A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa

Effect of eHealth Interventions on Medication Adherence in Kidney Transplant Recipients: Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Kidney transplant recipients must take immunosuppressive drugs for life, and medication non-adherence is a primary risk factor for graft loss and death. With the advancement of technology, electronic health applications are widely used in chronic disease management and offer the potential to improve medication adherence in kidney transplant recipients.

AIM

This meta-analysis aims to evaluate randomised controlled trials (RCTs) that assess the effectiveness of eHealth interventions in improving medication adherence among kidney transplant recipients.

METHODS

This study, which was designed as a systematic review and meta-analysis, followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocols in the planning and reporting phases. Electronic databases and manual literature searches were the two main data sources. Full-text RCTs in PubMed, Medline, Web of Science and Scopus databases were systematically searched. The searches covered studies from 2014 to March 2024.

RESULTS

The search yielded 524 articles. Eight RCTs with 779 participants were included in the analysis. The meta-analysis results indicated that, compared with the control group, adherence rates (RR: 1.19; 95% CI: 1.06-1.35; p = 0.01. Heterogeneity: Q = 8.69; p = 0.28; I2 = 19%) and adherence scores (SMD: 0.17; 95% CI: 0.05-0.29; p = 0.02. Heterogeneity: Q = 0.45; p = 0.93; I2 = 0%) significantly increased in the eHealth intervention group compared with the control group.

CONCLUSION

The findings of this report show that eHealth interventions to improve medication adherence in kidney transplant recipients show favourable outcomes compared with standard care. We recommend eHealth interventions to improve long-term survival and patient outcomes in kidney transplant recipients.

Mobile health (mHealth) technologies for fall prevention among older adults in low-middle income countries: bibliometrics, network analysis and integrative review

Introduction

mHealth technologies offer promising solutions to reduce the incidence of falls among older adults. Unfortunately, publications on their application to Low-Middle Income Countries (LMIC) settings have not been collectively examined.

Methods

A triadic research design involving bibliometrics, network analysis, and model-based integrative review was conducted to process articles (n = 22) from 629 publications extracted from major databases using keywords related to mHealth, falls prevention, and LMIC. The web-based application Covidence and stand-alone VosViewer software were used to process data following previously published review standards.

Results

Published articles in the field feature multidisciplinary authorships from multiple scholars in the domains of health and technology. Network analysis revealed the most prominent stakeholders and keyword clusters related to mHealth technology features and applications in healthcare. The papers predominantly focused on the development of mHealth technology, usability, and affordances and less on the physiologic and sociologic attributes of technology use. mHealth technologies in low and middle-income countries are mostly smartphone-based, static, and include features for home care settings with fall detection accuracy of 86%-99.62%. Mixed reality-based mobile applications have not yet been explored.

Conclusion

Overall, key findings and information from the articles highlight a gradually advancing research domain. Outcomes reinforce the need to expand the focus of mHealth investigations to include emerging technologies, update current technology models, create a more human-centered technology design, test mHealth technologies in the clinical setting, and encourage continued cooperation between and among researchers from various fields and environments.

Factors Associated With the Intention to Use mHealth Among Thai Middle-Aged Adults and Older Adults: Cross-Sectional Study

Background

Mobile health care (mHealth) apps are emerging worldwide as a vital component of internet health care, but there are issues, especially among older adults.

Objective

We aim to investigate the factors influencing the intention to use (ITU) mHealth apps, focusing on those with and without prior mHealth experience.

Methods

A cross-sectional study conducted from August 2022 to July 2023 included Thai citizens aged 45 years or older. Self-reported questionnaires collected data on sociodemographic information, health conditions, smartphone or tablet ownership, and mHealth usage experience. The Thai mHealth Senior Technology Acceptance Model questionnaires with a 10-point Likert scale evaluated mHealth acceptance. A multivariable logistic regression analysis, adjusted for age, gender, education, income, and living area, was performed for 2 subgroups: those who used ITU mHealth apps and those who did not.

Results

Of 1100 participants, 537 (48.8%) intended to use mHealth apps, while 563 (51.2%) did not. The ITU group had a younger average age, higher education levels, higher income, and fewer underlying diseases compared to those who did not intend to use mHealth apps. For those who had never used mHealth apps, having a smartphone was strongly associated with higher odds of ITU (adjusted odds ratio 2.81, 95% CI 1.6 to 4.93; P<.001), while having any underlying disease was associated with lower odds of ITU (adjusted odds ratio 0.63, 95% CI 0.42 to 0.97; P=.034). Higher acceptance levels, characterized by a positive attitude toward mHealth and lower fear of making mistakes, were also associated with higher ITU. For those with prior mHealth experience, acceptance in areas such as perceived ease of use, gerontechnology anxiety, and facilitating conditions was significantly associated with ITU.

Conclusions

Among inexperienced users, a positive attitude toward mHealth significantly enhanced ITU. Conversely, having an underlying disease decreased ITU, indicating a need for tailored mHealth apps. For experienced users, acceptance levels in areas such as ease of use and gerontechnology anxiety were crucial. Future research should explore specific mHealth apps for more targeted insights.

Developing and testing tele-support psychotherapy using mobile phones for depression among youth in Kampala district, Uganda: study protocol for a pilot randomized controlled trial

Introduction

In the post-COVID-19 era, depressive disorders among youth have risen significantly, creating an urgent need for accessible, cost-effective mental health interventions. This study adapts Group Support Psychotherapy into Tele-Support Psychotherapy (TSP) via mobile phones. It aims to evaluate its feasibility, acceptability, effectiveness, and cost-efficiency in addressing mild to moderate depression among youth in central Uganda.

Methods and analysis

This study will use a mixed-methods approach, starting with a qualitative phase to adapt Group Support Psychotherapy into Tele-Support Psychotherapy (TSP) via mobile phones. Guided by ecological theories and the Unified Theory of Acceptance and Use of Technology (UTAUT), focus group discussions and interviews with youth, mental health professionals, and stakeholders will inform the development of a youth-tailored call platform integrated into Rocket Health Africa's telehealth services. Data will be analyzed using grounded theory and MAXQDA Analytics Pro 2022 to guide intervention adaptation. An open-label randomized controlled trial will enroll 300 youth (15-30 years) with mild to moderate depression from Kampala, Uganda, to evaluate Tele-Support Psychotherapy (TSP). Participants will be randomized to TSP with standard mental health services (SMHS) or SMHS alone. Primary outcomes include feasibility and acceptability, with secondary outcomes assessing cost-effectiveness, depressive symptom changes, and social support. Intention-to-treat analysis using structural equation modeling will evaluate treatment effects, complemented by qualitative insights into implementation barriers and facilitators.

Discussion

This study protocol develops and evaluates Tele-Support Psychotherapy (TSP) for youth depression in resource-limited settings, addressing mental health gaps exacerbated by COVID-19. Using user-centered design and mixed methods, it explores TSP's feasibility, adaptability, and cost-effectiveness while addressing barriers like technology literacy, laying the groundwork for accessible digital mental health solutions.

Trial Registration

PACTR202201684613316.

Qualitative Evaluation of mHealth Implementation for Infectious Disease Care in Low- and Middle-Income Countries: Narrative Review

Background

Mobile health (mHealth) interventions have the potential to improve health outcomes in low- and middle-income countries (LMICs) by aiding health workers to strengthen service delivery, as well as by helping patients and communities manage and prevent diseases. It is crucial to understand how best to implement mHealth within already burdened health services to maximally improve health outcomes and sustain the intervention in LMICs.

Objective

We aimed to identify key barriers to and facilitators of the implementation of mHealth interventions for infectious diseases in LMICs, drawing on a health systems analysis framework.

Methods

We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist to select qualitative or mixed methods studies reporting on determinants of already implemented infectious disease mHealth interventions in LMICs. We searched MEDLINE, Embase, PubMed, CINAHL, the Social Sciences Citation Index, and Global Health. We extracted characteristics of the mHealth interventions and implementation experiences, then conducted an analysis of determinants using the Tailored Implementation for Chronic Diseases framework.

Results

We identified 10,494 titles for screening, among which 20 studies met our eligibility criteria. Of these, 9 studies examined mHealth smartphone apps and 11 examined SMS text messaging interventions. The interventions addressed HIV (n=7), malaria (n=4), tuberculosis (n=4), pneumonia (n=2), dengue (n=1), human papillomavirus (n=1), COVID-19 (n=1), and respiratory illnesses or childhood infectious diseases (n=2), with 2 studies addressing multiple diseases. Within these studies, 10 interventions were intended for use by health workers and the remainder targeted patients, at-risk individuals, or community members. Access to reliable technological resources, familiarity with technology, and training and support were key determinants of implementation. Additional themes included users forgetting to use the mHealth interventions and mHealth intervention designs affecting ease of use.

Conclusions

Acceptance of the intervention and the capacity of existing health care system infrastructure and resources are 2 key factors affecting the implementation of mHealth interventions. Understanding the interaction between mHealth interventions, their implementation, and health systems will improve their uptake in LMICs.

Enhancing the implementation and integration of mHealth interventions in resource-limited settings: a scoping review

BACKGROUND

Although mobile health (mHealth) interventions have shown promise in improving health outcomes, most of them rarely translate to scale. Prevailing mHealth studies are largely small-sized, short-term and donor-funded pilot studies with limited evidence on their effectiveness. To facilitate scale-up, several frameworks have been proposed to enhance the generic implementation of health interventions. However, there is a lack of a specific focus on the implementation and integration of mHealth interventions in routine care in low-resource settings. Our scoping review aimed to synthesize and develop a framework that could guide the implementation and integration of mHealth interventions.

