Targeting strategies of mHealth interventions for maternal health in low and middle-income countries: a systematic review protocol

Exploring perceptions and operational considerations for use of a smartphone application to self-monitor blood pressure in pregnancy in Lombok, Indonesia: protocol for a qualitative study

INTRODUCTION

Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal deaths globally and require close monitoring of blood pressure (BP) to mitigate potential adverse effects. Despite the recognised need for research on self-monitoring of blood pressure (SMBP) among pregnant populations, there are very few studies focused on low and middle income contexts, which carry the greatest burden of HDPs. The study aims to understand the perceptions, barriers, and operational considerations for using a smartphone software application to perform SMBP by pregnant women in Lombok, Indonesia.

METHODS AND ANALYSIS

This study includes a combination of focus group discussions, in-depth interviews and workshop observations. Pregnant women will also be provided with a research version of the smartphone BP application to use in their home and subsequently provide feedback on their experiences. The study will include pregnant women with current or past HDP, their partners and the healthcare workers involved in the provision of antenatal care services within the catchment area of six primary healthcare centres. Data obtained from the interviews and observations will undergo thematic analyses using a combination of both inductive and deductive approaches.

ETHICS AND DISSEMINATION

The study was approved by the World Health Organization (WHO) and Human Reproduction Programme (HRP) Research Project Review Panel and WHO Ethical Review Committee (A65932) as well as the Health Research Ethics Committee, Faculty of Medicine, Universitas Mataram in Indonesia (004/UN18/F7/ETIK/2023).Findings will be disseminated through research publications and communicated to the Lombok district health offices. The analyses from this study will also inform the design of a subsequent impact evaluation.

mHealth Interventions for Contraceptive Behavior Change in the United States: A Systematic Review

Ensuring people have access to their preferred method of contraception can be key for meeting their reproductive goals. A growing number of mHealth interventions show promise for improving access to contraception, but no literature review has identified the effects of mHealth interventions among both adolescents and adults in the United States. The purpose of this systematic review was to describe the format, theoretical basis, and impact of mHealth interventions for contraceptive behavior change (contraceptive initiation and continuation) among people of all ages in the US. A systematic review of the literature was conducted using six electronic databases guided by Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data on study design, frequency, duration, mHealth modality, contraceptive method, behavior change theory, and behavioral outcome were extracted to facilitate comparison. Eighteen studies met eligibility criteria. The majority (11; 61%) used SMS (short message service). Twelve studies focused on contraceptive initiation, most (n = 8) of which also measured continued use over time. The remaining six interventions focused on continuation alone, generally through appointment reminders. Very little contraceptive behavior change was identified across studies. Current mHealth interventions may hold promise for some health areas but there is little evidence that they change contraceptive behavior. Future mHealth interventions should focus on assessing person-centered outcomes, including satisfaction, side effects, and reasons for discontinuation, to best support people to use their preferred contraceptive method.

The effect of a decision-support mHealth application on maternal and neonatal outcomes in two district hospitals in Rwanda: pre – post intervention study

Background

Globally, mobile health (mHealth) applications are known for their potential to improve healthcare providers’ access to relevant and reliable health information. Besides, electronic decision support tools, such as the Safe Delivery mHealth Application (SDA), may help to reduce clinical errors and to ensure quality care at the point of service delivery. The current study investigated the use of the SDA and its relationship to basic emergency obstetric and newborn care (BEmONC) outcomes for the most frequent complications in Rwanda; post-partum haemorrhage (PPH) and newborn asphyxia.

Methods

The study adopted a pre–post intervention design. A pre-intervention record review of BEmONC outcomes: Apgar score and PPH progressions, was conducted for 6 months’ period (February 2019 - July 2019). The intervention took place in two district hospitals in Rwanda and entails the implementation of the SDA for 6 months (October 2019- March 2020), and included 54 nurses and midwives using the SDA to manage PPH and neonatal resuscitation. Six months’ post-SDA intervention, the effect of the SDA on BEmONC outcomes was evaluated. The study included 327 participants (114 cases of PPH and 213 cases of neonatal complications). The analysis compared the outcome variables between the baseline and the endline data. Fisher’s exact test was used to compare the proportions and test between-group differences and significance level set at p < 0.05.

Results

Unstable newborn outcomes following neonatal resuscitation were recorded in 62% newborns cases at baseline and 28% newborns cases at endline, P-value = 0.000. Unstable maternal outcomes following PPH management were recorded in 19% maternal cases at baseline and 6% maternal cases at endline, P-value = 0.048. There was a significant association between the SDA intervention and newborns’ and maternal’ outcomes following neonatal resuscitation and PPH management, 6 months after baseline.

