Reviewing mHealth in Developing Countries: A Stakeholder Perspective

Examining the challenges in sustaining user engagement with a mobile app to enhance multidrug-resistant tuberculosis (MDR-TB) care in Vietnam and its implications for implementing person-centred mHealth interventions

Digital health technologies, especially mobile application (mHealth), offer great potential for enhancing person-centred care and managing MDR-TB. The rapid expansion of digital infrastructure in Vietnam presents a valuable opportunity for such interventions. This qualitative study examines user experiences to explain reported reduction in engagement with (i.e. use of) a smartphone app which is being trialed to improve early detection and management of adverse events (AEs) among MDR-TB patients in Vietnam (VSMART trial). We conducted 37 in-depth interviews with patients and healthcare workers (HCWs) and thematically analyzed the data. Initially, patients were motivated to use the app seeing it as a promise of the provision of 'good care' from trusted healthcare workers, and over-estimated its functional capacity. However, as patients realized its functional limitations for AE reporting and management they reverted to communicating with HCWs through existing communication channels. While the app empowered patients to communicate with HCWs for AE reporting, it inadvertently increased HCWs' workloads which became difficult to manage. This resulted in a paradox where the app was used because of its social value, in spite of its limited functional value. This study reveals how relational and socially mediated effects of technology may complicate mHealth design and implementation, illuminating why 'acceptable' technologies within pilot/projects could struggle to sustain engagement a scale. To support attention to this process, we propose an explanatory framework that captures the social-functional dynamics of mHealth interventions which can guide much needed qualitative evaluation to support the design of mHealth technologies to align with stakeholders' needs and suited for integration into local healthcare systems.

A mixed-method study exploring experiences, perceptions, and acceptability of using a safe delivery mHealth application in two district hospitals in Rwanda

BACKGROUND

Innovative use of mobile health (mHealth) technology in timely management of childbirth complications is a promising strategy, but its evidence base is limited. The Safe Delivery mHealth Application (SDA) is one of the recent mhealth applications (loaded in smartphones) which is a clinical decision support and training tool for basic emergency obstetric and newborn care (BEmONC). This paper describes, the health providers' experiences, perceptions, and acceptability of using the SDA, as well as the perceptions of key stakeholders.

METHODS

A mixed-methods approach was utilized. Quantitative methods consisted of a self-reported acceptability survey, administered to 54 nurses and midwives, including questions on their usage and perceptions of the SDA. Descriptive statistics were employed to analyze the survey data. Qualitative methods included two focus group discussions with 24 nurses and midwives, and six key informant interviews with stakeholders (maternity matrons, responsible for maternal and child health, and district hospital managers). Thematic analysis was performed and selected quotations used to illustrate themes. The study took place in two district hospitals in Rwanda.

RESULTS

Quantitative results found that 31 (57.4%) participants used the SDA four to six times per week. Many participants felt more confident (53.7%) and better at their job (40.7%) since having the SDA. Likert scale survey responses (1-5, 1 = Strongly Disagree, 5 = Strongly Agree) indicated general agreement that SDA is easy to use (Mean = 4.46), is an effective decision support tool (4.63), and training tool (4.65). Qualitative results included themes on perceived usefulness; professional growth acquired through the use of the SDA; SDA, an empowering, intuitive, and user-friendly technology; desired SDA features and functions; benefits of SDA as perceived by key informants, and future use of the SDA.

CONCLUSIONS

The nurses and midwives perceive the SDA as having improved their ability to manage childbirth complications. Key stakeholders also perceive the SDA as a useful tool with a reasonable cost and recommend its implementation in routine practices. This study deepens the understanding of the potential benefits of mHealth such as the SDA in low-income settings, like Rwanda. It also provides more evidence on the impact of mHealth in assuring quality BEmONC.

