applied using Stead's System Development Life Cycle (SDLC) and Bennett and Shackel's usability models.

RESULTS

Analysis of 73 of 1002 articles that met inclusion criteria reveals that HIT usability evaluations in Africa have increased in recent years and mainly focused on later SDLC stage (stages 4 and 5) evaluations in sub-Saharan Africa. Forty percent of the articles examined system-user-task-environment (type 4) interactions. Most articles used mixed methods to measure usability. Interviews and surveys were often used at each development stage, while other methods, such as quality-adjusted life year analysis, were only found at stage 5. Sixty percent of articles did not include a theoretical model or framework.

DISCUSSION

The use of multistage evaluation and mixed methods approaches to obtain a comprehensive understanding HIT usability is critical to ensure that HIT meets user needs.

CONCLUSIONS

Developing and enhancing usable HIT is critical to promoting equitable health service delivery and high-quality care in Africa. Early-stage evaluations (stages 1 and 2) and interactions (types 0 and 1) should receive special attention to ensure HIT usability prior to implementing HIT in the field.

Healthcare Workers' Perspectives of mHealth Adoption Factors in the Developing World: Scoping Review

BACKGROUND

mHealth applications provide health practitioners with platforms that enable disease management, facilitate drug adherence, facilitate drug adherence, speed up diagnosis, monitor outbreaks, take and transfer medical images, and provide advice. Many developing economies are investing more in mobile telecommunication infrastructure than in road transport and electric power generation. Despite this, mHealth has not seen widespread adoption by healthcare workers in the developing world. This study reports a scoping review of factors that impact the adoption of mHealth by healthcare workers in the developing world, and based on these findings, a framework is developed for enhancing mHealth adoption by healthcare workers in the developing world.

METHODS

A structured literature search was performed using PubMed and Scopus, supplemented by hand searching. The searches were restricted to articles in English during the period January 2009 to December 2019 and relevant to the developing world that addressed: mobile phone use by healthcare workers and identified factors impacting the adoption of mHealth implementations. All authors reviewed selected papers, with final inclusion by consensus. Data abstraction was performed by all authors. The results were used to develop the conceptual framework using inductive iterative content analysis.

RESULTS AND DISCUSSION

Of 919 articles, 181 met the inclusion criteria and, following a review of full papers, 85 reported factors that impact (promote or impede) healthcare worker adoption of mHealth applications. These factors were categorised into 18 themes and, after continued iterative review and discussion were reduced to 7 primary categories (engagement/funding, infrastructure, training/technical support, healthcare workers' mobile-cost/ownership, system utility, motivation/staffing, patients' mobile-cost/ownership), with 17 sub-categories. These were used to design the proposed framework.

CONCLUSIONS

Successful adoption of mHealth by healthcare workers in the developing world will depend on addressing the factors identified in the proposed framework. They must be assessed in each specific setting prior to mHealth implementation. Application of the proposed framework will help shape future policy and practice of mHealth implementation in the developing world and increase adoption by health workers.

Barriers and enablers to implementing and using clinical decision support systems for chronic diseases: a qualitative systematic review and meta-aggregation

Background

Clinical decision support (CDS) is increasingly used to facilitate chronic disease care. Despite increased availability of electronic health records and the ongoing development of new CDS technologies, uptake of CDS into routine clinical settings is inconsistent. This qualitative systematic review seeks to synthesise healthcare provider experiences of CDS—exploring the barriers and enablers to implementing, using, evaluating, and sustaining chronic disease CDS systems.

Methods

A search was conducted in Medline, CINAHL, APA PsychInfo, EconLit, and Web of Science from 2011 to 2021. Primary research studies incorporating qualitative findings were included if they targeted healthcare providers and studied a relevant chronic disease CDS intervention. Relevant CDS interventions were electronic health record-based and addressed one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolaemia. Qualitative findings were synthesised using a meta-aggregative approach.

Results

Thirty-three primary research articles were included in this qualitative systematic review. Meta-aggregation of qualitative data revealed 177 findings and 29 categories, which were aggregated into 8 synthesised findings. The synthesised findings related to clinical context, user, external context, and technical factors affecting CDS uptake. Key barriers to uptake included CDS systems that were simplistic, had limited clinical applicability in multimorbidity, and integrated poorly into existing workflows. Enablers to successful CDS interventions included perceived usefulness in providing relevant clinical knowledge and structured chronic disease care; user confidence gained through training and post training follow-up; external contexts comprised of strong clinical champions, allocated personnel, and technical support; and CDS technical features that are both highly functional, and attractive.

Conclusion

This systematic review explored healthcare provider experiences, focussing on barriers and enablers to CDS use for chronic diseases. The results provide an evidence-base for designing, implementing, and sustaining future CDS systems. Based on the findings from this review, we highlight actionable steps for practice and future research.

Trial registration

PROSPERO CRD42020203716

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00326-x.

Community-based medication delivery program for antihypertensive medications improves adherence and reduces blood pressure

Non-adherence to antihypertensive medications is a major cause of uncontrolled hypertension, leading to cardiovascular morbidity and mortality. Ensuring consistent medication possession is crucial in addressing non-adherence. Community-based medication delivery is a strategy that may improve medication possession, adherence, and blood pressure (BP) reduction. Our program in Kenya piloted a community medication delivery program, coupled with blood pressure monitoring and adherence evaluation. Between September 2019 and March 2020, patients who received hypertension care from our chronic disease management program also received community-based delivery of antihypertensive medications. We calculated number of days during which each patient had possession of medications and analyzed the relationship between successful medication delivery and self-reported medication adherence and BP. A total of 128 patient records (80.5% female) were reviewed. At baseline, mean systolic blood pressure (SBP) was 155.7 mmHg and mean self-reported adherence score was 2.7. Sixty-eight (53.1%) patients received at least 1 successful medication delivery. Our pharmacy dispensing records demonstrated that medication possession was greater among patients receiving medication deliveries. Change in self-reported medication adherence from baseline worsened in patients who did not receive any medication delivery (+0.5), but improved in patients receiving 1 delivery (-0.3) and 2 or more deliveries (-0.8). There was an SBP reduction of 1.9, 6.1, and 15.5 mmHg among patients who did not receive any deliveries, those who received 1 delivery, and those who received 2 or more medication deliveries, respectively. Adjusted mixed-effect model estimates revealed that mean SBP reduction and self-reported medication adherence were improved among individuals who successfully received medication deliveries, compared to those who did not. A community medication delivery program in western Kenya was shown to be implementable and enhanced medication possession, reduced SBP, and significantly improved self-reported adherence. This is a promising strategy to improve health outcomes for patients with uncontrolled hypertension that warrants further investigation.

Leveraging mHealth usage logs to inform health worker performance in a Resource-Limited setting: Case example of mUzima use for a chronic disease program in Western Kenya

BACKGROUND

Health systems in low- and middle-income countries (LMICs) can be strengthened when quality information on health worker performance is readily available. With increasing adoption of mobile health (mHealth) technologies in LMICs, there is an opportunity to improve work-performance and supportive supervision of workers. The objective of this study was to evaluate usefulness of mHealth usage logs (paradata) to inform health worker performance.

METHODOLOGY

This study was conducted at a chronic disease program in Kenya. It involved 23 health providers serving 89 facilities and 24 community-based groups. Study participants, who already used an mHealth application (mUzima) during clinical care, were consented and equipped with an enhanced version of the application that captured usage logs. Three months of log data were used to determine work performance metrics, including: (a) number of patients seen; (b) days worked; (c) work hours; and (d) length of patient encounters.