Conclusion

The use of the SDA supported nurses and midwives in the management of PPH and neonatal resuscitation which may have contributed to improved maternal and neonatal outcomes during 6 months of the SDA intervention. The findings of this study are promising as they contribute to a broader knowledge about the effectiveness of SDA in low and middle income hospital settings.

What role do mHealth interventions play in changing gender relations? A systematic review of qualitative findings. (Preprint)

Background

The rapid and widespread growth of mobile technologies in low- and middle-income countries can offer groundbreaking ways of disseminating public health interventions. However, gender-based inequalities present a challenge for women in accessing mobile technology. Research has shown that mobile health (mHealth) interventions can affect gender relations in both positive and negative ways; however, few mHealth programs use a gender-sensitive lens when designing, implementing, or analyzing programs.

Objective

This systematic review aims to identify and summarize the findings of qualitative research studies that explore the impact of mHealth interventions on gender relations as a result of participating in such initiatives in low- and middle-income countries.

Methods

We performed a systematic literature review to examine empirical evidence of changes in gender relations attributed to participation in an mHealth intervention in low- and middle-income countries. Peer-reviewed articles were included based on whether they evaluated an mHealth intervention and were published between 2013 and 2020. Articles using mHealth that solely targeted health workers, did not assess a specific intervention, used mobile technology for data collection only, or were formative or exploratory in nature were excluded. The search terms were entered into 4 key electronic databases—MEDLINE, EMBASE, PsycINFO, and Scopus—generating a comprehensive list of potentially relevant peer-reviewed articles. Thematic analysis was used to identify, analyze, and report the themes that emerged from our data.

Results

Of the 578 full-text articles retrieved, 14 (2.4%) were eligible for inclusion in the study. None of the articles appraised gender from the outset. The articles uncovered findings on gender relations through the course of the intervention or postprogram evaluation. Most studies took place in sub-Saharan Africa, with the remainder in South and Southeast Asia. The articles focused on maternal and child health, HIV diagnosis and treatment, and reproductive health. This review found that mHealth programs could enhance spousal communication, foster emotional support between couples, improve women’s self-efficacy and autonomy in seeking health information and services, and increase their involvement in health-related decision-making. Despite the positive impacts, some mHealth interventions had an adverse effect, reinforcing the digital divide, upholding men as gatekeepers of information and sole decision-makers, and exacerbating relationship problems.

Conclusions

These results suggest that given the rapid and persistent upscale of mHealth interventions in low- and middle-income settings, it is imperative to design interventions that consider their impact on power dynamics and gender relations. Future research is needed to fill the evidence gaps on gender and mHealth, acknowledging that women are not passive beneficiaries and that they need to actively participate and be empowered by mHealth interventions.

Mobile Health Intervention in the Maternal Care Pathway: Protocol for the Impact Evaluation of hAPPyMamma

Background

Mobile health (mHealth) has great potential to both improve the quality and efficiency of care and increase health literacy and empowerment of patient users. There are several studies related to the introduction of mHealth tools for supporting pregnancy and the postnatal period, with promising but not yet rigorously evaluated impacts. This article presents the protocol for evaluating an mHealth intervention (hAPPyMamma) applied in the maternal and child care pathway of a high-income country (in a pilot area of Tuscany Region, Italy).

Objective

The protocol describes hAPPyMamma and the methods for evaluating its impact, including the points of view of women and practitioners. The research hypothesis is that the use of hAPPyMamma will facilitate a more appropriate use of available services, a better care experience for women, and an improvement in the maternal competencies of the women using the app compared to the control group. The protocol also includes analysis of the organizational impact of the introduction of hAPPyMamma in the maternal pathway.

Methods

A pre-post quasiexperimental design with a control group is used to undertake difference-in-differences analysis for assessing the impact of the mHealth intervention from the mothers’ points of view. The outcome measures are improvement of maternal health literacy and empowerment as well as experience in the maternal care pathway of the control and intervention groups of sampled mothers. The organizational impact is evaluated through a quantitative and qualitative survey addressing professionals and managers of the maternal care pathway involved in the intervention.

Results

Following study recruitment, 177 women were enrolled in the control group and 150 in the intervention group, with a participation rate of 97%-98%. The response rate was higher in the control group than in the intervention group (96% vs 67%), though the intervention group had less respondent loss at the postintervention survey (10% compared to 33% of the control group). Data collection from the women was completed in April 2018, while that from professionals and managers is underway.

Conclusions

The study helps consolidate evidence of the utility of mHealth interventions for maternal and child care in developed countries. This paper presents a protocol for analyzing the potential role of hAPPyMamma as an effective mHealth tool for improving the maternal care pathway at individual and organizational levels and consequently helps to understand whether and how to scale up this intervention, with local, national, and international scopes of application.