Implementing Electronic Health Records in Primary Care Using the Theory of Change: A Nigerian Case Study (Preprint)

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Objective

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Conclusions

"Now You Have Become Doctors": Lady Health Workers' Experiences Implementing an mHealth Application in Rural Pakistan

Background: PIERS on the Move (POM) is a mobile health application developed to support community health workers identification and management of women at risk of adverse outcomes from pre-eclampsia. The objective of this study was to evaluate the impact of using POM in Pakistan on Lady Health Workers' (LHWs) knowledge and self-efficacy related to caring for women with pre-eclampsia, and their perception of usefulness of the tool. Methodology: An evaluation was designed for health care workers involved in the Community-Level Intervention for Pre-eclampsia (CLIP) cluster randomized trial from 2014 to 2016 in Sindh Province, Pakistan (NCT01911494). A semi-structured focus group guide was developed based on the Technology Acceptance Model (TAM), which theorizes that an individual's behavioral intention to use a system is determined by perceived usefulness and ease of use. Preliminary qualitative analysis was undertaken by the Pakistan and Canadian teams to create a coding framework for full qualitative analysis, which was completed using NVivo12. Results: Three key informant interviews were conducted with two Lady Health Supervisors and one Senior Medical Officer. Sixty-two LHWs were included in three focus group discussions. LHWs found the POM app easy to use and useful for their work as a helpful repository for maternal health information and guiding counseling and management of pre-eclampsia. LHWs reported increased knowledge and confidence in their work. Availability of clinical homecare, including postpartum, was felt to positively impact healthcare provided to pregnant and postpartum women. Potential community level impacts included strengthening relationships between health care providers and communities and between LHWs and the health system. LHWs shared reports of earlier care-seeking and increased awareness of maternal health issues by community members. Conclusions: LHWs carry a large burden of responsibility for community health in rural Pakistan and appreciated the investment in their skills and capacity during the CLIP trial with the POM app. Investing in communications technology for community health workers through improved referrals and follow up may strengthen cohesiveness of the health system overall.

Determinants of a mobile phone-based Interactive Voice Response (mIVR) system for monitoring childhood illnesses in a rural district of Ghana: Empirical evidence from the UTAUT model

Background

The use of a mobile phone-based Interactive Voice Response (mIVR) System for real time monitoring of childhood illnesses provides an opportunity to improve childhood survival and health systems. However, little is known about the factors that facilitate its use. This study sought to identify key determinants and moderators of mIVR system use among caregivers in a rural district of Ghana using the Unified Theory of Acceptance and Use of Technology (UTAUT) model.

Methods

The mIVR system was designed to provide real-time data on common symptoms of childhood illnesses after answering several questions by caregivers with sick children. A structured questionnaire with closed questions was used to collect data from 354 caregivers of children under-five living in rural communities, four (4) months after introducing the system. Regression analysis was used to identify key determinants and moderating factors that facilitate the use of the system based on the UTAUT model.

Results

A total of 101 (28.5%) caregivers had used the system and 328 (92.7%) had intention to use the mIVR system. Caregivers’ level of education and household wealth were associated with use of the mIVR systems (p<0.001). Behavioural intention (BI) to use mIVR system was positively influenced by performance expectancy (PE) (β = 0.278, 95% CI: 0.207, 0.349), effort expectancy (EE) (β = 0.242, 95% CI: 0.159, 0.326) and social influence (SI) (β = 0.081, 95% CI: 0.044, 0.120). Facilitating conditions (FC) (β = 0.609, 95% CI: 0.502, 0.715) and behavioural intention (β = 0.426, 95% CI: 0.255, 0.597) had a positive influence on user behaviour (UB). Mobile phone experience and household wealth significantly moderated the effect of PE, EE, SI, and FC on behavioural intention and usage of mIVR systems.

Conclusion

The perceived usefulness of the mIVR system, ease of use, social influences, and facilitating conditions are key determinants of users’ attitude and use of mIVR system. These relationships are significantly moderated by users’ phone experience and wealth status.

Considerations for Improved Mobile Health Evaluation: Retrospective Qualitative Investigation

BACKGROUND

Mobile phone use and, consequently, mobile health (mHealth) interventions have seen an exponential increase in the last decade. There is an excess of 318,000 health-related apps available free of cost for consumers to download. However, many of these interventions are not evaluated and are lacking appropriate regulations. Randomized controlled trials are often considered the gold standard study design in determining the effectiveness of interventions, but recent literature has identified limitations in the methodology when used to evaluate mHealth.