METHODS

We searched the PubMed, Google Scholar, and ScienceDirect databases for published theories, models, and frameworks related to the implementation and integration of clinical interventions from 1st January 2000 to 31st December 2023. The data processing was guided by a scoping review methodology proposed by Arksey and O'Malley. Studies were included if they were i) peer-reviewed and published between 2000 and 2023, ii) explicitly described a framework for clinical intervention implementation and integration, or iii) available in full text and published in English. We integrated different domains and constructs from the reviewed frameworks to develop a new framework for implementing and integrating mHealth interventions.

RESULTS

We identified eight eligible papers with eight frameworks composed of 102 implementation domains. None of the identified frameworks were specific to the integration of mHealth interventions in low-resource settings. Two constructs (skill impartation and intervention awareness) related to the training domain, four constructs (technical and logistical support, identifying committed staff, supervision, and redesigning) from the restructuring domain, two constructs (monetary incentives and nonmonetary incentives) from the incentivize domain, two constructs (organizational mandates and government mandates) from the mandate domain and two constructs (collaboration and routine workflows) from the integrate domain. Therefore, a new framework that outlines five main domains-train, restructure, incentivize, mandate, and integrate (TRIMI)-in relation to the integration and implementation of mHealth interventions in low-resource settings emerged.

CONCLUSION

The TRIMI framework presents a realistic and realizable solution for the implementation and integration deficits of mHealth interventions in low-resource settings.

Enhancing the Implementation and Integration of mHealth Interventions in Resource-Limited Settings: A Scoping Review

Background

Although mobile health (mHealth) interventions have shown promise in improving health outcomes, most of them rarely translate to scale. Prevailing mHealth studies are largely small-sized, short-term and donor-funded pilot studies with limited evidence on their effectiveness. To facilitate scale-up, several frameworks have been proposed to enhance the generic implementation of health interventions. However, there is a lack of a specific focus on the implementation and integration of mHealth interventions in routine care in low-resource settings. Our scoping review aimed to synthesize and develop a framework that could guide the implementation and integration of mHealth interventions.

Methods

We searched the PubMed, Google Scholar, and ScienceDirect databases for published theories, models, and frameworks related to the implementation and integration of clinical interventions from 1st January 2000 to 31st December 2023. The data processing was guided by a scoping review methodology proposed by Arksey and O'Malley. Studies were included if they were i) peer-reviewed and published between 2000 and 2023, ii) explicitly described a framework for clinical intervention implementation and integration, or iii) available in full text and published in English. We integrated different domains and constructs from the reviewed frameworks to develop a new framework for implementing and integrating mHealth interventions.

Results

We identified eight eligible papers with eight frameworks composed of 102 implementation domains. None of the identified frameworks were specific to the integration of mHealth interventions in low-resource settings. Two constructs (skill impartation and intervention awareness) related to the training domain, four constructs (technical and logistical support, identifying committed staff, supervision, and redesigning) from the restructuring domain, two constructs (monetary incentives and nonmonetary incentives) from the incentivize domain, two constructs (organizational mandates and government mandates) from the mandate domain and two constructs (collaboration and routine workflows) from the integrate domain. Therefore, a new framework that outlines five main domains-train, restructure, incentivize, mandate, and integrate (TRIMI)-in relation to the integration and implementation of mHealth interventions in low-resource settings emerged.

Conclusion

The TRIMI framework presents a realistic and realizable solution for the implementation and integration deficits of mHealth interventions in low-resource settings.

Peer support interventions in maternal and child healthcare delivery in sub-Saharan Africa: protocol for a realist review

BACKGROUND

Peer support has been proposed as a promising policy intervention for addressing adverse maternal and child healthcare (MCH) outcomes in sub-Saharan Africa (SSA). Existing reviews on peer support largely draw on evidence from high-income countries or focus on single services like breastfeeding, nutrition or postnatal care. In contrast, this review aims to provide a comprehensive overview of the empirical literature on peer support interventions across various MCH services in sub-Saharan Africa. Specifically, we aim to understand how, why, for whom, and in what circumstances different forms of MCH peer support interventions contribute to improving healthcare outcomes in sub-Saharan Africa.

METHODS

This review follows five iterative steps for undertaking realist reviews (1) defining the review scope; (2) developing initial programme theories; (3) searching for evidence; (4) selecting and appraising evidence; and (5) extracting, analysing and synthesising evidence. Four databases-Cochrane Library, PubMed, CINAHL, and EMBASE-were repeatedly searched between March and June 2021. From a large volume of records retrieved from the database and citation search, 61 papers have been selected for review. We will conduct a second search of the same database covering June 2021 to the present before the final extraction and synthesis. The final list of selected papers will be imported into NVivo 12 software and organised, extracted, analysed and synthesised iteratively to examine and illustrate the causal links between contexts, mechanisms and outcomes of MCH peer support interventions in SSA. We have drawn on the existing literature on peer support in healthcare generally to develop initial programme theories. We will then use the empirical literature on MCH peer support interventions in SSA, inputs from a stakeholders' workshop in Ghana and a conference presentation to refine the initial programme theory.

DISCUSSION

The review will develop an explicit theory of peer support intervention in healthcare delivery and provide insights for developing evidence-informed policy on the intervention. Drawing lessons from the different national contexts and diverse areas of MCH in SSA, the review will provide an analytically generalizable programme theory that can guide intervention design and implementation. While focusing on MCH peer support interventions in SSA, the review contributes to evolving conversations on the use of theory for health policy planning and complex intervention design and implementation globally.

TRIAL REGISTRATION

PROSPERO registration ID: CRD42023427751 .

Prioritizing non-communicable diseases in the post-pandemic era based on a comprehensive analysis of the GBD 2019 from 1990 to 2019

This study aimed to assess the burden of communicable diseases (CDs) and non-communicable diseases (NCDs) globally, regionally, and nationally from 1990 to 2019, and propose global strategies to transform the public health policy. Using data from the Global Burden of Disease Study (GBD) 2019, we analyzed CDs and NCDs across various factors such as sex, age, year, and location, and evaluate the temporal trends of these diseases with joinpoint analysis. We also examined the differences between regions based on their socio-demographic index (SDI). In 2019, there were 7,862,907 (95% uncertainty interval [UI], 7,183,475 to 8,654,104) deaths from CDs and 42,034,124 (40,081,323 to 43,942,475) deaths from NCDs recorded worldwide. The low SDI region had markedly high age-standardized death and DALY rates of CDs. Although the age-standardized incidence rate of CDs has decreased in about half of the regions since 1990, NCDs have been on the rise in most regions. Over the past 30 years, the global burden of CDs has decreased significantly, while the burden of NCDs has aggrandized to an extent. In the post-pandemic era, effective interventions and cooperation among countries should be promoted to allocate medical resources more reasonably and improve healthcare for NCD patients.

An mHealth Intervention to Improve Guardians' Adherence to Children's Follow-Up Care for Acute Lymphoblastic Leukemia in Tanzania (GuardiansCan Project): Protocol for a Development and Feasibility Study

BACKGROUND

Cancer is a leading cause of death during childhood and in low- and middle-income countries survival rates can be as low as 20%. A leading reason for low childhood cancer survival rates in low- and middle-income countries such as Tanzania is treatment abandonment. Contributing factors include poor communication between health care providers and children's guardians, insufficient cancer knowledge, and psychological distress.

OBJECTIVE

Our aim is to respond to Tanzanian guardians' poor adherence to children's follow-up care after treatment for acute lymphoblastic leukemia with the help of mobile health (mHealth) technology. Our goal is to increase guardians' adherence to children's medications and follow-up visits and to decrease their psychological distress.

METHODS

Following the Medical Research Council framework for developing and evaluating complex interventions, we will undertake the GuardiansCan project in an iterative phased approach to develop an mHealth intervention for subsequent testing. Public contribution activities will be implemented throughout via the establishment of a Guardians Advisory Board consisting of guardians of children with acute lymphoblastic leukemia. We will examine the acceptability, feasibility, and perceived impact of Guardians Advisory Board activities via an impact log and semistructured interviews (study I). In phase 1 (intervention development) we will explore guardians' needs and preferences for the provision of follow-up care reminders, information, and emotional support using focus group discussions and photovoice (study II). We will then co-design the mHealth intervention with guardians, health care professionals, and technology experts using participatory action research (study III). In phase 2 (feasibility), we will examine clinical, methodological, and procedural uncertainties associated with the intervention and study procedures to prepare for the design and conduct of a future definitive randomized controlled trial using a single-arm pre-post mixed methods feasibility study (study IV).

RESULTS

Data collection for the GuardiansCan project is anticipated to take 3 years. We plan to commence study I by recruiting Guardians Advisory Board members in the autumn of 2023.

CONCLUSIONS

By systematically following the intervention development and feasibility phases of the Medical Research Council Framework, and working alongside an advisory board of guardians, we intend to develop an acceptable, culturally appropriate, feasible, and relevant mHealth intervention with the potential to increase guardians' adherence to children's follow-up care after treatment of acute lymphoblastic leukemia, leading to a positive impact on children's health and chances to survive, and reducing distress for guardians.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/48799.