PRINCIPAL FINDINGS

Pearson correlation coefficient for days worked per participant as derived from logs as well as from records in the Electronic Medical Record system showed a strong positive correlation between the two data sources (r(11) = .92, p < .0005), indicating mUzima logs could be relied upon for analyses. Over the study period, only 13 (56.3%) participants used mUzima in 2,497 clinical encounters. 563 (22.5%) of encounters were entered outside of regular work hours, with five health providers working on weekends. On average, 14.5 (range 1-53) patients were seen per day by providers.

CONCLUSIONS / SIGNIFICANCE

mHealth-derived usage logs can reliably inform work patterns and augment supervision mechanisms made particularly challenging during the COVID-19 pandemic. Derived metrics highlight variabilities in work performance between providers. Log data also highlight areas of suboptimal use, of the application, such as for retrospective data entry for an application meant for use during the patient encounter to best leverage built-in clinical decision support functionality.

Digital Solutions for Community and Primary Health Workers: Lessons From Implementations in Africa

The agenda for Universal Health Coverage has driven the exploration of various innovative approaches to expanding health services to the general population. As more African countries have adopted digital health tools as part of the strategic approach to expanding health services, there is a need for defining a standard framework for implementation across board. Therefore, there is a need to review and employ an evidence-based approach to inform managing challenges, adopting best approaches, and implement informed recommendations. We reviewed a variety of digital health tools applied to different health conditions in primary care settings and highlighted the challenges faced, approaches that worked and relevant recommendations. These include limited coverage and network connectivity, lack of technological competence, lack of power supply, limited mobile phone usage and application design challenges. Despite these challenges, this review suggests that mHealth solutions could attain effective usage when healthcare workers receive adequate onsite training, deploying applications designed in an intuitive and easy to understand approach in a manner that fits into the users existing workflows, and involvement of the stakeholders at all levels in the design, planning, and implementation stages of the interventions.

Use of technology to prevent, detect, manage and control hypertension in sub-Saharan Africa: a systematic review

OBJECTIVE

To identify and assess the use of technologies, including mobile health technology, internet of things (IoT) devices and artificial intelligence (AI) in hypertension healthcare in sub-Saharan Africa (SSA).

DESIGN

Systematic review.

DATA SOURCES

Medline, Embase, Scopus and Web of Science.

ELIGIBILITY CRITERIA

Studies addressing outcomes related to the use of technologies for hypertension healthcare (all points in the healthcare cascade) in SSA.

METHODS

Databases were searched from inception to 2 August 2021. Screening, data extraction and risk of bias assessment were done in duplicate. Data were extracted on study design, setting, technology(s) employed and outcomes. Blood pressure (BP) reduction due to intervention was extracted from a subset of randomised controlled trials. Methodological quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

1717 hits were retrieved, 1206 deduplicated studies were screened and 67 full texts were assessed for eligibility. 22 studies were included, all reported on clinical investigations. Two studies were observational, and 20 evaluated technology-based interventions. Outcomes included BP reduction/control, treatment adherence, retention in care, awareness/knowledge of hypertension and completeness of medical records. All studies used mobile technology, three linked with IoT devices. Short Message Service (SMS) was the most popular method of targeting patients (n=6). Moderate BP reduction was achieved in three randomised controlled trials. Patients and healthcare providers reported positive perceptions towards the technologies. No studies using AI were identified.

CONCLUSIONS

There are a range of successful applications of key enabling technologies in SSA, including BP reduction, increased health knowledge and treatment adherence following targeted mobile technology interventions. There is evidence to support use of mobile technology for hypertension management in SSA. However, current application of technologies is highly heterogeneous and key barriers exist, limiting efficacy and uptake in SSA. More research is needed, addressing objective measures such as BP reduction in robust randomised studies.

PROSPERO REGISTRATION NUMBER

CRD42020223043.

Role of mobile health in the situation of COVID-19 pandemics: pros and cons

Mobile health (mHealth), an abbreviated term used for portable healthcare, is characterized by the World Health Organization (WHO) as an utilization of portable healthcare monitoring equipments by the health care delivery system. The review article is based on the utilization of the mobile phones in the form of text information, image sharing, video call, doctor appointment, and auto-generated schedule during the global pandemics situations. Initially the motivation behind the technology was the availability of physical and psychological care for unreached communities. But, in the situation of pandemics, there is a high momentum to the mHealth application in the healthcare delivery system. The differential utilization of cell phone has led to the multiplication of health-related personalized applications day by day for the human race; there are numerous expected roads for mHealth to be fill in as an aide instrument to general health care when most of the developed and developing nations are in a cyclic process of lockdown of the century. In the present times, people are advised by the WHO to make a physical distance from everyone; hence the mHealth promptly came into existence with its importance. However, there are both pros and cons of every technology; here mHealth helps to provide improved treatment availability due to its promptness, ease, accessibility but on the another hand, there is the limitation of mHealth applications as personal data sharing with the network providers is easier. There are concerns like moral, legitimate, and clinical issues identified with mHealth usage, incorporating issues with information security, protection issues with limits, and interjurisdictional practice concerns. The technology-centric model launching incorporates the traditional medical approaches and training through the emerging technology-centric model into medical and educational systems to support medical practitioners and the patients. The review article presents the proof for the focal points and impediments of rebuilding a medicinal service framework on essential considerations. It depends on a fast, however, orderly audit of critical sources of strewn writing. The results are unpredictable for various reasons, including varying meanings of administrations, staff and the limits among essential and auxiliary consideration, changing hierarchical structures, and expanding dependence on essential consideration groups for mHealth.

mUzima Mobile Electronic Health Record (EHR) System: Development and Implementation at Scale

Background

The predominant implementation paradigm of electronic health record (EHR) systems in low- and middle-income countries (LMICs) relies on standalone system installations at facilities. This implementation approach exacerbates the digital divide, with facilities in areas with inadequate electrical and network infrastructure often left behind. Mobile health (mHealth) technologies have been implemented to extend the reach of digital health, but these systems largely add to the problem of siloed patient data, with few seamlessly interoperating with the EHR systems that are now scaled nationally in many LMICs. Robust mHealth applications that effectively extend EHR systems are needed to improve access, improve quality of care, and ameliorate the digital divide.

Objective

We report on the development and scaled implementation of mUzima, an mHealth extension of the most broadly deployed EHR system in LMICs (OpenMRS).

Methods

The “Guidelines for reporting of health interventions using mobile phones: mobile (mHealth) evidence reporting assessment (mERA)” checklist was employed to report on the mUzima application. The World Health Organization (WHO) Principles for Digital Development framework was used as a secondary reference framework. Details of mUzima’s architecture, core features, functionalities, and its implementation status are provided to highlight elements that can be adapted in other systems.

Results

mUzima is an open-source, highly configurable Android application with robust features including offline management, deduplication, relationship management, security, cohort management, and error resolution, among many others. mUzima allows providers with lower-end Android smartphones (version 4.4 and above) who work remotely to access historical patient data, collect new data, view media, leverage decision support, conduct store-and-forward teleconsultation, and geolocate clients. The application is supported by an active community of developers and users, with feature priorities vetted by the community. mUzima has been implemented nationally in Kenya, is widely used in Rwanda, and is gaining scale in Uganda and Mozambique. It is disease-agnostic, with current use cases in HIV, cancer, chronic disease, and COVID-19 management, among other conditions. mUzima meets all WHO’s Principles of Digital Development, and its scaled implementation success has led to its recognition as a digital global public good and its listing in the WHO Digital Health Atlas.

Conclusions

Greater emphasis should be placed on mHealth applications that robustly extend reach of EHR systems within resource-limited settings, as opposed to siloed mHealth applications. This is particularly important given that health information exchange infrastructure is yet to mature in many LMICs. The mUzima application demonstrates how this can be done at scale, as evidenced by its adoption across multiple countries and for numerous care domains.