International Registered Report Identifier (IRRID)

DERR1-10.2196/19073

Improving the Quality of Antenatal Care Using Mobile Health in Madagascar: Five-Year Cross-Sectional Study

Background

Despite many efforts, maternal mortality remains a major burden in most developing countries. Mobile health (mHealth) has the potential to improve access to obstetric care through apps that help patients and providers.

Objective

This study aimed to use mHealth to provide antenatal care (ANC) to 1446 pregnant women in a rural area in Madagascar and evaluate the quality of ANC provided by an mHealth system designed to change the behaviors of providers and patients.

Methods

We included 1446 women who attended ANC visits in rural Madagascar from 2015 to 2019 using an mHealth system called Pregnancy and Newborn Diagnostic Assessment (PANDA). This cross-sectional study used data from different participants, with information collected over several years, to analyze the outputs related to the quality of ANC over time. Specifically, we examined the timing of the first ANC visit, the relationship between the visit duration and the risk factors among pregnant women, and the number of ANC visits per woman.

Results

Following the implementation of the mHealth system in 2015, we observed that women started to come earlier for their first ANC visit; more women attended their first ANC visit in the second trimester of pregnancy in 2019 than in the previous years (P<.001). In 2019, fewer women attended their first ANC visit in the third trimester (57/277, 20.6%) than in 2015 (147/343, 42.9%). There were statistically significant associations between the ANC visit durations and the risk factors, including age (>35 years; 25.0 min, 95% CI 24.0-25.9), educational level (longer visit for women with lower than primary education and for women who attended university and shorter for women with primary school–level education; 40.7 min, 95% CI 30.2-51.3 and 25.3 min, 95% CI 24.4-26.3 vs 23.3 min, 95% CI 22.9-23.8; P=.001), experience of domestic violence during pregnancy, gravidity, parity, infectious diseases (HIV, malaria, and syphilis), and level of anemia. Statistically significant associations were observed for all quality indicator variables. We observed a statistically significant increase in the number of ANC visits per woman over time from 2015 to 2017; the number of ANC visits per woman then became stable after the third year of implementing the PANDA mHealth system.

Conclusions

This study shows the potential of an mHealth system to improve the quality of ANC, change provider behavior by standardizing ANC visits, and change patient behavior by increasing the willingness to return for subsequent visits and encouraging ANC attendance early in pregnancy. As this is an exploratory study, further studies are necessary to better understand how mHealth can change behavior and identify the conditions required for behavioral changes to persist over time.

Digital health, gender and health equity: invisible imperatives

A growing body of evidence shows the use of digital technologies in health—referred to as eHealth, mHealth or ‘digital health’—is improving and saving lives in low- and middle-income countries. Despite this prevalent and persistent narrative, very few studies examine its effects on health equity, gender and power dynamics. This journal supplement addresses these invisible imperatives by going beyond traditional measures of coverage, efficacy and cost-effectiveness associated with digital health interventions, to unpack different experiences of health workers and beneficiaries. The collection of papers presents findings from a cohort of implementation research projects in Africa, Asia, Latin America and the Middle East, and two commentaries offer observations from learning-oriented evaluative activities across the entire cohort. The story emerging from this cohort is comprised of three themes: (i) digital health can positively influence health equity; (ii) gender and power analyses are essential; and (iii) digital health can be used to strengthen upward and downward accountability. These findings, at the individual project level and at the level of the cohort, provide encouraging recommendations on how to approach the design, implementation and evaluation of digital health interventions to address the Sustainable Development Goals agenda of leaving no one behind.

Is More Always Better?: Discovering Incentivized mHealth Intervention Engagement Related to Health Behavior Trends

Behavioral medicine is devoting increasing attention to the topic of participant engagement and its role in effective mobile health (mHealth) behavioral interventions. Several definitions of the term "engagement" have been proposed and discussed, especially in the context of digital health behavioral interventions. We consider that engagement refers to specific interaction and use patterns with the mHealth tools such as smartphone applications for intervention, whereas adherence refers to compliance with the directives of the health intervention, independent of the mHealth tools. Through our analysis of participant interaction and self-reported behavioral data in a college student health study with incentives, we demonstrate an example of measuring "effective engagement" as engagement behaviors that can be linked to the goals of the desired intervention. We demonstrate how clustering of one year of weekly health behavior self-reports generate four interpretable clusters related to participants' adherence to the desired health behaviors: healthy and steady, unhealthy and steady, decliners, and improvers. Based on the intervention goals of this study (health promotion and behavioral change), we show that not all app usage metrics are indicative of the desired outcomes that create effective engagement. As such, mHealth intervention design might consider eliciting not just more engagement or use overall, but rather, effective engagement defined by use patterns related to the desired behavioral outcome.