Evaluation of a Mobile Health Approach to Tuberculosis Contact Tracing in Botswana

Recommendations for Developing a Telemedicine Strategy for Botswana: A Meta-Synthesis

Botswana is developing its eHealth capacity using a National eHealth Strategy. However, that strategy overlooks telemedicine, a potential solution for many healthcare challenges. For telemedicine to benefit Botswana, a telemedicine-specific strategy is required. While establishing a national strategy is a sovereign responsibility, guidance and recommendations can be provided. Using published resources specific to Botswana, key health-related issues were identified. These issues were matched with suitable telemedicine activities and delivery approaches. Recommendations were then derived from these for use in an effective telemedicine-specific strategy for Botswana. From 28 health-related issues, 6 were prioritised. Three telemedicine activities were identified (clinical services, education, and behaviour change), and one delivery approach was chosen (store-and-forward) because they align well with current needs, infrastructure, and mobile phone user capabilities. Since telemedicine has been proven to be effective, efficient, and cost-effective when implemented correctly, this knowledge and experience, plus a recognised strategy development framework, has led to evidence-based recommendations. Specific telemedicine options were identified as examples. As confidence grows, telemedicine options can be expanded to address additional clinical needs and explore alternative activities and delivery options. The recommendations can help the government develop a telemedicine-specific strategy that aligns with the National eHealth Strategy while actively promoting and supporting the adoption and system integration of straightforward telemedicine interventions. This foundation will facilitate the future expansion of telemedicine initiatives for the benefit of all Batswana.

mHealth to improve implementation of TB contact investigation: a case study from Uganda

BACKGROUND

Implementation science offers a systematic approach to adapting innovations and delivery strategies to new contexts but has yet to be widely applied in low- and middle-income countries. The Fogarty Center for Global Health Studies is sponsoring a special series, "Global Implementation Science Case Studies," to address this gap.

METHODS

We developed a case study for this series describing our approach and lessons learned while conducting a prospective, multi-modal study to design, implement, and evaluate an implementation strategy for TB contact investigation in Kampala, Uganda. The study included formative, evaluative, and summative phases that allowed us to develop and test an adapted contact investigation intervention involving home-based sample collection for TB and HIV testing. We concurrently developed a multi-component mHealth implementation strategy involving fingerprint scanning, electronic decision support, and automated reporting of test results via text message. We then conducted a household-randomized, hybrid implementation-effectiveness trial comparing the adapted intervention and implementation strategy to usual care. Our assessment included nested quantitative and qualitative studies to understand the strategy's acceptability, appropriateness, feasibility, fidelity, and costs. Reflecting on this process with a multi-disciplinary team of implementing researchers and local public health partners, we provide commentary on the previously published studies and how the results influenced the adaptation of international TB contact investigation guidelines to fit the local context.

RESULTS

While the trial did not show improvements in contact investigation delivery or public health outcomes, our multi-modal evaluation strategy helped us identify which elements of home-based, mHealth-facilitated contact investigation were feasible, acceptable, and appropriate and which elements reduced its fidelity and sustainability, including high costs. We identified a need for better tools for measuring implementation that are simple, quantitative, and repeatable and for greater attention to ethical issues in implementation science.

CONCLUSIONS

Overall, a theory-informed, community-engaged approach to implementation offered many learnings and actionable insights for delivering TB contact investigation and using implementation science in low-income countries. Future implementation trials, especially those incorporating mHealth strategies, should apply the learnings from this case study to enhance the rigor, equity, and impact of implementation research in global health settings.

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.

Toward a conceptual framework of the acceptability of tuberculosis treatment in children using a theory generative approach

To describe an early-stage holistic framework towards evaluating factors that impact the overall acceptability of TB treatment along the TB care cascade in children. We developed a conceptual framework utilising a theory generative approach. Domains were developed through review of existing definitions and analysis of existing qualitative data undertaken in acceptability studies of TB treatment in children. Clarity of domain definitions was achieved through iterative refinement among the research team. Three domains, each comprising several dimensions, were identified to holistically evaluate treatment acceptability: (1) usability, which involves the alignment between the requirements of treatment use and caregivers' and children's ability to integrate TB treatment into their everyday routines, (2) receptivity, which describes the end-user's perception and expectations of treatment and its actual use, and (3) integration, which describes the relationship between available health services and caregivers/children's capacity to make use of those services. Our framework addresses the gaps in current research which do not account for the influence of caregivers' and children's contexts on TB treatment uptake and overall acceptability. This approach may support the development of more standard, holistic measures to improve TB treatment delivery and experiences and future research in children.