Improving Predictability and Effectiveness in Preventive Digital Health Interventions: Scoping Review

BACKGROUND

Lifestyle-related diseases caused by inadequate diet and physical activity cause premature death, loss of healthy life years, and increased health care costs. Randomized controlled trial (RCT) studies indicate that preventive digital health interventions (P-DHIs) can be effective in preventing these health problems, but the results of these studies are mixed. Adoption studies have identified multiple factors related to individuals and the context in which they live that complicate the transfer of positive results from RCT studies to practical use. Implementation studies have revealed barriers to the large-scale implementation of mobile health (mHealth) solutions in general. Consequently, there is no clear path to delivering predictable outcomes from P-DHIs and achieving effectiveness when scaling up interventions to reduce health problems in society.

OBJECTIVE

This research aimed to expand our understanding of how to increase the outcome predictability of P-DHIs by focusing on physical activity and diet behaviors and amplify our understanding of how to improve effectiveness in large-scale implementations.

METHODS

The research objective was pursued through a multidisciplinary scoping review. This scoping review used the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) as a guide. A comprehensive search of Web of Science and PubMed limited to English-language journal articles published before January 2022 was conducted. Google Scholar was used for hand searches. Information systems theory was used to identify key constructs influencing outcomes of IT in general. Public health and mHealth literature were used to identify factors influencing the adoption of, outcomes from, and implementation of P-DHIs. Finally, the P-DHI investment model was developed based on information systems constructs and factors from the public health and mHealth literature.

RESULTS

In total, 203 articles met the eligibility criteria. The included studies used a variety of methodologies, including literature reviews, interviews, surveys, and RCT studies. The P-DHI investment model suggests which constructs and related factors should be emphasized to increase the predictability of P-DHI outcomes and improve the effectiveness of large-scale implementations.

CONCLUSIONS

The research suggests that outcome predictability could be improved by including descriptions of the constructs and factors in the P-DHI investment model when reporting from empirical studies. Doing so would increase our understanding of when and why P-DHIs succeed or fail. The effectiveness of large-scale implementations may be improved by using the P-DHI investment model to evaluate potential difficulties and possibilities in implementing P-DHIs to create better environments for their use before investing in them and when designing and implementing them. The cost-effectiveness of large-scale implementations is unknown; implementations are far more complicated than just downloading and using apps, and there is uncertainty accompanying implementations given the lack of coordinated control over the constructs and factors that influence the outcome.

Acceptability and feasibility of home and hospital follow-up in Burkina Faso and Guinea: A mixed-method study among patients of the COVID-19 Coverage-Africa clinical trial

Patient experiences and perspectives on trial participation and follow-up may influence their compliance with research procedures or negatively impact their well-being. We aimed to explore the acceptability and feasibility of home-based and hospital-based follow-up modalities among COVID-19 patients enrolled in the ANTICOV ANRS COV33 Coverage-Africa trial in Burkina Faso and Guinea. The trial (2021-2022) evaluated the efficacy of treatments to prevent clinical worsening among COVID-19 patients with mild to moderate symptoms. Patients were either based at home or hospitalized, as per national recommendations, and followed-up through face-to-face visits and phone calls. We conducted a mixed-methods sub-study administering a questionnaire to all consenting participants and individually interviewing purposively selected participants. We performed descriptive analyses of Likert scale questions for the questionnaires and thematic analysis for the interviews. We conducted framework analysis and interpretation. Of the 400 trial patients, 220 completed the questionnaire (n = 182 in Burkina Faso, n = 38 in Guinea) and 24 were interviewed (n = 16 and n = 8, respectively). Participants were mostly followed-up at home in Burkina Faso; all patients from Guinea were first hospitalized, then followed-up at home. Over 90% of participants were satisfied with follow-up. Home follow-up was considered acceptable if (i) participants perceived they were not severely ill, (ii) it was combined with telemedicine, and (iii) the risk of stigma could be avoided. Hospital-based follow-up was viewed as a way to prevent contamination of family members, but could be badly experienced when mandatory and conflicting with family responsibilities and commitments. Phone calls were seen as reassuring and as a way to ensure continuity of care. These overall positive findings support the development of home-based follow-up for mildly ill patients in West-Africa, provided that both emotional and cognitive factors at individual, familial/inter-relational, healthcare and national levels be addressed when planning the implementation of a trial, or developing any public health strategy.

Using telehealth to support community health workers in Uganda during COVID-19: a mixed-method study

Background

At the onset of the COVID-19 pandemic, a local consortium in Uganda set up a telehealth approach that aimed to educate 3,500 Community Health Workers (CHW) in rural areas about COVID-19, help them identify, refer and care for potential COVID-19 cases, and support them in continuing their regular community health work. The aim of this study was to assess the functioning of the telehealth approach that was set up to support CHWs during the COVID-19 pandemic.

Methods

For this mixed-method study, we combined analysis of routine consultation data from the call-center, 24 interviews with key-informants and two surveys of 150 CHWs. Data were analyzed using constant comparative method of analysis.

Results

Between March 2020 and June 2021, a total of 35,553 consultations took place via the call center. While the CHWs made extensive use of the call center, they rarely asked for support for potential Covid-19 cases. According to the CHWs, there were no signs that people in their communities were suffering from severe health problems due to COVID-19. People compared the lack of visible symptoms to diseases such as Ebola and were skeptical about the danger of COVID-19. At the same time, people in rural areas were afraid to report relevant symptoms and get tested for fear of being quarantined and stigmatized. The telehealth approach did prove useful for other purposes, such as supporting CHWs with their regular tasks and coordinating the supply of essential products. The health professionals at the call center supported CHWs in diagnosing, referring and treating patients and adhering to infection prevention and control practices. The CHWs felt more informed and less isolated, saying the support from the call center helped them to provide better care and improved the supply of medicine and other essential health products.

Conclusions

The telehealth approach, launched at the start of the COVID-19 pandemic, provided useful support to thousands of CHWs in rural communities in Uganda. The telehealth approach could be quickly set up and scaled up and offers a low cost strategy for providing useful and flexible support to CHWs in rural communities.

A stroke rehabilitation training program for community-based primary health care, South Africa

Background

With an increasing burden of stroke and a lack of access to rehabilitation services in rural South African settings, stroke survivors rely on untrained family caregivers for support and care. Community health workers (CHWs) support these families but have no stroke-specific training.

Objectives

To describe the development of a contextually appropriate stroke training program for CHWs in the Cape Winelands District, South Africa.

Method

Twenty-six health professionals and CHWs from the local primary healthcare services participated in action research over a 15-month period from September 2014 to December 2015. The groups participated in two parallel cooperative inquiry (CI) groups. The inquiry followed the cyclical steps of planning, action, observation and reflection. In this article, the planning step and how the CI groups used the first three steps of the analyse, design, develop, implement, evaluate (ADDIE) instructional design model are described.

Results

The CHWs' scope of practice, learning needs, competencies and characteristics, as well as the needs of the caregivers and stroke survivors, were identified in the analysis step. The program design consisted of 16 sessions to be delivered over 20 h. Program resources were developed with appropriate technology, language and instructional methodology.

Conclusion

The program aims to equip CHWs to support family caregivers and stroke survivors in their homes as part of their generalist scope of practice. The implementation and initial evaluation will be described in a future article.

Contribution

The study developed a unique training program for CHWs to support caregivers and stroke survivors in a resource-constrained, rural, middle-income country setting.

Clinical decision-support for acute burn referral and triage at specialized centres - Contribution from routine and digital health tools

BACKGROUND

Specialized care is crucial for severe burn injuries whereas minor burns should be handled at point-of-care. Misdiagnosis is common which leads to overburdening the system and to a lack of treatment for others due to resources shortage.

OBJECTIVES

The overarching aim was to evaluate four decision-support tools for diagnosis, referral, and triage of acute burns injuries in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis.

METHODS

Study I retrospectively assessed adherence to referral criteria of 1165 patients admitted to the paediatric burns centre of the Western Cape of South Africa. Study II assessed mortality prediction of 372 patients admitted to the adults burns centre by evaluating an existing score (ABSI), and by using logistic regression. In study III, an online survey was used to assess the diagnostic accuracy of burn experts' image-based estimations using their smartphone or tablet. In study IV, two deep-learning algorithms were developed using 1105 acute burn images in order to identify the burn, and to classify burn depth.

RESULTS

Adherence to referral criteria was of 93.4%, and the age and severity criteria were associated with patient care. In adults, the ABSI score was a good predictor of mortality which affected a fifth of the patients and which was associated with gender, burn size and referral status. Experts were able to diagnose burn size, and burn depth using handheld devices. Finally, both a wound identifier and a depth classifier algorithm could be developed with relatively high accuracy.

CONCLUSIONS

Altogether the findings inform on the use of four tools along the care trajectory of patients with acute burns by assisting with the diagnosis, referral and triage from point-of-care to burns centres. This will assist with reducing inequities by improving access to the most appropriate care for patients.

A model for the uptake of advance care planning in older cancer adults: a scoping review

BACKGROUND AND AIMS

Advance care planning (ACP) might assist older cancer patients in expressing their goals, values, and care preferences; yet, the ACP uptake rates in this group are low. The goal of this study is to discover factors that influence ACP uptake in older cancer adults and to construct a model that integrates these factors.

METHODS

Using Arksey and O' Malley's methodology, we systematically searched seven electronic databases of ACP literature in older cancer adults from inception to March 2022. To identify factors linked to ACP uptake in elderly cancer patients, researchers used a pre-piloted extraction form. There were two phases to the thematic analysis of the labeled factors. First, factors were grouped into one of three categories using a directed content analysis approach: patient context, provider context, or mechanism. Second, we took both a deductive and inductive thematic approach to identifying and coding contributing factors in each category to identify themes and subthemes. Deductive coding was undertaken using the Andersen's Behavioral Model of Health Services Utilization. Finally, results were visualized into a conceptual model.