Human-centered implementation research: a new approach to develop and evaluate implementation strategies for strengthening referral networks for hypertension in western Kenya

Background

Human-centered design (HCD) is an increasingly recognized approach for engaging stakeholders and developing contextually appropriate health interventions. As a component of the ongoing STRENGTHS study (Strengthening Referral Networks for Management of Hypertension Across the Health System), we report on the process and outcomes of utilizing HCD to develop the implementation strategy prior to a cluster-randomized controlled trial.

Methods

We organized a design team of 15 local stakeholders to participate in an HCD process to develop implementation strategies. We tested prototypes for acceptability, appropriateness, and feasibility through focus group discussions (FGDs) with various community stakeholder groups and a pilot study among patients with hypertension. FGD transcripts underwent content analysis, and pilot study data were analyzed for referral completion and reported barriers to referral. Based on this community feedback, the design team iteratively updated the implementation strategy. During each round of updates, the design team reflected on their experience through FGDs and a Likert-scale survey.

Results

The design team developed an implementation strategy consisting of a combined peer navigator and a health information technology (HIT) package. Overall, community participants felt that the strategy was acceptable, appropriate, and feasible. During the pilot study, 93% of referrals were completed. FGD participants felt that the implementation strategy facilitated referral completion through active peer engagement; enhanced communication between clinicians, patients, and health administrators; and integrated referral data into clinical records. Challenges included referral barriers that were not directly addressed by the strategy (e.g. transportation costs) and implementation of the HIT package across multiple health record systems. The design team reflected that all members contributed significantly to the design process, but emphasized the need for more transparency in how input from study investigators was incorporated into design team discussions.

Conclusions

The adaptive process of co-creation, prototyping, community feedback, and iterative redesign aligned our implementation strategy with community stakeholder priorities. We propose a new framework of human-centered implementation research that promotes collaboration between community stakeholders, study investigators, and the design team to develop, implement, and evaluate HCD products for implementation research. Our experience provides a feasible and replicable approach for implementation research in other settings.

Trial registration

Clinicaltrials.gov, NCT02501746, registration date: July 17, 2015,

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06930-2.

A realist systematic review of evidence from low- and middle-income countries of interventions to improve immunization data use

BACKGROUND

The use of routine immunization data by health care professionals in low- and middle-income countries remains an underutilized resource in decision-making. Despite the significant resources invested in developing national health information systems, systematic reviews of the effectiveness of data use interventions are lacking. Applying a realist review methodology, this study synthesized evidence of effective interventions for improving data use in decision-making.

METHODS

We searched PubMed, POPLINE, Centre for Agriculture and Biosciences International Global Health, and African Journals Online for published literature. Grey literature was obtained from conference, implementer, and technical agency websites and requested from implementing organizations. Articles were included if they reported on an intervention designed to improve routine data use or reported outcomes related to data use, and targeted health care professionals as the principal data users. We developed a theory of change a priori for how we expect data use interventions to influence data use. Evidence was then synthesized according to data use intervention type and level of the health system targeted by the intervention.

RESULTS

The searches yielded 549 articles, of which 102 met our inclusion criteria, including 49 from peer-reviewed journals and 53 from grey literature. A total of 66 articles reported on immunization data use interventions and 36 articles reported on data use interventions for other health sectors. We categorized 68 articles as research evidence and 34 articles as promising strategies. We identified ten primary intervention categories, including electronic immunization registries, which were the most reported intervention type (n = 14). Among the research evidence from the immunization sector, 32 articles reported intermediate outcomes related to data quality and availability, data analysis, synthesis, interpretation, and review. Seventeen articles reported data-informed decision-making as an intervention outcome, which could be explained by the lack of consensus around how to define and measure data use.

CONCLUSIONS

Few immunization data use interventions have been rigorously studied or evaluated. The review highlights gaps in the evidence base, which future research and better measures for assessing data use should attempt to address.

Group Medical Visit and Microfinance Intervention for Patients With Diabetes or Hypertension in Kenya

BACKGROUND

Incorporating social determinants of health into care delivery for chronic diseases is a priority.

OBJECTIVES

The goal of this study was to evaluate the impact of group medical visits and/or microfinance on blood pressure reduction.

METHODS

The authors conducted a cluster randomized trial with 4 arms and 24 clusters: 1) usual care (UC); 2) usual care plus microfinance (MF); 3) group medical visits (GMVs); and 4) GMV integrated into MF (GMV-MF). The primary outcome was 1-year change in systolic blood pressure (SBP). Mixed-effects intention-to-treat models were used to evaluate the outcomes.

RESULTS

A total of 2,890 individuals (69.9% women) were enrolled (708 UC, 709 MF, 740 GMV, and 733 GMV-MF). Average baseline SBP was 157.5 mm Hg. Mean SBP declined -11.4, -14.8, -14.7, and -16.4 mm Hg in UC, MF, GMV, and GMV-MF, respectively. Adjusted estimates and multiplicity-adjusted 98.3% confidence intervals showed that, relative to UC, SBP reduction was 3.9 mm Hg (-8.5 to 0.7), 3.3 mm Hg (-7.8 to 1.2), and 2.3 mm Hg (-7.0 to 2.4) greater in GMV-MF, GMV, and MF, respectively. GMV and GMV-MF tended to benefit women, and MF and GMV-MF tended to benefit poorer individuals. Active participation in GMV-MF was associated with greater benefit.

CONCLUSIONS

A strategy combining GMV and MF for individuals with diabetes or hypertension in Kenya led to clinically meaningful SBP reductions associated with cardiovascular benefit. Although the significance threshold was not met in pairwise comparison hypothesis testing, confidence intervals for GMV-MF were consistent with impacts ranging from substantive benefit to neutral effect relative to UC. Incorporating social determinants of health into care delivery for chronic diseases has potential to improve outcomes. (Bridging Income Generation With Group Integrated Care [BIGPIC]; NCT02501746).

Supply-chain strategies for essential medicines in rural western Kenya during COVID-19

Problem

The coronavirus disease 2019 (COVID-19) pandemic has disrupted health systems worldwide and threatened the supply of essential medicines. Especially affected are vulnerable patients in low- and middle-income countries who can only afford access to public health systems.

Approach

Soon after physical distancing and curfew orders began on 15 March 2020 in Kenya, we rapidly implemented three supply-chain strategies to ensure a continuous supply of essential medicines while minimizing patients’ COVID-19 exposure risks. We redistributed central stocks of medicines to peripheral health facilities to ensure local availability for several months. We equipped smaller, remote health facilities with medicine tackle boxes. We also made deliveries of medicines to patients with difficulty reaching facilities.

Local setting

Τo implement these strategies we leveraged our 30-year partnership with local health authorities in rural western Kenya and the existing revolving fund pharmacy scheme serving 85 peripheral health centres.

Relevant changes

In April 2020, stocks of essential chronic and non-chronic disease medicines redistributed to peripheral health facilities increased to 835 140 units, as compared with 316 330 units in April 2019. We provided medicine tackle boxes to an additional 46 health facilities. Our team successfully delivered medications to 264 out of 311 patients (84.9%) with noncommunicable diseases whom we were able to reach.

Lessons learnt

Our revolving fund pharmacy model has ensured that patients’ access to essential medicines has not been interrupted during the pandemic. Success was built on a community approach to extend pharmaceutical services, adapting our current supply-chain infrastructure and working quickly in partnership with local health authorities.

Effect of Nurse-Based Management of Hypertension in Rural Western Kenya

Background

Elevated blood pressure is the leading cause of death worldwide; however, treatment and control rates remain very low. An expanding literature supports the strategy of task redistribution of hypertension care to nurses.

Objective

We aimed to evaluate the effect of a nurse-based hypertension management program in Kenya.