eHealth in TB clinical management

BACKGROUND: The constant expansion of internet and mobile technologies has created new opportunities in the field of eHealth, or the digital delivery of healthcare services. This TB meta-analysis aims to examine eHealth and its impact on TB clinical management in order to formulate recommendations for further development.METHODS: A systematic search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework in PubMed and Embase of articles published up to April 2021. Screening, extraction and quality assessment were performed by two independent researchers. Studies evaluating an internet and/or mobile-based eHealth intervention with an impact on TB clinical management were included. Outcomes were organised following the five domains described in the WHO "Recommendations on Digital Interventions for Health System Strengthening" guideline.RESULTS: Search strategy yielded 3,873 studies, and 89 full texts were finally included. eHealth tended to enhance screening, diagnosis and treatment indicators, while being cost-effective and acceptable to users. The main challenges concern hardware malfunction and software misuse.CONCLUSION: This study offers a broad overview of the innovative field of eHealth applications in TB. Different studies implementing eHealth solutions consistently reported on benefits, but also on specific challenges. eHealth is a promising field of research and could enhance clinical management of TB.

Widening or narrowing inequalities? The equity implications of digital tools to support COVID-19 contact tracing: A qualitative study

Background

As digital tools are increasingly used to support COVID‐19 contact tracing, the equity implications must be considered. As part of a study to understand the public's views of digital contact tracing tools developed for the national ‘Test and Protect’ programme in Scotland, we aimed to explore the views of groups often excluded from such discussions. This paper reports on their views about the potential for contact tracing to exacerbate inequalities.

Methods

A qualitative study was carried out; interviews were conducted with key informants from organizations supporting people in marginalized situations, followed by interviews and focus groups with people recruited from these groups. Participants included, or represented, minority ethnic groups, asylum seekers and refugees and those experiencing multiple disadvantage including severe and enduring poverty.

Results

A total of 42 people participated: 13 key informants and 29 members of the public. While public participants were supportive of contact tracing, key informants raised concerns. Both sets of participants spoke about how contact tracing, and its associated digital tools, might increase inequalities. Barriers included finances (inability to afford smartphones or the data to ensure access to the internet); language (digital tools were available only in English and required a degree of literacy, even for English speakers); and trust (many marginalized groups distrusted statutory organizations and there were concerns that data may be passed to other organizations). One strength was that NHS Scotland, the data guardian, is seen as a generally trustworthy organization. Poverty was recognized as a barrier to people's ability to self‐isolate. Some participants were concerned about giving contact details of individuals who might struggle to self‐isolate for financial reasons.

Conclusions

The impact of contact tracing and associated digital tools on marginalized populations needs careful monitoring. This should include the contact tracing process and the ability of people to self‐isolate. Regular clear messaging from trusted groups and community members could help maintain trust and participation in the programme.

Patient and Public Contribution

Our patient and public involvement coapplicant, L. L., was involved in all aspects of the study including coauthorship. Interim results were presented to our local Public and Patient Involvement and Engagement Group, who commented on interpretation and made suggestions about further recruitment.

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.

Investigation of Contacts for Latent Mycobacterium Tuberculosis Infection: Application Software Development

Introduction:

Tuberculosis is a pathology that continues to be worthy of special attention from health professionals and society due to its high prevalence, proving to be a crucial public health problem.

Objectives:

To describe the development of an application for family health strategy professionals’ investigation of tuberculosis contacts for Latent Mycobacterium tuberculosis Infection.

Methods:

This study is applied research on an application software developed according to three of the five phases described by Falkembach for developing digital educational materials, which include analysis and planning, modeling, and implementation.

Results:

The application is dynamic; that is, it guides health professionals through sequenced screens according to professionals’ self-informed answers. This functionality helps them deciding whether to proceed to the treatment of the patient with Latent Mycobacterium tuberculosis Infection or returning to the initial stage of a tuberculosis contact.

The screens of the application follow the flowchart presented in the Ministry of Health’s Manual of recommendations for tuberculosis control in Brazil of 2018.

Conclusion:

The application developed to guide Family Health Strategy professionals regarding Latent Infection by Mycobacterium Tuberculosis can prevent human errors and increase the care quality when assessing tuberculosis contacts.

Feasibility of using a mobile App to monitor and report COVID-19 related symptoms and people's movements in Uganda

BACKGROUND

Feasibility of mobile Apps to monitor diseases has not been well documented particularly in developing countries. We developed and studied the feasibility of using a mobile App to collect daily data on COVID-19 symptoms and people's movements.