RESULTS

In the including 37 articles, 131 factors were extracted. Thematic analysis of patient context factors (n = 72) showed that ACP uptake in older cancer adults is associated with predisposing characteristics, enabling resources and need. Factors attributed to provider context (n = 28) concerned predisposing characteristics and enabling resources. Mechanism factors (n = 31) are related to perceived value and patient trust, and the C-ACP uptake model was created.

CONCLUSION

ACP uptake in older cancer patients is commonly influenced by patient-provider-related contextual factors, and highlights the fact that ACP uptake is more likely to be mediated through both perceived value and patient trust. This review serves as a resource for providers exploring ACP implementation options in older cancer adults.

Assessing the potential of wearable health monitors for health system strengthening in low- and middle-income countries: a prospective study of technology adoption in Cambodia

Wearable health monitors are a rapidly evolving technology that may offer new opportunities for strengthening health system responses to cardiovascular and other non-communicable diseases (NCDs) in low- and middle-income countries (LMICs). In light of this, we explored opportunities for, and potential challenges to, technology adoption in Cambodia, considering the complexity of contextual factors that may influence product uptake and sustainable health system integration. Data collection for this study involved in-depth interviews with national and international stakeholders and a literature review. The analytical approach was guided by concepts and categories derived from the non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework-an evidence-based framework that was developed for studying health technology adoption and the challenges to scale-up, spread and sustainability of such technologies in health service organizations. Three potential applications of health wearables for the prevention and control of NCDs in Cambodia were identified: health promotion, follow-up and monitoring of patients and surveys of NCD risk factors. However, several challenges to technology adoption emerged across the research domains, associated with the intended adopters, the organization of the national health system, the wider infrastructure, the regulatory environment and the technology itself. Our findings indicate that, currently, wearables could be best used to conduct surveys of NCD risk factors in Cambodia and in other LMICs with similar health system profiles. In the future, a more integrated use of wearables to strengthen monitoring and management of patients could be envisaged, although this would require careful consideration of feasibility and organizational issues.

Frameworks for Implementation, Uptake, and Use of Cardiometabolic Disease-Related Digital Health Interventions in Ethnic Minority Populations: Scoping Review

BACKGROUND

Digital health interventions have become increasingly common across health care, both before and during the COVID-19 pandemic. Health inequalities, particularly with respect to ethnicity, may not be considered in frameworks that address the implementation of digital health interventions. We considered frameworks to include any models, theories, or taxonomies that describe or predict implementation, uptake, and use of digital health interventions.

OBJECTIVE

We aimed to assess how health inequalities are addressed in frameworks relevant to the implementation, uptake, and use of digital health interventions; health and ethnic inequalities; and interventions for cardiometabolic disease.

METHODS

SCOPUS, PubMed, EMBASE, Google Scholar, and gray literature were searched to identify papers on frameworks relevant to the implementation, uptake, and use of digital health interventions; ethnically or culturally diverse populations and health inequalities; and interventions for cardiometabolic disease. We assessed the extent to which frameworks address health inequalities, specifically ethnic inequalities; explored how they were addressed; and developed recommendations for good practice.

RESULTS

Of 58 relevant papers, 22 (38%) included frameworks that referred to health inequalities. Inequalities were conceptualized as society-level, system-level, intervention-level, and individual. Only 5 frameworks considered all levels. Three frameworks considered how digital health interventions might interact with or exacerbate existing health inequalities, and 3 considered the process of health technology implementation, uptake, and use and suggested opportunities to improve equity in digital health. When ethnicity was considered, it was often within the broader concepts of social determinants of health. Only 3 frameworks explicitly addressed ethnicity: one focused on culturally tailoring digital health interventions, and 2 were applied to management of cardiometabolic disease.

CONCLUSIONS

Existing frameworks evaluate implementation, uptake, and use of digital health interventions, but to consider factors related to ethnicity, it is necessary to look across frameworks. We have developed a visual guide of the key constructs across the 4 potential levels of action for digital health inequalities, which can be used to support future research and inform digital health policies.

Design and Process of Implementation Mobile Application Based Modular Training on Early Detection of Cancers (M-OncoEd) for Primary Care Physicians in India

BACKGROUND

Early detection of curable cancers is a cost-effective way to address the cancer care burden of low- and middle-income countries and active engagement of primary care physicians using mobile technology can have a significant impact on cancer outcomes in a short time.

AIMS

To describe the process of mHealth study; Oncology Education and Training for Providers using Mobile Phones which developed a mobile application (M-OncoEd) to educate physicians on approaches to early detection of curable cancers. It also aims to describe how the insight gained through qualitative research by the researchers was used in the design and implementation of the project.

METHODOLOGY

Qualitative research methods were used in all the phases of the study. Phenomenology was used in the formative phase with three expert meetings, two Focus Group Discussion (FGD) and five In-depth Interviews (IDI), and during the implementation stage with two FGDs, three IDI, and five informal discussions.

OBSERVATIONS

The majority of curable cancers are detected at a late stage and poorly managed in India, and active engagement of primary care physicians can have a significant impact on cancer outcomes. There is a lack of knowledge and skills for early detection of cancers among consultants and physicians and this can be attributed to the training gap. M-OncoEd was a need-based well designed engaging learning platform to educate primary care physicians on Breast, Cervical, and Oral Cancer early detection. It was found to be very useful by the beneficiaries and made them more confident for early detection of cancers from the community.

CONCLUSIONS

This research study could design a need-based, cost-effective mobile-based learning tool for primary care physicians using the expertise and experience of the experts in cancer care using qualitative methods.

Child health interventions delivered by lay health workers to parents: A realist review

There is a growing body of evidence that lay health worker (LHW) interventions are a cost-effective model of care which can improve health outcomes and reduce the burden on existing health and community services. Nonetheless, there is a dearth of information to specify which intervention characteristics contribute to their success. This realist review aimed to identify how, why and in what context UK-based LHW interventions aimed at improving child health parenting behaviours can lead to health promoting behaviour and improve child health outcomes. Results show that the 'peerness' of the LHW role gives parents a sense of equality with, and trust in, LHWs which facilitates continued engagement with interventions and sustained positive behaviour. Training and support is crucial to retention of LHWs, enhancing confidence and perceived value of the role in the context of the intervention. LHW interventions which are embedded within communities as a result of stakeholder buy-in demonstrate stable models of delivery and ease the burden on existing health and community services. In conclusion, this review found that LHW interventions can positively influence child health parenting behaviours in certain contexts and provide programme theory to inform future development of LHW interventions.

An Iterative and Collaborative End-to-End Methodology Applied to Digital Mental Health

Artificial intelligence (AI) algorithms together with advances in data storage have recently made it possible to better characterize, predict, prevent, and treat a range of psychiatric illnesses. Amid the rapidly growing number of biological devices and the exponential accumulation of data in the mental health sector, the upcoming years are facing a need to homogenize research and development processes in academia as well as in the private sector and to centralize data into federalizing platforms. This has become even more important in light of the current global pandemic. Here, we propose an end-to-end methodology that optimizes and homogenizes digital research processes. Each step of the process is elaborated from project conception to knowledge extraction, with a focus on data analysis. The methodology is based on iterative processes, thus allowing an adaptation to the rate at which digital technologies evolve. The methodology also advocates for interdisciplinary (from mathematics to psychology) and intersectoral (from academia to the industry) collaborations to merge the gap between fundamental and applied research. We also pinpoint the ethical challenges and technical and human biases (from data recorded to the end user) associated with digital mental health. In conclusion, our work provides guidelines for upcoming digital mental health studies, which will accompany the translation of fundamental mental health research to digital technologies.

Acceptance of a Smartphone-Based Visual Field Screening Platform for Glaucoma: Pre-Post Study

Background

Glaucoma, the silent thief of sight, is a major cause of blindness worldwide. It is a burden for people in low-income countries, specifically countries where glaucoma-induced blindness accounts for 15% of the total incidence of blindness. More than half the people living with glaucoma in low-income countries are unaware of the disease until it progresses to an advanced stage, resulting in permanent visual impairment.

Objective

This study aims to evaluate the acceptability of the Glaucoma Easy Screener (GES), a low-cost and portable visual field screening platform comprising a smartphone, a stereoscopic virtual reality headset, and a gaming joystick.

Methods

A mixed methods study that included 24 eye care professionals from 4 hospitals in Southwest Ethiopia was conducted to evaluate the acceptability of GES. A pre-post design was used to collect perspectives before and after using the GES by using questionnaires and semistructured interviews. A Wilcoxon signed-rank test was used to determine the significance of any change in the scores of the questionnaire items (two-tailed, 95% CI; α=.05). The questionnaire and interview questions were guided by the Unified Theory of Acceptance and Use of Technology.

Results

Positive results were obtained both before and after use, suggesting the acceptance of mobile health solutions for conducting glaucoma screening by using a low-cost headset with a smartphone and a game controller. There was a significant increase (two-tailed, 95% CI; α=.05) in the average scores of 86% (19/22) of postuse questionnaire items compared with those of preuse questionnaire items. Ophthalmic professionals perceived GES as easy to use and as a tool that enabled the conduct of glaucoma screening tests, especially during outreach to rural areas. However, positive evaluations are contingent on the accuracy of the tool. Moreover, ophthalmologists voiced the need to limit the tool to screening only (ie, not for making diagnoses).

Conclusions

This study supports the feasibility of using a mobile device in combination with a low-cost virtual reality headset and classic controller for glaucoma screening in rural areas. GES has the potential to reduce the burden of irreversible blindness caused by glaucoma. However, further assessment of its sensitivity and specificity is required.