Methods

We conducted a retrospective data analysis of patients with hypertension who initiated nurse-based hypertension management care between January 1, 2011, and October 31, 2013. The primary outcome measure was change in systolic blood pressure (SBP) over one year, analyzed using piecewise linear mixed-effect models with a cut point at 3 months. The primary comparison of interest was care provided by nurses versus clinical officers. Secondary outcomes were change in diastolic blood pressure (DBP) over one year, and blood pressure control analyzed using a zero-inflated Poisson model.

Results

The cohort consisted of 1051 adult patients (mean age 61 years; 65% women). SBP decreased significantly from baseline to three months (nurse-managed patients: slope -4.95 mmHg/month; clinical officer-managed patients: slope -5.28), with no significant difference between groups. DBP also significantly decreased from baseline to three months with no difference between provider groups. Retention in care at 12 months was 42%.

Conclusions

Nurse-managed hypertension care can significantly improve blood pressure. However, retention in care remains a challenge. If these results are reproduced in prospective trial settings with improvements in retention in care, this could be an effective strategy for hypertension care worldwide.

The Promise of Clinical Decision Support Systems Targetting Low-Resource Settings

Low-resource clinical settings are plagued by low physician-to-patient ratios and a shortage of high-quality medical expertise and infrastructure. Together, these phenomena lead to over-burdened healthcare systems that under-serve the needs of the community. Alleviating this burden can be undertaken by the introduction of clinical decision support systems (CDSSs); systems that support stakeholders (ranging from physicians to patients) within the clinical setting in their day-to-day activities. Such systems, which have proven to be effective in the developed world, remain to be under-explored in low-resource settings. This review attempts to summarize the research focused on clinical decision support systems that either target stakeholders within low-resource clinical settings or diseases commonly found in such environments. When categorizing our findings according to disease applications, we find that CDSSs are predominantly focused on dealing with bacterial infections and maternal care, do not leverage deep learning, and have not been evaluated prospectively. Together, these highlight the need for increased research in this domain in order to impact a diverse set of medical conditions and ultimately improve patient outcomes.

Effectiveness of an mHealth application to improve hypertension health literacy in India

AIM

The purpose of this research was to determine the effectiveness of a mobile health or mHealth application to improve hypertension health literacy among vulnerable populations in India. Additionally, we sought to estimate relationships between participant knowledge on hypertension and sociodemographic variables.

BACKGROUND

The World Health Organization advocates for the use of mobile technology to improve public health outcomes.

INTRODUCTION

The incidence of hypertension is on the rise in India, and effective and sustainable interventions are needed.

METHODS

A quantitative single arm pre-test post-test interventional and correlational design was used to test the hypertension mHealth application among participants in a limited resource setting. A paired t-test was performed to compare pre- and post-test results after participant use of the mHealth application. A regression model was used to estimate relationships between participant hypertension health literacy and sociodemographic variables.

RESULTS

A statistically significant improvement in test scores among participants after use of the mHealth app was found. Sociodemographic characteristics such as living in an urban environment, married, increased number of people living in household and alcohol use were determined to have a statistically significant effect on improvement of test score.

DISCUSSION

Results indicated the application was effective among participants with varied literacy and health literacy levels. These findings contribute to the potential widespread scalability of the app among populations with varied demographics.

CONCLUSION

This application provides an effective and valuable culturally tailored educational resource for nurses and other health providers to use to improve hypertension health literacy among vulnerable populations in India.

IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY

This study contributes to nursing and health policy by answering a call from the World Health Organization to implement and research mHealth interventions to improve health outcomes, particularly in a low and middle income country where preventive health access is limited.

An Attitude Survey and Assessment of the Feasibility, Acceptability, and Usability of a Traumatic Brain Injury Decision Support Tool in Uganda

BACKGROUND

Traumatic brain injury (TBI) prognostic models are potential solutions to severe human and technical shortages. Although numerous TBI prognostic models have been developed, none are widely used in clinical practice, largely because of a lack of feasibility research to inform implementation. We previously developed a prognostic model and Web-based application for in-hospital TBI care in low-resource settings. In this study, we tested the feasibility, acceptability, and usability of the application with potential end-users.

METHODS

We performed our feasibility assessment with providers involved in TBI care at both a regional and national referral hospital in Uganda. We collected qualitative and quantitative data on decision support needs, application ease of use, and implementation design.

RESULTS

We completed 25 questionnaires on potential uses of the app and 11 semistructured feasibility interviews. Top-cited uses were informing the decision to operate, informing the decision to send the patient to intensive care, and counseling patients and relatives. Participants affirmed the potential of the application to support difficult triage situations, particularly in the setting of limited access to diagnostics and interventions, but were hesitant to use this technology with end-of-life decisions. Although all participants were satisfied with the application and agreed that it was easy to use, several expressed a need for this technology to be accessible by smartphone and offline.

CONCLUSIONS

We elucidated several potential uses for our app and important contextual factors that will support future implementation. This investigation helps address an unmet need to determine the feasibility of TBI clinical decision support systems in low-resource settings.

Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis

BACKGROUND

Mobile health (mHealth), refers to healthcare practices supported by mobile devices, such as mobile phones and tablets. Within primary care, health workers often use mobile devices to register clients, track their health, and make decisions about care, as well as to communicate with clients and other health workers. An understanding of how health workers relate to, and experience mHealth, can help in its implementation.

OBJECTIVES

To synthesise qualitative research evidence on health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services, and to develop hypotheses about why some technologies are more effective than others.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, Science Citation Index and Social Sciences Citation Index in January 2018. We searched Global Health in December 2015. We screened the reference lists of included studies and key references and searched seven sources for grey literature (16 February to 5 March 2018). We re-ran the search strategies in February 2020. We screened these records and any studies that we identified as potentially relevant are awaiting classification.

SELECTION CRITERIA

We included studies that used qualitative data collection and analysis methods. We included studies of mHealth programmes that were part of primary healthcare services. These services could be implemented in public or private primary healthcare facilities, community and workplace, or the homes of clients. We included all categories of health workers, as well as those persons who supported the delivery and management of the mHealth programmes. We excluded participants identified as technical staff who developed and maintained the mHealth technology, without otherwise being involved in the programme delivery. We included studies conducted in any country.

DATA COLLECTION AND ANALYSIS

We assessed abstracts, titles and full-text papers according to the inclusion criteria. We found 53 studies that met the inclusion criteria and sampled 43 of these for our analysis. For the 43 sampled studies, we extracted information, such as country, health worker category, and the mHealth technology. We used a thematic analysis process. We used GRADE-CERQual to assess our confidence in the findings.