METHODS

We used an open source software "KoBo Toolbox" to develop the App and installed it on low cost smart mobile phones. We named this App "Wetaase" ("protect yourself"). The App was tested on 30 selected households from 3 densely populated areas of Kampala, Uganda, and followed them for 3 months. One trained member per household captured the data in the App for each enrolled member and uploaded it to a virtual server on a daily basis. The App is embedded with an algorithm that flags participants who report fever and any other COVID-19 related symptom.

RESULTS

A total of 101 participants were enrolled; 61% female; median age 23 (interquartile range (IQR): 17-36) years. Usage of the App was 78% (95% confidence interval (CI): 77.0%-78.8%). It increased from 40% on day 1 to a peak of 81% on day 45 and then declined to 59% on day 90. Usage of the App did not significantly vary by site, sex or age. Only 57/6617 (0.86%) records included a report of at least one of the 17 listed COVID-19 related symptoms. The most reported symptom was flu/runny nose (21%) followed by sneezing (15%), with the rest ranging between 2% and 7%. Reports on movements away from home were 45% with 74% going to markets or shops. The participants liked the "Wetaase" App and recommended it for use as an alert system for COVID-19.

CONCLUSION

Usage of the "Wetaase" App was high (78%) and it was similar across the three study sites, sex and age groups. Reporting of symptoms related to COVID-19 was low. Movements were mainly to markets and shops. Users reported that the App was easy to use and recommended its scale up. We recommend that this App be assessed at a large scale for feasibility, usability and acceptability as an additional tool for increasing alerts on COVID-19 in Uganda and similar settings.

Development of a conceptual framework for linking mHealth applications to eRecord systems in Botswana

BACKGROUND

The proliferation of mHealth solutions and eRecord systems is inevitable in developing countries, and ensuring their bi-directional interoperability is essential. Interoperability has been described as the ability for two or more systems or components to exchange information and use the information that has been exchanged. Given the importance of linking mHealth solutions to eRecord systems in the developing world, a suitable interoperability framework is required to provide an agreed approach to interoperability and specify common elements. Although eHealth interoperability frameworks exist in the literature, none meet all the requirements for linking mHealth solutions to eRecord systems in developing countries. The aim of this paper was to describe the design and development of a conceptual framework for linking mHealth solutions to eRecord systems in Botswana, as an exemplar.

METHODS

An iterative and reflective process was adopted, supported by existing literature and research including consultations with eHealth experts, and guidance from existing frameworks. These collectively identified key elements, concepts, and standards relevant and essential for framework design and development.

RESULTS

The mHealth-eRecord Interoperability Framework (mHeRIF) was developed which highlights the need for: governance and regulation of mHealth and eRecord systems, a national health information exchange, and which interoperability levels to achieve. Each of these are supported by integral themes and concepts. It also addresses the need for regular review, accreditation, and alignment of framework concepts and themes with a National eHealth Strategy Interoperability Development Process. To demonstrate the framework's applicability, a proposed architecture for the Kgonafalo mobile telemedicine programme is presented.

CONCLUSION

Interoperable mHealth solutions and eRecords systems have the potential to strengthen health systems. This paper reports the design and development of an evidence-based mHeRIF to align with, build upon, and expand National eHealth Strategies by guiding the linking of mHealth solutions to eRecord systems in Botswana and other developing countries facing similar circumstances.

Covid-19 and tracing methodologies: A lesson for the future society

As the new coronavirus (SARS-CoV-2) surged across the globe, new technical solutions have supported policy makers and health authorities to plan and modulate containment measures. The introduction of these solutions provoked a large debate which has focused on risks for privacy and data protection. In this paper we offer an analysis of the available technical approaches and provide new arguments to move beyond the ongoing discussions. In particular, we argue that the past debate missed the opportunity to highlight the societal aspects of privacy and to stimulate a broader reflection on the actions needed to serve the good of society. With this paper, as well as providing an accessible review of the technical and legal aspects of the proposed solutions, we aim to offer new stimuli to reconsider contact tracing and its role in helping countries navigate the current pandemic.