A review of mobile health interventions for public private mix in tuberculosis care

BACKGROUND

The World Health Organization (WHO) recommends the use of mobile health (mHealth) technologies as emerging opportunities to closing the gaps in Tuberculosis (TB) care through enhancing Public Private Mix (PPM). However, little is known about mHealth interventions that have been used for enhancing PPM in TB care, those that worked and those that did not.

OBJECTIVE

This review summarizes the published evidence on the utilization and effectiveness of mHealth interventions for public private mix in TB care from literature.

METHODS

Google scholar, PUBMED, IEEE Xplore and ScienceDirect databases were searched for peer reviewed literature from 1st January 2003 to 31st December 2020 for studies about the mHealth interventions for public private mix in TB care. This was guided by the scoping review methodology proposed by Arksey and O' Malley. In order to assess the quality of the selected studies, mHealth evidence reporting and assessment (mERA) checklist was utilized. Studies that discussed the utilization of mHealth interventions for implementing PPM in TB care were included. Nine studies met the inclusion criteria and were analyzed for review.

RESULTS

The review found out the application of mHealth in Public Private Mix in TB care through the following ways; 1) TB screening, 2) TB case notification 3) TB treatment adherence 4) data collection and management 5) patient referral and follow up, and 6) education. This resulted into high user experience, significant time reduction in data aggregation, increased case notification and referrals and proactive tracking and provision of follow up care hence reduced treatment and completion gaps. One study yielded suboptimal utilization due to the technical and operational challenges encountered by the healthcare workers.

CONCLUSION

Although this scoping review highlights the role of mHealth technologies in enhancing PPM in TB care, its utilization is still limited in African settings. No Africa-based study was identified by this review. Future studies should focus on assessing the utilization of mHealth for PPM in Africa.

Mobile phone use and the welfare of community health nurses in Ghana: An analysis of unintended costs

The use of mobile phones is fast transforming the healthcare delivery landscape in Ghana. A substantial number of health facilities are now dependent on mobile phones to facilitate their work. Evidence of the use of mobile phones in Ghana's healthcare is however limited. In order to contribute to the evidence of the value of using mobile phones to promote healthcare, we interrogated and highlighted unexpected costs imposed on community health nurses who use their personal mobile phones for healthcare delivery in the country. Data for the study were derived from 598 completed questionnaires and extracts from focus group discussions with community health nurses who were sampled from three regions across the three main ecological zones of Ghana. The results show that over 90% of nurses bear the cost of paying for airtime, bundles and chargers used for work-related activities, yet less than 10% of them receive direct compensation. This costly burden has the potential to demotivate the nurses and threaten the country's progress towards the achievement of universal health coverage. More significantly, the data strongly suggest that physical distance, regional location and gender are the main factors triggering extra costs incurred by the nurses. We conclude that the use of personal mobile phones for healthcare delivery imposed huge financial burden on community health workers in Ghana. A suggested intervention to forestall negative consequences on performance is to offer incentive packages to nurses as a compensation for the financial and non-physical costs of using personal mobile phones for work-related activities.

Understanding factors critical to the implementation of ehealth in chronic disease management: a realist review protocol

INTRODUCTION

Canadians are living longer, many with multiple chronic conditions. This population of older, frail Canadians continues to grow in size as do concurrent demands for community-based, outpatient and ambulatory models of care. Ideally, a multifaceted, proactive, planned and integrated care model includes ehealth. Although several factors are known to facilitate the implementation of ehealth in chronic disease management (CDM), for example, adequate support, usability, alignment of programme objectives, there is a growing body of inconclusive evidence on what is critical for implementation. We aim to achieve a fulsome understanding of factors critical to implementation by conducting a realist review-an approach suitable for understanding complex interventions. Our proposed review will identify factors critical to the implementation of ehealth in CDM (heart failure, chronic obstructive pulmonary disease, chronic kidney disease and/or diabetes (type 1 or 2)) without limitations to care setting, language, publication year or geography. Findings will be presented in configurations of contexts, mechanisms and outcomes (CMOs).

METHODS AND ANALYSIS

A search strategy will be iteratively developed based on the concepts of 'implementation' and 'adoption' of 'ehealth' interventions used within 'CDM' to identify the peer-reviewed and grey literature published before 31 March 2021 from five databases (Medline, Embase, Cochrane, CINAHL and PsychInfo) on ehealth interventions actively involving a healthcare provider for CDM among adults. Data extraction and synthesis will be guided by Realist and Meta-review Evidence Synthesis: Evolving Standards (RAMESES) guidelines informing core concepts of CMOs, and a study output will include a middle-range-theory describing the implementation of ehealth in CDM.

ETHICS AND DISSEMINATION

Findings will be published in an open-access peer-reviewed journal and presented at relevant conferences. A multistakeholder (patients, caregivers, healthcare providers and practitioners, decision-makers and policy-makers) perspective will be used in our dissemination approach. No formal ethics approval is required for this review.

PROSPERO REGISTRATION NUMBER

CRD42020208275.

Determining the potential of mobilephone-based health interventions in Kumasi, Ghana

Background

Numerous reviews have reported generally positive outcomes of mobile phone-based health (mHealth) interventions in the sub-Saharan African countries, especially for people with non-communicable diseases. At the same time, the mHealth landscape is burdened by a lack of sustainability. A recently published review has identified several context factors that influence the successful implementation of mHealth. Therefore, the aim is to use these contextual factors to assess the potential for mHealth in a particular clinical setting.

Design

The study used a cross-sectional, descriptive design.

Setting

The clinical setting of the study was the ‘Komfo Anokye Teaching Hospital’ in Kumasi, Ghana.

Participants

150 patients attending the diabetes clinic were surveyed.

Main outcome measures

Context factors that influence the perceived usefulness and ease of use of mHealth.

Results

The survey revealed that patients at the diabetes centre had a positive attitude towards mobile phones, but also a low familiarity. Whereas patients faced several access barriers to care, most enabling resources for the successful and sustainable implementation of mHealth interventions such as access to mobile phones and electricity were available.

Conclusions

There is a high potential for mHealth in the setting of the diabetes clinic in Kumasi, Ghana.

Funding

None Declared

Stakeholder perspectives and requirements to guide the development of digital technology for palliative cancer services: a multi-country, cross-sectional, qualitative study in Nigeria, Uganda and Zimbabwe

Introduction

Coverage of palliative care in low and middle-income countries is very limited, and global projections suggest large increases in need. Novel approaches are needed to achieve the palliative care goals of Universal Health Coverage. This study aimed to identify stakeholders’ data and information needs and the role of digital technologies to improve access to and delivery of palliative care for people with advanced cancer in Nigeria, Uganda and Zimbabwe.

Methods

We conducted a multi-country cross-sectional qualitative study in sub-Saharan Africa. In-depth qualitative stakeholder interviews were conducted with N = 195 participants across Nigeria, Uganda and Zimbabwe (advanced cancer patients n = 62, informal caregivers n = 48, health care professionals n = 59, policymakers n = 26). Verbatim transcripts were subjected to deductive and inductive framework analysis to identify stakeholders needs and their preferences for digital technology in supporting the capture, transfer and use of patient-level data to improve delivery of palliative care.

Results

Our coding framework identified four main themes: i) acceptability of digital technology; ii) current context of technology use; iii) current vision for digital technology to support health and palliative care, and; iv) digital technologies for the generation, reporting and receipt of data. Digital heath is an acceptable approach, stakeholders support the use of secure data systems, and patients welcome improved communication with providers. There are varying preferences for how and when digital technologies should be utilised as part of palliative cancer care provision, including for increasing timely patient access to trained palliative care providers and the triaging of contact from patients.

Conclusion

We identified design and practical challenges to optimise potential for success in developing digital health approaches to improve access to and enhance the delivery of palliative cancer care in Nigeria, Uganda and Zimbabwe. Synthesis of findings identified 15 requirements to guide the development of digital health approaches that can support the attainment of global health palliative care policy goals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-020-00694-y.

Interest in Communication Technology by Rural Caregivers of Adolescents with Mental Health Issues in South Africa: The Mmogo-Method®

Caregivers determine the level of care adolescents with mental issues receive; however, caregivers' own needs are often unmet. Communication technology can be tailored to address these challenges, especially in a rural environment. This study aimed to explore caregivers' interest in using communication technology to provide support to address challenges. This study involved a visual-based narrative inquiry that gathered data through the Mmogo-method^®. Three (n = 3) groups were held with rural caregivers (n = 17) of adolescents with mental health issues in a rural area in the Free State province of South Africa during 2017. Three themes captured challenges confronting caregivers, namely, psychosocial, social resources, and informational challenges. Interest in communication technology was captured in a fourth theme. The findings indicate that communication technology can address caregivers' challenges by providing support and information to caregivers in rural areas. Communication technology, including mobile phones, electronic devices, and the Internet, has transformed healthcare services and proved to be valuable in resource constraint environments.