MAIN RESULTS

Most of the 43 included sample studies were from low- or middle-income countries. In many of the studies, the mobile devices had decision support software loaded onto them, which showed the steps the health workers had to follow when they provided health care. Other uses included in-person and/or text message communication, and recording clients' health information. Almost half of the studies looked at health workers' use of mobile devices for mother, child, and newborn health. We have moderate or high confidence in the following findings. mHealth changed how health workers worked with each other: health workers appreciated being more connected to colleagues, and thought that this improved co-ordination and quality of care. However, some described problems when senior colleagues did not respond or responded in anger. Some preferred face-to-face connection with colleagues. Some believed that mHealth improved their reporting, while others compared it to "big brother watching". mHealth changed how health workers delivered care: health workers appreciated how mHealth let them take on new tasks, work flexibly, and reach clients in difficult-to-reach areas. They appreciated mHealth when it improved feedback, speed and workflow, but not when it was slow or time consuming. Some health workers found decision support software useful; others thought it threatened their clinical skills. Most health workers saw mHealth as better than paper, but some preferred paper. Some health workers saw mHealth as creating more work. mHealth led to new forms of engagement and relationships with clients and communities: health workers felt that communicating with clients by mobile phone improved care and their relationships with clients, but felt that some clients needed face-to-face contact. Health workers were aware of the importance of protecting confidential client information when using mobile devices. Some health workers did not mind being contacted by clients outside working hours, while others wanted boundaries. Health workers described how some community members trusted health workers that used mHealth while others were sceptical. Health workers pointed to problems when clients needed to own their own phones. Health workers' use and perceptions of mHealth could be influenced by factors tied to costs, the health worker, the technology, the health system and society, poor network access, and poor access to electricity: some health workers did not mind covering extra costs. Others complained that phone credit was not delivered on time. Health workers who were accustomed to using mobile phones were sometimes more positive towards mHealth. Others with less experience, were sometimes embarrassed about making mistakes in front of clients or worried about job security. Health workers wanted training, technical support, user-friendly devices, and systems that were integrated into existing electronic health systems. The main challenges health workers experienced were poor network connections, access to electricity, and the cost of recharging phones. Other problems included damaged phones. Factors outside the health system also influenced how health workers experienced mHealth, including language, gender, and poverty issues. Health workers felt that their commitment to clients helped them cope with these challenges.

AUTHORS' CONCLUSIONS

Our findings propose a nuanced view about mHealth programmes. The complexities of healthcare delivery and human interactions defy simplistic conclusions on how health workers will perceive and experience their use of mHealth. Perceptions reflect the interplay between the technology, contexts, and human attributes. Detailed descriptions of the programme, implementation processes and contexts, alongside effectiveness studies, will help to unravel this interplay to formulate hypotheses regarding the effectiveness of mHealth.

Artificial Intelligence in Gastrointestinal Endoscopy in a Resource-constrained Setting: A Reality Check

Artificial intelligence (AI) is being increasingly explored in different domains of gastroenterology, particularly in endoscopic image analysis, cancer screening, and prognostication models. It is widely touted to become an integral part of routine endoscopies, considering the bulk of data handled by endoscopists and the complex nature of critical analyses performed. However, the application of AI in endoscopy in resource-constrained settings remains fraught with problems. We conducted an extensive literature review using the PubMed database on articles covering the application of AI in endoscopy and the difficulties encountered in resource-constrained settings. We have tried to summarize in the present review the potential problems that may hinder the application of AI in such settings. Hopefully, this review will enable endoscopists and health policymakers to ponder over these issues before trying to extrapolate the advancements of AI in technically advanced settings to those having constraints at multiple levels.

How to cite this article: Anirvan P, Meher D, Singh SP. Artificial Intelligence in Gastrointestinal Endoscopy in a Resource-constrained Setting: A Reality Check. Euroasian J Hepato-Gastroenterol 2020;10(2): 92–97.

The effect of an mHealth clinical decision-making support system on neonatal mortality in a low resource setting: A cluster-randomized controlled trial

BACKGROUND

MHealth interventions promise to bridge gaps in clinical care but documentation of their effectiveness is limited. We evaluated the utilization and effect of an mhealth clinical decision-making support intervention that aimed to improve neonatal mortality in Ghana by providing access to emergency neonatal protocols for frontline health workers.

METHODS

In the Eastern Region of Ghana, sixteen districts were randomized into two study arms (8 intervention and 8 control clusters) in a cluster-randomized controlled trial. Institutional neonatal mortality data were extracted from the District Health Information System-2 during an 18-month intervention period. We performed an intention-to-treat analysis and estimated the effect of the intervention on institutional neonatal mortality (primary outcome measure) using grouped binomial logistic regression with a random intercept per cluster. This trial is registered at ClinicalTrials.gov (NCT02468310 ) and Pan African Clinical Trials Registry (PACTR20151200109073).

FINDINGS

There were 65,831 institutional deliveries and 348 institutional neonatal deaths during the study period. Overall, 47 ∙ 3% of deliveries and 56 ∙ 9% of neonatal deaths occurred in the intervention arm. During the intervention period, neonatal deaths increased from 4 ∙ 5 to 6 ∙ 4 deaths and, from 3 ∙ 9 to 4 ∙ 3 deaths per 1000 deliveries in the intervention arm and control arm respectively. The odds of neonatal death was 2⋅09 (95% CI (1 ∙ 00;4 ∙ 38); p = 0 ∙ 051) times higher in the intervention arm compared to the control arm (adjusted odds ratio). The correlation between the number of protocol requests and the number of deliveries per intervention cluster was 0 ∙ 71 (p = 0 ∙ 05).

INTERPRETATION

The higher risk of institutional neonatal death observed in intervention clusters may be due to problems with birth and death registration, unmeasured and unadjusted confounding, and unintended use of the intervention. The findings underpin the need for careful and rigorous evaluation of mHealth intervention implementation and effects.

FUNDING

Netherlands Foundation for Scientific Research - WOTRO, Science for Global Development; Utrecht University.

Using Mobile Health to Support Clinical Decision-Making to Improve Maternal and Neonatal Health Outcomes in Ghana: Insights of Frontline Health Worker Information Needs

BACKGROUND

Developing and maintaining resilient health systems in low-resource settings like Ghana requires innovative approaches that adapt technology to context to improve health outcomes. One such innovation was a mobile health (mHealth) clinical decision-making support system (mCDMSS) that utilized text messaging (short message service, SMS) of standard emergency maternal and neonatal protocols via an unstructured supplementary service data (USSD) on request of the health care providers. This mCDMSS was implemented in a cluster randomized controlled trial (CRCT) in the Eastern Region of Ghana.

OBJECTIVE

This study aimed to analyze the pattern of requests made to the USSD by health workers (HWs). We assessed the relationship between requests made to the USSD and types of maternal and neonatal morbidities reported in health facilities (HFs).

METHODS

For clusters in the intervention arm of the CRCT, all requests to the USSD during the 18-month intervention period were extracted from a remote server, and maternal and neonatal health outcomes of interest were obtained from the District Health Information System of Ghana. Chi-square and Fisher exact tests were used to compare the proportion and type of requests made to the USSD by cluster, facility type, and location; whether phones accessing the intervention were shared facility phones or individual-use phones (type-of-phone); or whether protocols were accessed during the day or at night (time-of-day). Trends in requests made were analyzed over 3 6-month periods. The relationship between requests made and the number of cases reported in HFs was assessed using Spearman correlation.

RESULTS

In total, 5329 requests from 72 (97%) participating HFs were made to the intervention. The average number of requests made per cluster was 667. Requests declined from the first to the third 6-month period (44.96% [2396/5329], 39.82% [2122/5329], and 15.22% [811/5329], respectively). Maternal conditions accounted for the majority of requests made (66.35% [3536/5329]). The most frequently accessed maternal conditions were postpartum hemorrhage (25.23% [892/3536]), other conditions (17.82% [630/3536]), and hypertension (16.49% [583/3536]), whereas the most frequently accessed neonatal conditions were prematurity (20.08% [360/1793]), sepsis (15.45% [277/1793]), and resuscitation (13.78% [247/1793]). Requests made to the mCDMSS varied significantly by cluster, type of request (maternal or neonatal), facility type and its location, type-of-phone, and time-of-day at 6-month interval (P<.001 for each variable). Trends in maternal and neonatal requests showed varying significance over each 6-month interval. Only asphyxia and sepsis cases showed significant correlations with the number of requests made (r=0.44 and r=0.79; P<.001 and P=.03, respectively).

CONCLUSIONS

There were variations in the pattern of requests made to the mCDMSS over time. Detailed information regarding the use of the mCDMSS provides insight into the information needs of HWs for decision-making and an opportunity to focus support for HW training and ultimately improved maternal and neonatal health.