A bibliometric analysis of medical informatics and telemedicine in sub-Saharan Africa and BRICS nations

The advances in eHealth have dramatically changed the face of healthcare delivery around the world, with Sub-Saharan Africa being no exception. It is essential to identify the prominent, emerging researchers, successful areas of research within the field of health informatics (HI) and telemedicine (TM) to be duplicated where there is a need. This study gives a bibliometric overview of original research articles on medical informatics and telemedicine indexed in Scopus, PubMed, and Science Direct over the last 20 years in sub-Saharan Africa. Keywords related to health informatics and telemedicine were used to retrieve relevant literature. We specifically analyzed the evolution, standard metrics, domains of medical informatics (MI) and TM in sub-Saharan Africa (SSA) and Brazil, Russia, India, China, and South Africa (BRIC) nations. Our results identified mhealth as the main field of research in telemedicine that has seen significant growth in both BRIC and SSA nations and is poised to be the focus of research activity in the near future. Research production in mhealth and telemedicine showed a considerable increase from 1999-2018. The production was dominated by articles from South Africa in Africa and China from the BRIC nations. Most prolific authors have resources and are leaders of health informatics projects. The production came from 26 sub-Saharan African countries, denoting this field's devotion in different areas around sub-Sahara. Research in mhealth needs to be encouraged, mostly in the fight against infectious and non-infectious diseases in sub-Saharan Africa, where technology can improve health services and decrease disease burden.

COVIDTAS COVID-19 Tracing App Scale—An Evaluation Framework

Mobile apps play an important role in COVID-19 tracing and tracking, with different countries taking different approaches. Our study focuses on 17 government owned COVID-19 Contact Tracing Apps (CTAs) and analyze them using a proposed COVIDTAS framework. User satisfaction is not directly related to the COVIDTAS score or the interaction between users and the app developers. To increase adoption of CTAs, government leadership must offer assurance to its citizens that their identify will be concealed and emphasize the benefits of CTAs as it relates to shared public health. While no country has topped the list on all three major factors (COVIDTAS Score, User Reviews, and User Ratings), the CTA from India seems to have above average performance on all three factors.

Treatment outcomes among tuberculosis patients in Jeddah, Saudi Arabia: Results of a community mobile outreach directly observed Treatment, Short-course (DOTS) project, compared to a standard facility-based DOTS: A randomized controlled trial

INTRODUCTION

Tuberculosis (TB) remains a global public health threat affecting people in many developing countries, including the Kingdom of Saudi Arabia. Maintaining a long-term treatment regimen has always been the cornerstone of successful treatment outcomes among tuberculosis patients. In the Jeddah region, the National Tuberculosis Control and Prevention Program is now treating TB patients by means of a community mobile outreach team approach.The objective of this study was to compare the effectiveness of the community mobile outreach approach in improving treatment outcomes (success rate) among local tuberculosis patients with those being treated with a facility-based directly observed treatment, short-course (DOTS).

STUDY DESIGN

Our study consisted of a two-sample, parallel design [1:1], statistician -blind randomized control trial with 200 newly diagnosed, TB patients as subjects.

SETTING/PARTICIPANTS

The patients had all presented at the Madain Alfahd Primary Health Care Center, Jeddah. Between Nov 2017 and Nov 2018, a total of 221 TB patients were screened of whom 200 were randomly selected using randomly generated sequences.

INTERVENTION

Patients in the intervention sample group were treated by means of mobile outreach teams with oral anti-TB treatment under the DOTS, and control group patients were given the traditional facility-based DOTS treatment according to the WHO recommendations and national guidelines.

MAIN OUTCOME

The primary outcome was the level of overall treatment success rate. It was finally determined and compared in the two sample groups using chi-square analysis and relative risk assessment.

RESULTS

In the analysis stage, 97 patients were in the intervention group, while the control group consisted of 76. The overall response rate was 86.5% (173/200). We found that the percentage of overall treatment success rate among the patients served by the mobile outreach team was 97%, compared to 76% in the non-mobile team treated patients. The relative risk of treatment success rate among the intervention group was 1.27 (95% CI = 1.13-1.43) times greater than that amongst the control group. Log-rank test (log-rank statistics = 18.91; p < 0.001) identified a significant difference in the default rate after six months of treatment.

CONCLUSION

This study has shown that a mobile outreach DOTS approach is an effective and acceptable strategy for treating TB patients. It also provides important data on the efficacy of using mobile outreach teams to improve TB treatment outcomes in Jeddah. Our results provide evidence and highlight the positive and significant impact of mobile outreach teams in mitigating TB recurrence rates and in improving TB treatment outcomes.Clinical Trial Registration: Clinicaltrials.gov: NCT03787914.

The experience of contact tracing in Singapore in the control of COVID-19: highlighting the use of digital technology

Purpose

Containing the coronavirus disease 2019 (COVID-19) pandemic would require aggressive contact tracing and isolation of suspected or confirmed COVID-19 cases. Models in published literature have suggested that digital rather than manual contact tracing might be more effective in containing the pandemic. This article seeks to examine the forms of contact tracing that Singapore, a highly dense city-state, adopts with a focus on new innovations including the use of digital technology.