Accessibility to First-Mile health services: A time-cost model for rural Uganda

This study estimates the geographical disconnection in rural Low-Middle-Income Countries (LMIC) between First-Mile suppliers of healthcare services and end-users. This detachment is due to geographical barriers and to a shortage of technical, financial, and human resources that enable peripheral health facilities to perform effective and prompt diagnosis. End-users typically have easier access to cell-phones than hospitals, so mHealth can help to overcome such barriers, transforming inpatients/outpatients into home-patients, decongesting hospitals, especially during epidemics. This generates savings for patients and the healthcare system. The advantages of mHealth are well known, but there is a literature gap in the description of its economic returns. This study applies a geographical model to a typical LMIC, Uganda, quantifying the time-cost to reach an equipped medical center. Time-cost measures the disconnection between First-Mile hubs and end-users, the potential demand of mHealth by remote end-users, and the consequent savings. The results highlight an average time-cost of 75 min, well above the recommended thresholds, and estimate that mHealth leads to significant savings (1.5 monthly salaries and 21% of public health budget). Community health workers and private actors may re-engineer healthcare resources through Public-Private Partnerships (PPP), remunerated with results-based financing (RBF). These findings can contribute to improving healthcare resource allocation in LMIC.

Operability, Usefulness, and Task-Technology Fit of an mHealth App for Delivering Primary Health Care Services by Community Health Workers in Underserved Areas of Pakistan and Afghanistan: Qualitative Study

BACKGROUND

The recent proliferation of digital health technology in low- and middle-income countries has made it possible for community health workers (CHWs) to use mobile health (mHealth) to perform tasks such as data collection and training. Although most studies focus on the prospect of digital apps to motivate and connect CHW, only a few have captured end-user experiences with mobile-based apps. We examined the experience of frontline health workers with a move towards digitalized real-time data to record maternal and childcare services in remote areas of Afghanistan and Pakistan.

OBJECTIVE

Our study aimed to explore CHW perceptions on the operability of the mHealth app in a community setting, usefulness of the app in the delivery of assigned maternal and childcare functions, and the task-technology fit with monitoring information systems.

METHODS

The Hayat app, designed to digitalize and facilitate electronic record keeping, was evaluated to be embedded into mainstream health systems. The app had 2 components: smartphone app for data entry and web dashboard for visualization of the maternal, newborn, and child health reports. Using a qualitative exploratory study design, we conducted a total of 8 focus group discussions with purposively selected lady health workers (LHWs) and CHWs in 3 districts of Pakistan and 3 hamlets of Afghanistan, respectively. Focus group discussions were conducted in the local language, audio recorded, and converted into expanded notes for thematic analysis.

RESULTS

Although a majority of LHWs used the app with ease, some initially faced difficulties in operating it and requested a longer duration of training. Contrary to LHWs, the CHWs were able to use the app without difficulty, as they were using it only to register clients. Overall, use of the mHealth app in both countries resulted in a positive impact on health education sessions, easier communication with parents or clients, tracking of routine immunization defaulters and follow-ups, improved data validity, easily accessible vaccination schedules, and faster registration. In addition to building up their image in the community and personal development, the improved reporting and monitoring mechanisms also set the stage for the LHWs to get recognized for their hard work. CHWs in Afghanistan also reported the app provided immediate access to information when requested by their supervisor. Although the Hayat app eliminates the need to carry multiple registers and helps in recalling client information at the touch of a button, technical issues around connectivity and data inputting tabs were highlighted by the participants.

CONCLUSIONS

The digitization of records not only provided CHWs support in their daily routine but also strengthened monitoring mechanisms and improved motivation. We recommend conducting end user experience studies before embedding apps into mainstream health systems as high acceptability does not always result in high uptake of digital technology.

Smoking and cessation-related attitudes among men who have sex with men in the country of Georgia

Among men who have sex with men (MSM) in low- or middle-income countries, smoking and related factors have been understudied. We examined correlates of smoking status, level, and importance and confidence regarding quitting among 608 MSM in the country of Georgia recruited in June-September, 2016 (493 without HIV via peer referral in 3 Georgian cities; 115 with HIV via the National AIDS Center). Median age was 26 years, 78.6% reported current (past 30-day) alcohol use, and 22.4% reported past-year illicit drug use. Overall, 73.8% reported current smoking; of these, 87.1% smoked daily, mean cigarettes per day (cpd) was 19.8, 64.6% smoked ≤30 min of waking, and mean quitting importance and confidence were 6.8 and 6.4 (0 = not at all to 10 = extremely), respectively. Multivariable analyses indicated that current smoking correlated with past-month alcohol and past-year illicit drug use (p's < .001). Among smokers, cpd correlated with being older and smoking within 30 min of waking; greater quitting importance (≥7) correlated with higher education and no illicit substance use; and greater quitting confidence (≥7) was associated with fewer cpd, smoking ≤30 min of waking, and regional versus capital city residence. Given these findings, addressing tobacco and other substance use among MSM in Georgia is critical.

Informal mobile phone use by marginalised groups in a plural health system to bridge healthcare gaps in Sierra Leone

The possibility to use mobile phones to provide affordable, effective and accessible healthcare solutions has continued to attract significant investments in the application of formal m-health schemes in Africa. However, while the formal m-health schemes in Africa are limited and benefited only a handful of people, a majority of individuals are using their own phones to create an informal m-health ecosystem in an attempt to bridge primary healthcare access gaps. This paper draws on qualitative data from a four-year (2012-2016) anthropological study involving marginalised groups in Sierra Leone to document these health-seeking practices along with the benefits and challenges they create in a complex plural health system. It argues that the informal integration of mobile phones into the plural health system offers opportunities for marginalised individuals to search and secure primary healthcare of their choices, but poor network connectivity, high out of pocket maintenance costs, low digital literacy skills, and the lack of policy to streamline and regulate the practices can promise the effectiveness of the informal m-health system. It concludes by offering suggestions for addressing these challenges in the Sierra Leone context.

A critical realist synthesis of cross-disciplinary health policy and systems research: defining characteristic features, developing an evaluation framework and identifying challenges

BACKGROUND

Health policy and systems research (HPSR) is an inherently cross-disciplinary field of investigation. However, conflicting conceptualisations about inter-, multi- and transdisciplinary research have contributed to confusion about the characteristics of cross-disciplinary approaches in HPSR. This review was conducted to (1) define the characteristic features of context-mechanism-outcome (CMO) configurations in cross-disciplinary HPSR, (2) develop criteria for evaluating cross-disciplinarity and (3) synthesise emerging challenges of the approach.

METHOD

The paper is a critical realist synthesis conducted in three phases, as follows: (1) scoping the literature, (2) searching for and screening the evidence, and (3) extracting and synthesising the evidence. Five databases, namely the International Bibliography of the Social Sciences and Web of Science, PubMed central, Embase and CINHAL, and reference lists of studies that qualified for inclusion in the review were searched. The search covered peer-reviewed original research, reviews, commentary papers, and institutional or government reports published in English between January 1998 and January 2020.

RESULTS

A total of 7792 titles were identified in the online search and 137 publications, comprising pilot studies as well as anecdotal and empirical literature were selected for the final review. The review draws attention to the fact that cross-disciplinary HPSR is not defined by individual characteristics but by the combination of a particular type of research question and setting (context), a specific way of researchers working together (mechanism), and research output (outcome) that is superior to what could be achieved under a monodisciplinary approach. This CMO framework also informs the criteria for assessing whether a given HPSR is truly cross-disciplinary. The challenges of cross-disciplinary HPSR and their accompanying coping mechanisms were also found to be context driven, originating mainly from conceptual disagreements, institutional restrictions, communication and information management challenges, coordination problems, and resource limitations.

CONCLUSION

These findings have important implications. First, the CMO framework of cross-disciplinary HPSR can provide guidance for researchers engaging in new projects and for policy-makers using their findings. Second, the proposed criteria for evaluating theory and practice of cross-disciplinary HPSR may inform the systematic development of new research projects and the structured assessment of existing ones. Third, a better understanding of the challenges of cross-disciplinary HPSR and potential response mechanisms may help researchers to avoid these problems in the future.

Facilitators and Barriers to Chronic Disease Self-Management and Mobile Health Interventions for People Living With Diabetes and Hypertension in Cambodia: Qualitative Study

Background

In many low- and middle-income countries (LMICs), heart disease and stroke are the leading causes of death as cardiovascular risk factors such as diabetes and hypertension rapidly increase. The Cambodian nongovernmental organization, MoPoTsyo, trains local residents with diabetes to be peer educators (PEs) to deliver chronic disease self-management training and medications to 14,000 people with hypertension and/or diabetes in Cambodia. We collaborated with MoPoTsyo to develop a mobile-based messaging intervention (mobile health; mHealth) to link MoPoTsyo’s database, PEs, pharmacies, clinics, and people living with diabetes and/or hypertension to improve adherence to evidence-based treatment guidelines.

Objective

This study aimed to understand the facilitators and barriers to chronic disease management and the acceptability, appropriateness, and feasibility of mHealth to support chronic disease management and strengthen community-clinical linkages to existing services.

Methods

We conducted an exploratory qualitative study using semistructured interviews and focus groups with PEs and people living with diabetes and/or hypertension. Interviews were recorded and conducted in Khmer script, transcribed and translated into the English language, and uploaded into Atlas.ti for analysis. We used a thematic analysis to identify key facilitators and barriers to disease management and opportunities for mHealth content and format. The information-motivation-behavioral model was used to guide data collection, analysis, and message development.

Results

We conducted six focus groups (N=59) and 11 interviews in one urban municipality and five rural operating districts from three provinces in October 2016. PE network participants desired mHealth to address barriers to chronic disease management through reminders about medications, laboratory tests and doctor’s consultations, education on how to incorporate self-management into their daily lives, and support for obstacles to disease management. Participants preferred mobile-based voice messages to arrive at dinnertime for improved phone access and family support. They desired voice messages over texts to communicate trust and increase accessibility for persons with limited literacy, vision, and smartphone access. PEs shared similar views and perceived mHealth as acceptable and feasible for supporting their work. We developed 34 educational, supportive, and reminder mHealth messages based on these findings.