Provider- and Patient-Related Barriers to and Facilitators of Digital Health Technology Adoption for Hypertension Management: Scoping Review

Background

The uptake of digital health technology (DHT) has been surprisingly low in clinical practice. Despite showing great promise to improve patient outcomes and disease management, there is limited information on the factors that contribute to the limited adoption of DHT, particularly for hypertension management.

Objective

This scoping review provides a comprehensive summary of barriers to and facilitators of DHT adoption for hypertension management reported in the published literature with a focus on provider- and patient-related barriers and facilitators.

Methods

This review followed the methodological framework developed by Arskey and O’Malley. Systematic literature searches were conducted on PubMed or Medical Literature Analysis and Retrieval System Online, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medica database. Articles that reported on barriers to and/or facilitators of digital health adoption for hypertension management published in English between 2008 and 2017 were eligible. Studies not reporting on barriers or facilitators to DHT adoption for management of hypertension were excluded. A total of 2299 articles were identified based on the above criteria after removing duplicates, and they were assessed for eligibility. Of these, 2165 references did not meet the inclusion criteria. After assessing 134 studies in full text, 98 studies were excluded (full texts were either unavailable or studies did not fulfill the inclusion criteria), resulting in a final set of 32 articles. In addition, 4 handpicked articles were also included in the review, making it a total of 36 studies.

Results

A total of 36 studies were selected for data extraction after abstract and full-text screening by 2 independent reviewers. All conflicts were resolved by a third reviewer. Thematic analysis was conducted to identify major themes pertaining to barriers and facilitators of DHT from both provider and patient perspectives. The key facilitators of DHT adoption by physicians that were identified include ease of integration with clinical workflow, improvement in patient outcomes, and technology usability and technical support. Technology usability and timely technical support improved self-management and patient experience, and positive impact on patient-provider communication were most frequently reported facilitators for patients. Barriers to use of DHTs reported by physicians include lack of integration with clinical workflow, lack of validation of technology, and lack of technology usability and technical support. Finally, lack of technology usability and technical support, interference with patient-provider relationship, and lack of validation of technology were the most commonly reported barriers by patients.

Conclusions

Findings suggest the settings and context in which DHTs are implemented and individuals involved in implementation influence adoption. Finally, to fully realize the potential of digitally enabled hypertension management, there is a greater need to validate these technologies to provide patients and providers with reliable and accurate information on both clinical outcomes and cost effectiveness.

Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil: Mixed-Methods Field Study on Usability, Feasibility, and Utility

Background

Despite being an important cardiovascular risk factor, hypertension has low control levels worldwide. Computerized clinical decision support systems (CDSSs) might be effective in reducing blood pressure with a potential impact in reducing cardiovascular risk.

Objective

The goal of the research was to evaluate the feasibility, usability, and utility of a CDSS, TeleHAS (tele–hipertensão arterial sistêmica, or arterial hypertension system), in the care of patients with hypertension in the context of a primary care setting in a middle-income country.

Methods

The TeleHAS app consists of a platform integrating clinical and laboratory data on a particular patient, from which it performs cardiovascular risk calculation and provides evidence-based recommendations derived from Brazilian and international guidelines for the management of hypertension and cardiovascular risk. Ten family physicians from different primary care units in the city of Montes Claros, Brazil, were randomly selected to use the CDSS for the care of hypertensive patients for 6 months. After 3 and 6 months, the feasibility, usability, and utility of the CDSS in the routine care of the health team was evaluated through a standardized questionnaire and semistructured interviews.

Results

Throughout the study, clinicians registered 535 patients with hypertension, at an average of 1.24 consultations per patient. Women accounted for 80% (8/10) of participant doctors, median age was 31.5 years (interquartile range 27 to 59 years). As for feasibility, 100% of medical users claimed it was possible to use the app in the primary care setting, and for 80% (8/10) of them it was easy to incorporate its use into the daily routine and home visits. Nevertheless, 70% (7/10) of physicians claimed that the time taken to fill out the CDSS causes significant delays in service. Clinicians evaluated TeleHAS as good (8/10, 80% of users), with easy completion and friendly interface (10/10, 100%) and the potential to improve patients’ treatment (10/10, 100%). A total of 90% (9/10) of physicians had access to new knowledge about cardiovascular risk and hypertension through the app recommendations and found it useful to promote prevention and optimize treatment.

Conclusions

In this study, a CDSS developed to assist the management of patients with hypertension was feasible in the context of a primary health care setting in a middle-income country, with good user satisfaction and the potential to improve adherence to evidence-based practices.

How and why front-line health workers (did not) use a multifaceted mHealth intervention to support maternal and neonatal healthcare decision-making in Ghana

Introduction

Despite increasing use of mHealth interventions, there remains limited documentation of 'how and why' they are used and therefore the explanatory mechanisms behind observed effects on beneficiary health outcomes. We explored 'how and why' an mHealth intervention to support clinical decision-making by front-line providers of maternal and neonatal healthcare services in a low-resource setting was used. The intervention consisted of phone calls (voice calls), text messaging (short messaging service (SMS)), internet access (data) and access to emergency obstetric and neonatal protocols via an Unstructured Supplementary Service Data (USSD). It was delivered through individual-use and shared facility mobile phones with unique Subscriber Identification Module (SIM) cards networked in a Closed User Group.

Methods

A single case study with multiple embedded subunits of analysis within the context of a cluster randomised controlled trial of the impact of the intervention on neonatal health outcomes in the Eastern Region of Ghana was performed. We quantitatively analysed SIM card activity data for patterns of voice calls, SMS, data and USSD. We conducted key informant interviews and focus group discussions with intervention users and manually analysed the data for themes.

Results

Overall, the phones were predominantly used for voice calls (64%), followed by data (28%), SMS (5%) and USSD (2%), respectively. Over time, use of all intervention components declined. Qualitative analysis showed that individual health worker factors (demographics, personal and work-related needs, perceived timeliness of intervention, tacit knowledge), organisational factors (resource availability, information flow, availability, phone ownership), technological factors (attrition of phones, network quality) and client perception of health worker intervention usage explain the pattern of intervention use observed.

Conclusion

How and why the mHealth intervention was used (or not) went beyond the technology itself and was influenced by individual and context-specific factors. These must be taken into account in designing similar interventions to optimise effectiveness.

Pharmacy-based hypertension care employing mHealth in Lagos, Nigeria - a mixed methods feasibility study

BACKGROUND

Access to quality hypertension care is often poor in sub-Saharan Africa. Some community pharmacies offer hypertension monitoring services, with and without involvement of medical doctors. To directly connect pharmacy staff and cardiologists a care model including a mobile application (mHealth) for remote patient monitoring was implemented and pilot tested in Lagos, Nigeria. Pharmacists provided blood pressure measurements and counselling. Cardiologists enrolled patients in the pilot program and remotely monitored them, for which patients paid a monthly fee. We evaluated the feasibility of this care model at five private community pharmacies. Outcome measures were retention in care, blood pressure change, quality of care, and patients' and healthcare providers' satisfaction with the care model.

METHODS

Patients participated in the care model's pilot at one of the five pharmacies for approximately 6-8 months from February 2016. We conducted structured patient interviews and blood pressure measurements at pilot entry and exit, and used exports of the mHealth-application, in-depth interviews and focus group discussions with patients, pharmacists and cardiologists.

RESULTS

Of 336 enrolled patients, 236 (72%) were interviewed at pilot entry and exit. According to the mHealth data 71% returned to the pharmacy after enrollment, with 3.3 months (IQR: 2.2-5.4) median duration of activity in the mHealth-application. Patients self-reported more visits than recorded in the mHealth data. Pharmacists mentioned use of paper records, understaffing, the application not being user-friendly, and patients' unwillingness to pay as reasons for underreporting. Mean systolic blood pressure decreased 9.9 mmHg (SD: 18). Blood pressure on target increased from 24 to 56% and an additional 10% had an improved blood pressure at endline, however this was not associated with duration of mHealth activity. Patients were satisfied because of accessibility, attention, adherence and information provision.