Methods

An exploratory literature search in PubMed, MEDLINE and EMBASE for studies reviewing technological approaches and responses to COVID-19 was performed. Information published by national agencies was also analysed to ascertain how technology was utilised in contact tracing.

Results

Contact tracing in Singapore is overseen by the Ministry of Health (MOH). COVID-19 cases are interviewed on their whereabouts during a backward and forward activity mapping process to identify close contacts. Extensive contact tracing even involving the police and serological tools have helped to establish links between cases and closed several local clusters. Examination of patient’s digital footprint has helped in contact tracing. Other digital technology introduced includes SafeEntry and TraceTogether. SafeEntry is a cloud-based visitor registration system while TraceTogether is a mobile phone application which operates by exchanging anonymised identifiers between nearby phones via Bluetooth connection.

Conclusion

Digital contact tracing is likely to expand and continue to complement human-based contact tracing for the current and future pandemics. However, at this juncture, it is not ready to replace the manual and meticulous work that only Singapore contact tracers can achieve.

Digital contact tracing technologies in epidemics: a rapid review

BACKGROUND

Reducing the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a global priority. Contact tracing identifies people who were recently in contact with an infected individual, in order to isolate them and reduce further transmission. Digital technology could be implemented to augment and accelerate manual contact tracing. Digital tools for contact tracing may be grouped into three areas: 1) outbreak response; 2) proximity tracing; and 3) symptom tracking. We conducted a rapid review on the effectiveness of digital solutions to contact tracing during infectious disease outbreaks.

OBJECTIVES

To assess the benefits, harms, and acceptability of personal digital contact tracing solutions for identifying contacts of an identified positive case of an infectious disease.

SEARCH METHODS

An information specialist searched the literature from 1 January 2000 to 5 May 2020 in CENTRAL, MEDLINE, and Embase. Additionally, we screened the Cochrane COVID-19 Study Register.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, quasi-RCTs, cohort studies, cross-sectional studies and modelling studies, in general populations. We preferentially included studies of contact tracing during infectious disease outbreaks (including COVID-19, Ebola, tuberculosis, severe acute respiratory syndrome virus, and Middle East respiratory syndrome) as direct evidence, but considered comparative studies of contact tracing outside an outbreak as indirect evidence. The digital solutions varied but typically included software (or firmware) for users to install on their devices or to be uploaded to devices provided by governments or third parties. Control measures included traditional or manual contact tracing, self-reported diaries and surveys, interviews, other standard methods for determining close contacts, and other technologies compared to digital solutions (e.g. electronic medical records).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened records and all potentially relevant full-text publications. One review author extracted data for 50% of the included studies, another extracted data for the remaining 50%; the second review author checked all the extracted data. One review author assessed quality of included studies and a second checked the assessments. Our outcomes were identification of secondary cases and close contacts, time to complete contact tracing, acceptability and accessibility issues, privacy and safety concerns, and any other ethical issue identified. Though modelling studies will predict estimates of the effects of different contact tracing solutions on outcomes of interest, cohort studies provide empirically measured estimates of the effects of different contact tracing solutions on outcomes of interest. We used GRADE-CERQual to describe certainty of evidence from qualitative data and GRADE for modelling and cohort studies.

MAIN RESULTS

We identified six cohort studies reporting quantitative data and six modelling studies reporting simulations of digital solutions for contact tracing. Two cohort studies also provided qualitative data. Three cohort studies looked at contact tracing during an outbreak, whilst three emulated an outbreak in non-outbreak settings (schools). Of the six modelling studies, four evaluated digital solutions for contact tracing in simulated COVID-19 scenarios, while two simulated close contacts in non-specific outbreak settings. Modelling studies Two modelling studies provided low-certainty evidence of a reduction in secondary cases using digital contact tracing (measured as average number of secondary cases per index case - effective reproductive number (R _eff)). One study estimated an 18% reduction in R _eff with digital contact tracing compared to self-isolation alone, and a 35% reduction with manual contact-tracing. Another found a reduction in R _eff for digital contact tracing compared to self-isolation alone (26% reduction) and a reduction in R _eff for manual contact tracing compared to self-isolation alone (53% reduction). However, the certainty of evidence was reduced by unclear specifications of their models, and assumptions about the effectiveness of manual contact tracing (assumed 95% to 100% of contacts traced), and the proportion of the population who would have the app (53%). Cohort studies Two cohort studies provided very low-certainty evidence of a benefit of digital over manual contact tracing. During an Ebola outbreak, contact tracers using an app found twice as many close contacts per case on average than those using paper forms. Similarly, after a pertussis outbreak in a US hospital, researchers found that radio-frequency identification identified 45 close contacts but searches of electronic medical records found 13. The certainty of evidence was reduced by concerns about imprecision, and serious risk of bias due to the inability of contact tracing study designs to identify the true number of close contacts. One cohort study provided very low-certainty evidence that an app could reduce the time to complete a set of close contacts. The certainty of evidence for this outcome was affected by imprecision and serious risk of bias. Contact tracing teams reported that digital data entry and management systems were faster to use than paper systems and possibly less prone to data loss. Two studies from lower- or middle-income countries, reported that contact tracing teams found digital systems simpler to use and generally preferred them over paper systems; they saved personnel time, reportedly improved accuracy with large data sets, and were easier to transport compared with paper forms. However, personnel faced increased costs and internet access problems with digital compared to paper systems. Devices in the cohort studies appeared to have privacy from contacts regarding the exposed or diagnosed users. However, there were risks of privacy breaches from snoopers if linkage attacks occurred, particularly for wearable devices.