OBJECTIVE

The objective of this study was to investigate the system developers' experiences of evaluating mHealth interventions in the context of a developing country.

METHODS

We employed a qualitative exploratory approach, conducting semistructured interviews with multidisciplinary members of an mHealth project consortium. A conventional content analysis approach was used to allow codes and themes to be identified directly from the data.

RESULTS

The findings from this study identified the system developers' perceptions of mHealth evaluation, providing an insight into the requirements of an effective mHealth evaluation. This study identified social and technical factors which should be taken into account when evaluating an mHealth intervention.

CONCLUSIONS

Contextual issues represented one of the most recurrent challenges of mHealth evaluation in the context of a developing country, highlighting the importance of a mixed method evaluation. There is a myriad of social, technical, and regulatory variables, which may impact the effectiveness of an mHealth intervention. Failure to account for these variables in an evaluation may limit the ability of the intervention to achieve long-term implementation and scale.

Impact of mobile health interventions during the perinatal period for mothers in low- and middle-income countries: a systematic review protocol

REVIEW QUESTION

The objective of this review is to determine the impact of mother-targeted mobile health (mHealth) education interventions available during the perinatal period in low- and middle-income countries on maternal and newborn outcomes. Thus, the review questions are: what is the impact of mother-targeted mHealth education interventions on.

Cell phone ownership and modern contraceptive use in Burkina Faso: implications for research and interventions using mobile technology

Objectives

With over 420 million unique cell phone subscribers in sub-Saharan Africa, the opportunities to use personal cell phones for public health research and interventions are increasing. We assess the association between cell phone ownership and modern contraceptive use among women in Burkina Faso to understand the opportunity to track family planning indicators using cell phone surveys or provide family planning interventions remotely.

Study design

We analyzed data from a cross-sectional, nationally representative population-based survey of women of reproductive age in Burkina Faso, the Performance Monitoring and Accountability 2020 Round 4, which was conducted between November 2016 and January 2017.

Results

Among the 3215 female respondents aged 15 to 49 years, 47% reported cell phone ownership. Overall, 22% of women reported current modern contraceptive use. Women who owned a cell phone were more likely to report modern contraceptive use than those who did not (29% versus 15%). Adjusted for covariates (age, wealth, education, area of residence and marital status), the odds of reporting modern contraceptive use were 68% higher among cell phone owners compared to nonowners (odds ratio=1.68, 95% confidence interval 1.3–2.1). Method mix was substantially more diverse among those who owned cell phones compared to their counterparts.

Conclusions

The study shows that cell phone ownership is significantly associated with modern contraceptive use in Burkina Faso, even after adjusting for women's sociodemographic characteristics. These results suggest that cell phone ownership selectivity and associated biases need to be addressed when planning family planning programs or conducting surveys using cell phones.

Implications

Cell phones can be used for myriad family planning purposes, from confidential data collection to contraceptive promotion and knowledge dissemination, but ownership bias is significant. A cell-phone-based intervention or population-based survey is unlikely to reach a critical mass of the population at highest risk for unintended pregnancy.

Mobile health solutions in developing countries: a stakeholder perspective

Infrastructural deficiencies, limited access to medical care, and shortage of health care workers are just a few of the barriers to health care in developing countries. mHealth has the potential to overcome at least some of these challenges. To address this, a stakeholder perspective is adopted and an analysis of existing research is undertaken to look at mHealth delivery in developing countries. This study focuses on four key stakeholder groups i.e., health care workers, patients, system developers, and facilitators. A systematic review identifies 108 peer-reviewed articles, which are analysed to determine the extent these articles investigate the different types of stakeholder interactions, and to identify high-level themes emerging within these interactions. This analysis illustrates two key gaps. First, while interactions involving health care workers and/or patients have received significant attention, little research has looked at the role of patient-to-patient interactions. Second, the interactions between system developers and the other stakeholder groups are strikingly under-represented.