Conclusions

These mHealth messages are currently being tested in a cluster randomized controlled trial (#1R21TW010160) to improve diabetes and hypertension control in Cambodia. This study has implications for practice and policies in Cambodia and other LMICs and low-resource US settings that are working to engage PEs and build community-clinical linkages to facilitate chronic disease management.

Mobile phone usage in patients with type II diabetes and their intention to use it for self-management: a cross-sectional study in Iran

BACKGROUND

Mobile health has potential for promotion of self-management in patients with chronic diseases. This study was conducted to investigate smartphone usage in patients with type II diabetes and their intention to use it for self-management.

METHODS

This cross-sectional study was conducted in 2018 with 176 patients with type II diabetes visiting a specialized diabetes clinic or one of two endocrinology and metabolism specialists in north of Iran. Data were collected using a validated questionnaire containing items on demographic characteristics, disease information, use of mobile phones, smartphones and the internet, and intention to use mobile phones for diabetes self-management.

RESULTS

The majority of the participants had mobile phones (94.9%), smartphones (61.1%), and daily access to the internet (81.3%), and used phones two hours per day on average (80.1%). They mostly used mobile phones to contact friends (89.2%) and search for information (50.6%), and their greatest intention for using smartphones and the internet for self-management was related to dietary planning (96%), checking blood glucose (90.9%), and contacting specialists (87.5%). Younger participants were more interested in using smartphone applications (apps) (P < 0.001). About half of the participants argued that using apps can be interesting (54%) and useful (50%) for diabetes management, and intended to use apps much more in future (48.3%).

CONCLUSIONS

The majority of patients with type II diabetes are inclined to use mobile phone and the Internet, especially to plan their diet, check blood glucose, and contact their doctors. The present study provides valuable information for designing and implementing interventions based on mHealth to promote self-management in type II diabetes.

Combating non-communicable diseases: potentials and challenges for community health workers in a digital age, a narrative review of the literature

The use of community health workers (CHWs) has been explored as a viable option to provide home health education, counselling and basic health care, notwithstanding their challenges in training and retention. In this manuscript, we review the evidence and discuss how the digitalization affects the CHWs programmes for tackling non-communicable diseases (NCDs) in low- and middle-income countries (LMICs). We conducted a review of literature covering two databases: PubMED and Embase. A total of 97 articles were abstracted for full text review of which 26 are included in the analysis. Existing theories were used to construct a conceptual framework for understanding how digitalization affects the prospects of CHW programmes for NCDs. The results are divided into two themes: (1) the benefits of digitalization and (2) the challenges to the prospects of digitalization. We also conducted supplemental search in non-peer reviewed literature to identify and map the digital platforms currently in use in CHW programmes. We identified three benefits and three challenges of digitalization. Firstly, it will help improve the access and quality of services, notwithstanding its higher establishment and maintenance costs. Secondly, it will add efficiency in training and personnel management. Thirdly, it will leverage the use of data generated across grass-roots platforms to further research and evaluation. The challenges posed are related to funding, health literacy of CHWs and systemic challenges related to motivating CHWs. Several dozens of digital platforms were mapped, including mobile-based networking devices (used for behavioural change communication), Web-applications (used for contact tracking, reminder system, adherence tracing, data collection and decision support), videoconference (used for decision support) and mobile applications (used for reminder system, supervision, patients' management, hearing screening and tele-consultation). The digitalization efforts of CHW programmes are afflicted by many challenges, yet the rapid technological penetration and acceptability coupled with the gradual fall in costs constitute encouraging signals for the LMICs. Both CHWs interventions and digital technologies are not inexpensive, but they may provide better value for the money when applied at the right place and time.

Perspectives on a mobile application that maps assistive technology resources in Africa

Background

Access to assistive technology (AT) is poor in African countries because of a lack of knowledge, resources, services and products. A mobile application (app), the AT-Info-Map, was developed to map AT availability in southern Africa.

Objectives

This article aimed to describe users’ and suppliers’ perceptions of the AT-Info-Map app.

Method

Qualitative data were collected in Zambia, Botswana, Malawi and Lesotho, through nine focus group discussions with 72 participants. Participants included AT users, AT suppliers and representatives of disability organisations. Data were thematically analysed.

Results

Two broad themes, that is, usefulness of the AT-Info-Map application and technical issues and content, emerged from the data analysis. Subthemes under usefulness focused on the importance of using current technology, convenience of the app, the need for accuracy, responsiveness of supplier to user’s needs, influence on AT market and how the app creates an opportunity for networking. Challenges to download and navigate the app, the need for training in its use, exclusion of those not literate in English and those with visual impairments were subthemes under technical issues and content.

Conclusion

The app was perceived as an important step to increase access to AT for persons with disabilities in less resourced settings. The challenges that emerged from the data analysis have led to the development of a web-based system that will complement or replace the app and improve AT information provision. However, the information provided by the app and website is still only a partial solution to improve AT access in Southern Africa.

Community- and mHealth-based integrated management of diabetes in primary healthcare in Rwanda (D²Rwanda): the protocol of a mixed-methods study including a cluster randomised controlled trial

INTRODUCTION

In Rwanda, diabetes mellitus prevalence is estimated between 3.1% and 4.3%. To address non-communicable diseases and the shortage of health workforce, the Rwandan Ministry of Health has introduced the home-based care practitioners (HBCPs) programme: laypeople provide longitudinal care to chronic patients after receiving a six-month training. Leveraging technological mobile solutions may also help improve health and healthcare. The D²Rwanda study aims at: (a) determining the efficacy of an integrated programme for the management of diabetes in Rwanda, which will provide monthly patient assessments by HBCPs, and an educational and self-management mHealth patient tool, and; (b) exploring qualitatively the ways the interventions will have been enacted, their challenges and effects, and changes in the patients' health behaviours and HBCPs' work satisfaction.

METHODS AND ANALYSIS

This is a mixed-methods sequential explanatory study. First, there will be a one-year cluster randomised controlled trial including two interventions ((1) HBCPs' programme; (2) HBCPs' programme + mobile health application) and usual care (control). Currently, nine hospitals run the HBCPs' programme. Under each hospital, administrative areas implementing the HBCPs' programme will be randomised to receive intervention 1 or 2. Eligible patients from each area will receive the same intervention. Areas without the HBCPs' programme will be assigned to the control group. The primary outcome will be changes in glycated haemoglobin. Secondary outcomes include medication adherence, mortality, complications, health-related quality of life, diabetes-related distress and health literacy. Second, at the end of the trial, focus group discussions will be conducted with patients and HBCPs. Financial support was received from the Karen Elise Jensens Fond, and the Universities of Aarhus and Luxembourg.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Rwanda National Ethics Committee and the Ethics Review Panel of the University of Luxembourg. Findings will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03376607; Pre-results.

The effectiveness and acceptability of mobile telephone adherence support for management of depression in the Mental Health in Primary Care (MeHPriC) project, Lagos, Nigeria: A pilot cluster randomised controlled trial

BACKGROUND

To evaluate the effectiveness and acceptability of adding a mobile telephone adherence support to a Collaborative Stepped Care (CSC) intervention for primary care management of depression.

METHODS

A pilot cluster randomised controlled trial with 10 primary care centres in Lagos Nigeria, randomised into either the mobile telephone supported CSC (mCSC) group or the ordinary CSC (oCSC) group in ratio 1:1. The 5 mCSC clusters received in addition to the CSC intervention, a series of tailored informational text messages and reminders. Participants were adults (18-60 years) with depression. The primary outcome was the rate of adherence to intervention at 6th and 12th months follow up. Analysis was by intention to treat.

RESULTS

The mCSC group (n = 439 participants) had significantly better adherence rate compared to oCSC group (n = 456 participants) at 6th month (90.0% vs 67.8%, ARR 1.31, 95% CI 1.22-1.40) and at 12th month follow up (78.1% vs 59.2%, ARR 1.30, 95% CI 1.20-1.43). Compared to the oCSC group, the mCSC had significantly higher recovery rate, better quality of life, retention in treatment, was more cost effective and had high level of acceptance amongst clients LIMITATION: Self rating scales were not used for adherence score. We analysed according to Intention to Treat and we have not included mild depression CONCLUSION: The addition of our mobile telephony support significantly improves adherence and clinical outcomes for CSC intervention and was cost effective and acceptable to clients. Mobile telephone technology can substantially aid the scale up of mental health services in developing countries.

Achieving Sustainability and Scale-Up of Mobile Health Noncommunicable Disease Interventions in Sub-Saharan Africa: Views of Policy Makers in Ghana

Background

A growing body of evidence shows that mobile health (mHealth) interventions may improve treatment and care for the rapidly rising number of patients with noncommunicable diseases (NCDs) in sub-Saharan Africa (SSA). A recent realist review developed a framework highlighting the influence of context factors, including predisposing characteristics, needs, and enabling resources (PNE), for the long-term success of mHealth interventions. The views of policy makers will ultimately determine implementation and scale-up of mHealth interventions in SSA. However, their views about necessary conditions for sustainability and scale-up remain unexplored.

Objective

This study aimed to understand the views of policy makers in Ghana with regard to the most important factors for successful implementation, sustainability, and scale-up of mHealth NCD interventions.

Methods

Members of the technical working group responsible for Ghana’s national NCD policy were interviewed about their knowledge of and attitude toward mHealth and about the most important factors contributing to long-term intervention success. Using qualitative methods and applying a qualitative content analysis approach, answers were categorized according to the PNE framework.