AUTHORS' CONCLUSIONS

The effectiveness of digital solutions is largely unproven as there are very few published data in real-world outbreak settings. Modelling studies provide low-certainty evidence of a reduction in secondary cases if digital contact tracing is used together with other public health measures such as self-isolation. Cohort studies provide very low-certainty evidence that digital contact tracing may produce more reliable counts of contacts and reduce time to complete contact tracing. Digital solutions may have equity implications for at-risk populations with poor internet access and poor access to digital technology. Stronger primary research on the effectiveness of contact tracing technologies is needed, including research into use of digital solutions in conjunction with manual systems, as digital solutions are unlikely to be used alone in real-world settings. Future studies should consider access to and acceptability of digital solutions, and the resultant impact on equity. Studies should also make acceptability and uptake a primary research question, as privacy concerns can prevent uptake and effectiveness of these technologies.

An e-registry for household contacts exposed to multidrug resistant TB in Mongolia

BACKGROUND

The WHO recommends that individuals exposed to persons with multidrug resistant tuberculosis (MDRTB) should be screened for active TB and followed up for 2 years to detect and treat secondary cases early. Resource prioritisation means this is rarely undertaken and where it is performed it's usually using a paper-based record, without collation of data. Electronic data collection into a web-based registry offers the opportunity for simplified and systematic TB contact surveillance with automatic synthesis of data at local, regional and national level. This pilot study was designed to explore the feasibility of usage of a novel e-registry tool and explore obstacles and facilitating factors to implementation.

METHODS

In parallel with their paper records, seven dispensaries in Ulaanbaatar, Mongolia collected standardized data electronically using Open Data Kit (ODK). Patients with MDRTB and their contacts were recruited during a single clinic visit. Staff and patients were interviewed to gain insights into acceptability and to identify areas for improvement.

RESULTS

Seventy household contacts of 32 MDR-TB index patients were recruited. 7/70 contacts (10%) traced had active TB at the time they were recruited to the e-registry. Paper registry satisfaction was low; 88% of staff preferred the e-registry as it was perceived as faster and more secure. Patients and their contacts were generally supportive of the e-registry; however, a significant minority 10/42 (24%) of index cases who were invited, declined to participate in the e-registry, with data security cited as their top concern.

CONCLUSION

E-registries are a promising tool for MDRTB contact tracing, but their acceptability amongst patients should not be taken for granted.

Research Techniques Made Simple:Teledermatology in Clinical Trials

Telemedicine is well established as a means of providing high-quality healthcare at a distance, particularly to patients in underserved populations. Technologies in teledermatology can be used to complement traditional methodologies of clinical trials, expanding accessibility of trials to people typically unable to participate in research. Tools of communication technology may enhance many aspects of clinical trials in dermatology, from recruitment and retention of participants to collection of real-time data. Clinical trials can be made completely virtual or incorporate aspects of virtual technologies at any stage of research. Virtual clinical trials are considered highly patient-centered, as the ability of participants to engage with research staff from their own home often supplants the need for many or all on-site clinic visits. As technological advances influence every aspect of modern life, clinical trials will also evolve to incorporate these tools, meeting participant expectations and overcoming traditional challenges of conducting research. Virtual clinical trials come with specific issues pertaining to analysis of data, technology, and oversight. As more virtual trials are conducted, advantages and limitations of using such technology in research will become clearer and regulatory guidelines will be more firmly established.

Use of Digital Technology to Enhance Tuberculosis Control: Scoping Review

Background

Tuberculosis (TB) is the leading cause of death from a single infectious agent, with around 1.5 million deaths reported in 2018, and is a major contributor to suffering worldwide, with an estimated 10 million new cases every year. In the context of the World Health Organization’s End TB strategy and the quest for digital innovations, there is a need to understand what is happening around the world regarding research into the use of digital technology for better TB care and control.