CONCLUSION

Patients, pharmacists and cardiologists adopted the care model, albeit with gaps in mHealth data. Most patients were satisfied, and their mean blood pressure significantly reduced. Usage of the mHealth application, pharmacy incentives, and a modified financing model are opportunities for improvement. In addition, costs of implementation and availability of involved healthcare providers need to be investigated before such a care model can be further implemented.

The Application of Medical Artificial Intelligence Technology in Rural Areas of Developing Countries

Background: Artificial intelligence (AI) is a rapidly developing computer technology that has begun to be widely used in the medical field to improve the professional level and efficiency of clinical work, in addition to avoiding medical errors. In developing countries, the inequality between urban and rural health services is a serious problem, of which the shortage of qualified healthcare providers is the major cause of the unavailability and low quality of healthcare in rural areas. Some studies have shown that the application of computer-assisted or AI medical techniques could improve healthcare outcomes in rural areas of developing countries. Therefore, the development of suitable medical AI technology for rural areas is worth discussing and probing. Methods: This article reviews and discusses the literature concerning the prospects of medical AI technology, the inequity of healthcare, and the application of computer-assisted or AI medical techniques in rural areas of developing countries. Results: Medical AI technology not only could improve physicians' efficiency and quality of medical services, but other health workers could also be trained to use this technique to compensate for the lack of physicians, thereby improving the availability of healthcare access and medical service quality. This article proposes a multilevel medical AI service network, including a frontline medical AI system (basic level), regional medical AI support centers (middle levels), and a national medical AI development center (top level). Conclusion: The promotion of medical AI technology in rural areas of developing countries might be one means of alleviating the inequality between urban and rural health services. The establishment of a multilevel medical AI service network system may be a solution.

Pregnant women's experiences with an integrated diagnostic and decision support device for antenatal care in Ghana

Background

Quality antenatal care (ANC) is recognised as an opportunity for screening and early identification of pregnancy-related complications. In rural Ghana, challenges with access to diagnostic services demotivate women from ANC attendance and referral compliance, leading to absent or late identification and management of high-risk women. In 2016, an integrated diagnostic and clinical decision support system tagged ‘Bliss4Midwives’ (B4M), was piloted in Northern Ghana. The device facilitated non-invasive screening of pre-eclampsia, gestational diabetes and anaemia at the point-of-care. This study aimed to explore the experiences of pregnant women with B4M, and its influence on service utilisation (“pull effect”) and woman-provider relationships (“woman engagement”).

Methods

Through an embedded study design, qualitative methods including individual semi-structured interviews and non-participant observation were employed. Interviews were conducted with 20 pregnant women and 10 health workers, supplemented by ANC observations in intervention facilities. Secondary data on ANC registrations over a one-year period were extracted from health facility records to support findings on the perceived influence of B4M on service utilisation.

Results

Women’s first impressions of the device were mostly emotive (excitement, fear), but sometimes neutral. Although it is inconclusive whether B4M increased ANC registration, pregnant women generally valued the availability of diagnostic services at the point-of-care. Additionally, by fostering some level of engagement, the intervention made women feel listened to and cared for. Process outcomes of the B4M encounter also showed that it was perceived as improving the skills and knowledge of the health worker, which facilitated trust in diagnostic recommendations and was therefore believed to motivate referral compliance.

Conclusions

This study suggests that mHealth diagnostic and decision support devices enhance woman engagement and trust in health workers skills. There is need for further inquiry into how these interventions influence maternal health service utilization and women’s expectations of pregnancy care.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1853-7) contains supplementary material, which is available to authorized users.

Integration of a Technology-Based Mental Health Screening Program Into Routine Practices of Primary Health Care Services in Peru (The Allillanchu Project): Development and Implementation

BACKGROUND

Despite their high prevalence and significant burden, mental disorders such as depression remain largely underdiagnosed and undertreated.

OBJECTIVE

The aim of the Allillanchu Project was to design, develop, and test an intervention to promote early detection, opportune referral, and access to treatment of patients with mental disorders attending public primary health care (PHC) services in Lima, Peru.

METHODS

The project had a multiphase design: formative study, development of intervention components, and implementation. The intervention combined three strategies: training of PHC providers (PHCPs), task shifting the detection and referral of mental disorders, and a mobile health (mHealth) component comprising a screening app followed by motivational and reminder short message service (SMS) to identify at-risk patients. The intervention was implemented by 22 PHCPs from five health centers, working in antenatal care, tuberculosis, chronic diseases, and HIV or AIDS services.

RESULTS

Over a period of 9 weeks, from September 2015 to November 2015, 733 patients were screened by the 22 PHCPs during routine consultations, and 762 screening were completed in total. The chronic diseases (49.9%, 380/762) and antenatal care services (36.7%, 380/762) had the higher number of screenings. Time constraints and workload were the main barriers to implementing the screening, whereas the use of technology, training, and supervision of the PHCPs by the research team were identified as facilitators. Of the 733 patients, 21.7% (159/733) screened positively and were advised to seek specialized care. Out of the 159 patients with a positive screening result, 127 had a follow-up interview, 72.4% (92/127) reported seeking specialized care, and 55.1% (70/127) stated seeing a specialist. Both patients and PHCPs recognized the utility of the screening and identified some key challenges to its wider implementation.

CONCLUSIONS

The use of a screening app supported by training and supervision is feasible and uncovers a high prevalence of unidentified psychological symptoms in primary care. To increase its sustainability and utility, this procedure can be incorporated into the routine practices of existing health care services, following tailoring to the resources and features of each service. The early detection of psychological symptoms by a PHCP within a regular consultation, followed by adequate advice and support, can lead to a significant percentage of patients accessing specialized care and reducing the treatment gap of mental disorders.

Clinician-Driven Design of VitalPAD-An Intelligent Monitoring and Communication Device to Improve Patient Safety in the Intensive Care Unit

The pediatric intensive care unit (ICU) is a complex environment, in which a multidisciplinary team of clinicians (registered nurses, respiratory therapists, and physicians) continually observe and evaluate patient information. Data are provided by multiple, and often physically separated sources, cognitive workload is high, and team communication can be challenging. Our aim is to combine information from multiple monitoring and therapeutic devices in a mobile application, the VitalPAD, to improve the efficiency of clinical decision-making, communication, and thereby patient safety. We observed individual ICU clinicians, multidisciplinary rounds, and handover procedures for 54 h to identify data needs, workflow, and existing cognitive aid use and limitations. A prototype was developed using an iterative participatory design approach; usability testing, including general and task-specific feedback, was obtained from 15 clinicians. Features included map overviews of the ICU showing clinician assignment, patient status, and respiratory support; patient vital signs; a photo-documentation option for arterial blood gas results; and team communication and reminder functions. Clinicians reported the prototype to be an intuitive display of vital parameters and relevant alerts and reminders, as well as a user-friendly communication tool. Future work includes implementation of a prototype, which will be evaluated under simulation and real-world conditions, with the aim of providing ICU staff with a monitoring device that will improve their daily work, communication, and decision-making capacity. Mobile monitoring of vital signs and therapy parameters might help improve patient safety in wards with single-patient rooms and likely has applications in many acute and critical care settings.

Design and content validation of a set of SMS to promote seeking of specialized mental health care within the Allillanchu Project

BACKGROUND

The aim of this study was to design and develop a set of, short message service (SMS) to promote specialized mental health care seeking within the framework of the Allillanchu Project.