Objective

The purpose of this scoping review was to summarize the state of research on the use of digital technology to enhance TB care and control. This study provides an overview of publications covering this subject and answers 3 main questions: (1) to what extent has the issue been addressed in the scientific literature between January 2016 and March 2019, (2) which countries have been investing in research in this field, and (3) what digital technologies were used?

Methods

A Web-based search was conducted on PubMed and Web of Science. Studies that describe the use of digital technology with specific reference to keywords such as TB, digital health, eHealth, and mHealth were included. Data from selected studies were synthesized into 4 functions using narrative and graphical methods. Such digital health interventions were categorized based on 2 classifications, one by function and the other by targeted user.

Results

A total of 145 relevant studies were identified out of the 1005 published between January 2016 and March 2019. Overall, 72.4% (105/145) of the research focused on patient care and 20.7% (30/145) on surveillance and monitoring. Other programmatic functions 4.8% (7/145) and electronic learning 2.1% (3/145) were less frequently studied. Most digital health technologies used for patient care included primarily diagnostic 59.4% (63/106) and treatment adherence tools 40.6% (43/106). On the basis of the second type of classification, 107 studies targeted health care providers (107/145, 73.8%), 20 studies targeted clients (20/145, 13.8%), 17 dealt with data services (17/145, 11.7%), and 1 study was on the health system or resource management. The first authors’ affiliations were mainly from 3 countries: the United States (30/145 studies, 20.7%), China (20/145 studies, 13.8%), and India (17/145 studies, 11.7%). The researchers from the United States conducted their research both domestically and abroad, whereas researchers from China and India conducted all studies domestically.

Conclusions

The majority of research conducted between January 2016 and March 2019 on digital interventions for TB focused on diagnostic tools and treatment adherence technologies, such as video-observed therapy and SMS. Only a few studies addressed interventions for data services and health system or resource management.

Use of a mobile application for Ebola contact tracing and monitoring in northern Sierra Leone: a proof-of-concept study

Background

The 2014–2016 Ebola epidemic in West Africa was the largest Ebola epidemic to date. Contact tracing was a core surveillance activity. Challenges with paper-based contact tracing systems include incomplete identification of contacts, delays in communication and response, loss of contact lists, inadequate data collection and transcription errors.

The aim of this study was to design and evaluate an electronic system for tracing contacts of Ebola cases in Port Loko District, Sierra Leone, and to compare this with the existing paper-based system. The electronic system featured data capture using a smartphone application, linked to an alert system to notify the District Ebola Response Centre of symptomatic contacts.

Methods

The intervention was a customised three-tier smartphone application developed using Dimagi’s CommCare platform known as the Ebola Contact Tracing application (ECT app). Eligible study participants were all 26 Contact Tracing Coordinators (CTCs) and 86 Contact Tracers (CTs) working in the 11 Chiefdoms of Port Loko District during the study period (April–August 2015). Case detection was from 13th April to 17th July 2015. The CTCs and their CTs were provided with smartphones installed with the ECT app which was used to conduct contact tracing activities. Completeness and timeliness of contact tracing using the app were compared with data from April 13th-June 7th 2015, when the standard paper-based system was used.

Results

For 25 laboratory-confirmed cases for whom paper-based contact tracing was conducted, data for only 39% of 408 contacts were returned to the District, and data were often incomplete. For 16 cases for whom app-based contact tracing was conducted, 63% of 556 contacts were recorded as having been visited on the app, and the median recorded duration from case confirmation to first contact visit was 70 h.

Conclusion

There were considerable challenges to conducting high-quality contact tracing in this setting using either the paper-based or the app-based system. However, the study demonstrated that it was possible to implement mobile health (mHealth) in this emergency setting. The app had the benefits of improved data completeness, storage and accuracy, but the challenges of using an app in this setting and epidemic context were substantial.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4354-z) contains supplementary material, which is available to authorized users.

Specialized Smartphone Intervention Apps: Review of 2014 to 2018 NIH Funded Grants

Background

The widespread adoption of smartphones provides researchers with expanded opportunities for developing, testing and implementing interventions. National Institutes of Health (NIH) funds competitive, investigator-initiated grant applications. Funded grants represent the state of the science and therefore are expected to anticipate the progression of research in the near future.

Objective

The objective of this paper is to provide an analysis of the kinds of smartphone-based intervention apps funded in NIH research grants during the five-year period between 2014 and 2018.

Methods

We queried NIH Reporter to identify candidate funded grants that addressed mHealth and the use of smartphones. From 1524 potential grants, we identified 397 that met the requisites of including an intervention app. Each grant’s abstract was analyzed to understand the focus of intervention. The year of funding, type of activity (eg, R01, R34, and so on) and funding were noted.

Results

We identified 13 categories of strategies employed in funded smartphone intervention apps. Most grants included either one (35.0%) or two (39.0%) intervention approaches. These included artificial intelligence (57 apps), bionic adaptation (33 apps), cognitive and behavioral therapies (68 apps), contingency management (24 apps), education and information (85 apps), enhanced motivation (50 apps), facilitating, reminding and referring (60 apps), gaming and gamification (52 apps), mindfulness training (18 apps), monitoring and feedback (192 apps), norm setting (7 apps), skills training (85 apps) and social support and social networking (59 apps). The most frequently observed grant types included Small Business Innovation Research (SBIR) and Small Business Technology Transfer (STTR) grants (40.8%) and Research Project Grants (R01s) (26.2%). The number of grants funded increased through the five-year period from 60 in 2014 to 112 in 2018.

Conclusions

Smartphone intervention apps are increasingly competitive for NIH funding. They reflect a wide diversity of approaches that have significant potential for use in applied settings.

Use of Mobile Health (mHealth) Technologies and Interventions Among Community Health Workers Globally: A Scoping Review

There is mounting evidence to show that community health workers (CHWs) play a positive role in improving population health by connecting people to information, resources, and services. However, barriers faced by CHWs include not being able to access information quickly and in a language tailored to the communities they serve. Mobile health (mHealth) shows promise of bridging this gap. Although there are a number of studies published on mHealth interventions, there is a need to synthesize the literature specific to mHealth and CHWs globally. Therefore, the primary goals of this review are to identify and describe over ten years of studies on the use, effectiveness, and potential of mHealth involving CHWs. Findings provide evidence-based strategies for designing and implementing mHealth tools for and with CHWs. We used criteria and methodology for scoping reviews established by the Joanna Briggs Institute as well as PRISMA protocols. We searched scholarly databases for peer-reviewed articles published between 2007 and 2018. The initial search yielded 207 published articles; after applying inclusion criteria, the sample totaled 64. While research about mHealth use among CHWs is still emerging, we found out that large-scale, longitudinal, and clinical studies are lacking. The existing evidence indicates that interventions, which include both CHWs and mHealth tools, are effective. Challenges include the scarcity of culturally relevant mHealth interventions, lack of a consistent methodology to assess mHealth outcomes, the need for effective training for CHWs to adopt mHealth tools, and improved communication within health care teams working with CHWs.

Toward Developing a Standardized Core Set of Outcome Measures in Mobile Health Interventions for Tuberculosis Management: Systematic Review

Background

Tuberculosis (TB) management can be challenging in low- and middle-income countries (LMICs) not only because of its high burden but also the prolonged treatment period involving multiple drugs. With rapid development in mobile technology, mobile health (mHealth) interventions or using a mobile device for TB management has gained popularity. Despite the potential usefulness of mHealth interventions for TB, few studies have quantitatively synthesized evidence on its effectiveness, presumably because of variability in outcome measures reported in the literature.

Objective

The aim of this systematic review was to evaluate the outcome measures reported in TB mHealth literature in LMICs.

Methods

MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched to identify mHealth intervention studies for TB (published up to May 2018) that reported any type of outcome measures. The extracted information included the study setting, types of mHealth technology used, target population, study design, and categories of outcome measures. Outcomes were classified into 13 categories including treatment outcome, adherence, process measure, perception, technical outcome, and so on. The qualitative synthesis of evidence focused on the categories of outcome measures reported by the type of mHealth interventions.

Results

A total of 27 studies were included for the qualitative synthesis of evidence. The study designs varied widely, ranging from randomized controlled trials to economic evaluations. A total of 12 studies adopted short message service (SMS), whereas 5 studies used SMS in combination with additional technologies or mobile apps. The study populations were also diverse, including patients with TB, patients with TB/HIV, health care workers, and general patients attending a clinic. There was a wide range of variations in the definition of outcome measures across the studies. Among the diverse categories of outcome measures, treatment outcomes have been reported in 14 studies, but only 6 of them measured the outcome according to the standard TB treatment definitions by the World Health Organization.

Conclusions

This critical evaluation of outcomes reported in mHealth studies for TB management suggests that substantial variability exists in reporting outcome measures. To overcome the challenges in evidence synthesis for mHealth interventions, this study can provide insights into the development of a core set of outcome measures by intervention type and study design.