METHODS

The design phase consisted of 39 interviews with potential recipients of the SMS, about use of cellphones, and perceptions and motivations towards seeking mental health care. After the data collection, the research team developed a set of seven SMS for validation. The content validation phase consisted of 24 interviews. The participants answered questions regarding their understanding of the SMS contents and rated its appeal.

RESULTS

The seven SMS subjected to content validation were tailored to the recipient using their name. The reminder message included the working hours of the psychology service at the patient's health center. The motivational messages addressed perceived barriers and benefits when seeking mental health services. The average appeal score of the seven SMS was 9.0 (SD±0.4) of 10 points. Participants did not make significant suggestions to change the wording of the messages.

CONCLUSIONS

Five SMS were chosen to be used. This approach is likely to be applicable to other similar low-resource settings, and the methodology used can be adapted to develop SMS for other chronic conditions.

Reusable Software Usability Specifications for mHealth Applications

One of the key factors for the adoption of mobile technologies, and in particular of mobile health applications, is usability. A usable application will be easier to use and understand by users, and will improve user's interaction with it. This paper proposes a software requirements catalog for usable mobile health applications, which can be used for the development of new applications, or the evaluation of existing ones. The catalog is based on the main identified sources in literature on usability and mobile health applications. Our catalog was organized according to the ISO/IEC/IEEE 29148:2011 standard and follows the SIREN methodology to create reusable catalogs. The applicability of the catalog was verified by the creation of an audit method, which was used to perform the evaluation of a real app, S Health, application created by Samsung Electronics Co. The usability requirements catalog, along with the audit method, identified several usability flaws on the evaluated app, which scored 83%. Some flaws were detected in the app related to the navigation pattern. Some more issues related to the startup experience, empty screens or writing style were also found. The way a user navigates through an application improves or deteriorates user's experience with the application. We proposed a reusable usability catalog and an audit method. This proposal was used to evaluate a mobile health application. An audit report was created with the usability issues identified on the evaluated application.

The Feasibility and Usability of RunningCoach: A Remote Coaching System for Long-Distance Runners

Studies have shown that about half of the injuries sustained during long-distance running involve the knee. Cadence (steps per minute) has been identified as a factor that is strongly associated with these running-related injuries, making it a worthwhile candidate for further study. As such, it is critical for long-distance runners to minimize their risk of injury by running at an appropriate running cadence. In this paper, we present the results of a study on the feasibility and usability of RunningCoach, a mobile health (mHealth) system that remotely monitors running cadence levels of runners in a continuous fashion, among other variables, and provides immediate feedback to runners in an effort to help them optimize their running cadence.

A systematic review of portable electronic technology for health education in resource-limited settings

OBJECTIVE

The objective of this study is to conduct a systematic review of the literature of how portable electronic technologies with offline functionality are perceived and used to provide health education in resource-limited settings.

METHODS

Three reviewers evaluated articles and performed a bibliography search to identify studies describing health education delivered by portable electronic device with offline functionality in low- or middle-income countries. Data extracted included: study population; study design and type of analysis; type of technology used; method of use; setting of technology use; impact on caregivers, patients, or overall health outcomes; and reported limitations.

RESULTS

Searches yielded 5514 unique titles. Out of 75 critically reviewed full-text articles, 10 met inclusion criteria. Study locations included Botswana, Peru, Kenya, Thailand, Nigeria, India, Ghana, and Tanzania. Topics addressed included: development of healthcare worker training modules, clinical decision support tools, patient education tools, perceptions and usability of portable electronic technology, and comparisons of technologies and/or mobile applications. Studies primarily looked at the assessment of developed educational modules on trainee health knowledge, perceptions and usability of technology, and comparisons of technologies. Overall, studies reported positive results for portable electronic device-based health education, frequently reporting increased provider/patient knowledge, improved patient outcomes in both quality of care and management, increased provider comfort level with technology, and an environment characterized by increased levels of technology-based, informal learning situations. Negative assessments included high investment costs, lack of technical support, and fear of device theft.

CONCLUSIONS

While the research is limited, portable electronic educational resources present promising avenues to increase access to effective health education in resource-limited settings, contingent on the development of culturally adapted and functional materials to be used on such devices.

mHealth for Clinical Decision-Making in Sub-Saharan Africa: A Scoping Review

Background

In a bid to deliver quality health services in resource-poor settings, mobile health (mHealth) is increasingly being adopted. The role of mHealth in facilitating evidence-based clinical decision-making through data collection, decision algorithms, and evidence-based guidelines, for example, is established in resource-rich settings. However, the extent to which mobile clinical decision support systems (mCDSS) have been adopted specifically in resource-poor settings such as Africa and the lessons learned about their use in such settings are yet to be established.

Objective

The aim of this study was to synthesize evidence on the use of mHealth for point-of-care decision support and improved quality of care by health care workers in Africa.

Methods

A scoping review of 4 peer-reviewed and 1 grey literature databases was conducted. No date limits were applied, but only articles in English language were selected. Using pre-established criteria, 2 reviewers screened articles and extracted data. Articles were analyzed using Microsoft Excel and MAXQDA.

Results

We retained 22 articles representing 11 different studies in 7 sub-Saharan African countries. Interventions were mainly in the domain of maternal health and ranged from simple text messaging (short message service, SMS) to complex multicomponent interventions. Although health workers are generally supportive of mCDSS and perceive them as useful, concerns about increased workload and altered workflow hinder sustainability. Facilitators and barriers to use of mCDSS include technical and infrastructural support, ownership, health system challenges, and training.

Conclusions

The use of mCDSS in sub-Saharan Africa is an indication of progress in mHealth, although their effect on quality of service delivery is yet to be fully explored. Lessons learned are useful for informing future research, policy, and practice for technologically supported health care delivery, especially in resource-poor settings.

Hydra: A web-based system for cardiovascular analysis, diagnosis and treatment

BACKGROUND AND OBJECTIVE

Cardiovascular (CV) risk stratification is a highly complex process involving an extensive set of clinical trials to support the clinical decision-making process. There are many clinical conditions (e.g. diabetes, obesity, stress, etc.) that can lead to the early diagnosis or establishment of cardiovascular disease. In order to determine all these clinical conditions, a complete set of clinical patient analyses is typically performed, including a physical examination, blood analysis, electrocardiogram, blood pressure (BP) analysis, etc. This article presents a web-based system, called Hydra, which integrates a full and detailed set of services and functionalities for clinical decision support in order to help and improve the work of clinicians in cardiovascular patient diagnosis, risk assessment, treatment and monitoring over time.

METHODS

Hydra integrates a number of different services: a service for inputting all the information gathered by specialists (physical examination, habits, BP, blood analysis, electrocardiogram, etc.); a tool to automatically determine the CV risk stratification, including well-known standard risk stratification tables; and, finally, various tools to incorporate, analyze and graphically present the records of the ambulatory BP monitoring that provides BP analysis over a given period of time (24 or 48 hours). In addition, the platform presents a set of reports derived from all the information gathered from the patient in order to support physicians in their clinical decisions.

RESULTS

Hydra was tested and validated in a real domain. In particular, internal medicine specialists at the Hypertension Unit of the Santiago de Compostela University Hospital (CHUS) validated the platform and used it in different clinical studies to demonstrate its utility. It was observed that the platform increased productivity and accuracy in the assessment of patient data yielding a cost reduction in clinical practice.

CONCLUSIONS

This paper proposes a complete platform that includes different services for cardiovascular clinical decision support. It was also run as a web-based application to facilitate its use by clinicians, who can access the platform from any remote computer with Internet access. Hydra also includes different automated methods to facilitate the physicians' work and avoid potential errors in the analysis of patient data.