Results

A total of 19 policy makers were contacted and 13 were interviewed. Interviewees had long-standing work experience of an average of 26 years and were actively involved in health policy making in Ghana. They were well-informed about the potential of mHealth, and they strongly supported mHealth expansion in the country. Guided by the PNE framework’s categories, the policy makers ascertained which critical factors would support the successful implementation of mHealth interventions in Ghana. The policy makers mentioned many factors described in the literature as important for mHealth implementation, sustainability, and scale-up, but they focused more on enabling resources than on predisposing characteristics and need. Furthermore, they mentioned several factors that have been rather unexplored in the literature.

Conclusions

The study shows that the PNE framework is useful to guide policy makers toward a more systematic assessment of context factors that support intervention implementation, sustainability, and scale-up. Furthermore, the framework was refined by adding additional factors. Policy makers may benefit from using the PNE framework at the various stages of mHealth implementation. Researchers may (and should) use the framework when investigating reasons for success (or failure) of interventions.

The Comparative Effectiveness of Mobile Phone Interventions in Improving Health Outcomes: Meta-Analytic Review

Background

As mobile technology continues expanding, researchers have been using mobile phones to conduct health interventions (mobile health—mHealth—interventions). The multiple features of mobile phones offer great opportunities to disseminate large-scale, cost-efficient, and tailored messages to participants. However, the interventions to date have shown mixed results, with a large variance of effect sizes (Cohen d=−0.62 to 1.65).

Objective

The study aimed to generate cumulative knowledge that informs mHealth intervention research. The aims were twofold: (1) to calculate an overall effect magnitude for mHealth interventions compared with alternative interventions or conditions, and (2) to analyze potential moderators of mHealth interventions’ comparative efficacy.

Methods

Comprehensive searches of the Communication & Mass Media Complete, PsycINFO, Web of Knowledge, Academic Search Premier, PubMed and MEDLINE databases were conducted to identify potentially eligible studies in peer-reviewed journals, conference proceedings, and dissertations and theses. Search queries were formulated using a combination of search terms: “intervention” (Title or Abstract) AND “health” (Title or Abstract) AND “*phone*” OR “black-berr*” (OR mHealth OR “application*” OR app* OR mobile OR cellular OR “short messag*” OR palm* OR iPhone* OR MP3* OR MP4* OR iPod*) (Title or Abstract). Cohen d was computed as the basic unit of analysis, and the variance-weighted analysis was implemented to compute the overall effect size under a random-effects model. Analysis of variance–like and meta-regression models were conducted to analyze categorical and continuous moderators, respectively.

Results

The search resulted in 3424 potential studies, the abstracts (and full text, as necessary) of which were reviewed for relevance. Studies were screened in multiple stages using explicit inclusion and exclusion criteria, and citations were evaluated for inclusion of qualified studies. A total of 64 studies were included in the current meta-analysis. Results showed that mHealth interventions are relatively more effective than comparison interventions or conditions, with a small but significant overall weighted effect size (Cohen d=0.31). In addition, the effects of interventions are moderated by theoretical paradigm, 3 engagement types (ie, changing personal environment, reinforcement tracking, social presentation), mobile use type, intervention channel, and length of follow-up.

Conclusions

To the best of our knowledge, this is the most comprehensive meta-analysis to date that examined the overall effectiveness of mHealth interventions across health topics and is the first study that statistically tested moderators. Our findings not only shed light on intervention design using mobile phones, but also provide new directions for research in health communication and promotion using new media. Future research scholarship is needed to examine the effectiveness of mHealth interventions across various health issues, especially those that have not yet been investigated (eg, substance use, sexual health), engaging participants using social features on mobile phones, and designing tailored mHealth interventions for diverse subpopulations to maximize effects.

Digital health at fifteen: more human (more needed)

There is growing appreciation that the success of digital health - whether digital tools, digital interventions or technology-based change strategies - is linked to the extent to which human factors are considered throughout design, development and implementation. A shift in focus to individuals as users and consumers of digital health highlights the capacity of the field to respond to secular developments, such as the adoption of person-centred care and consumer health technologies. We argue that this project is not only incomplete, but is fundamentally 'uncompletable' in the face of a highly dynamic landscape of both technological and human challenges. These challenges include the effects of consumerist, technology-supported care on care delivery, the rapid growth of digital users in low-income and middle-income countries and the impacts of machine learning. Digital health research will create most value by retaining a clear focus on the role of human factors in maximising health benefit, by helping health systems to anticipate and understand the person-centred effects of technology changes and by advocating strongly for the autonomy, rights and safety of consumers.

Health systems readiness for adopting mhealth interventions for addressing non-communicable diseases in low- and middle-income countries: a current debate

In low-and-middle-income countries, epidemiologic transition is taking place very rapidly from communicable diseases to non-communicable diseases. NCDs mortality rates are increasing faster and nearly 80% of NCDs deaths occur in LMICs. Existing weak health systems of LMICs are undergoing a devastating human and economic toll as a result of increasing treatment costs and losses to productivity from NCDs. At the same time, the increasing penetration of mobile phone technology and the spread of cellular network and infrastructure have led to the introduction of the mHealth field. While mHealth field offers a great promise to prevent and control non-communicable diseases in low-and-middle-income countries: there is a great debate going on to explore health systems readiness for adopting mHealth technology to address NCDs in LMICs. There are a number of factors which determine health systems readiness and response for adoption of mHealth technology including preparedness of healthcare institutions, availability of the resources, willingness of healthcare providers and communities. We have discussed these factors to understand health systems preparedness to adopt mHealth field for prevention and control of NCDs. To adequately integrate mobile-phone-based health interventions into existing health systems, these factors should be dealt up-front through constant effort to improve health systems response for NCDs. Currently, there is insufficient empirical and policy evidence on this research area and therefore future research and policy dialogue should be directed to assess the health systems willingness for mHealth adoption principally to address NCDs in the context of LMICs.

Using community pharmacies to expand access to screening for noncommunicable diseases in suburban Ghana-A facility-based survey on client needs and acceptability

BACKGROUND

Many of the 28 million deaths from noncommunicable diseases (NCDs) in low- and middle-income countries each year could be prevented through early detection and intervention. The introduction of screening for NCDs in community pharmacies (CPs) in Ghana could enhance access to early detection.

METHODS

We surveyed clients in three districts in suburban Ghana to assess perceived need for screening, willingness to be screened in CPs, and willingness to receive NCD health promotion information through text messages (NCD m-Health). We performed regression analysis to identify predictors of NCD m-Health acceptability.

RESULTS

We interviewed 330 clients in six CPs, 134 (42.3%) of whom were females. The median age was 34 years (interquartile range, 27-43). Fifty-four (16.4%) had no formal education. Although most respondents knew obesity (74.9%), smoking (81.9%), and excessive dietary salt (91.7%) were risk factors for NCDs, only 27.0% knew family history carried similar risk. Most respondents, 61.6% and 70.6%, respectively, had not had their weight and blood pressure (BP) checked for more than 12 months. These included about a third of respondents who were known hypertensives. Similarly, 71.3% of 80 participants with a family history of hypertension had not had their BPs checked. Screening for NCDs in CPs and the sending of NCD m-Health messages was deemed acceptable to 98.5% and 83.1% of the participants, respectively. Formal education beyond junior high school (Grade 9) was the strongest independent predictor of NCD m-Health acceptance (OR = 4.77; 95% CI, 1.72-13.18; P value < 0.01). One hundred and twenty-five (39.4%) participants indicated they would consider unsolicited NCD m-Health messages an invasion of their privacy.

CONCLUSION

An urgent need exists to promote access to NCD screening in these communities. Its introduction into CPs is acceptable to nearly all the clients surveyed. The introduction of NCD m-Health as an accompaniment requires consideration for the privacy of clients.

What do emergency medicine and burns specialists from resource constrained settings expect from mHealth-based diagnostic support? A qualitative study examining the case of acute burn care

BACKGROUND

Traumatic injury is a serious global health burden, particularly in low- and middle-income countries where medical care often lacks resources and expertise. In these contexts, diagnostic telemedicine could prove a cost effective tool, yet it remains largely underused here, and knowledge on its potential impact is limited. Particularly scarce is the view of the expert user physicians, and how they themselves relate to this technology.

METHODS

This qualitative study investigated tele-experts' (n = 15) views on the potential for image based teleconsultation to be integrated in trauma and emergency care services. A semi-structured interview guide was used to gather data concerning an mHealth app for burns diagnostics in the acute care setting, in the Western Cape, South Africa. Questions examined challenges and opportunities in user acceptance and outcomes, in specific case management and in the wider healthcare system. Resulting data were subject to qualitative content analysis.

RESULTS

Experts perceived remote diagnostic support through mHealth as linking directly to several key ideas in medicine, including barriers to care, medical culture and hierarchy, and medical ethics within a society. Ideas running through the data pertained to the widening and narrowing of inherent gaps in the healthcare system, and the formalisation of processes, practices and relationships, effected by the introduction of an app. Wide consensus was stated on positive outcomes such as increased education opportunities, improved professional relationships and a better ability to advise and diagnose, all further facilitated through greater ease of access. The belief was that these could achieve a narrowing of systemic divides within healthcare, although it was acknowledged that the possibility to induce the opposite effect also arose. Differing opinions were voiced relating to the involvement of allied health professionals and feedback.

CONCLUSION

Experts see several aspects to an mHealth app for remote diagnostic support which could enhance provision of trauma and emergency care in a resource poor setting, relating to reduced delays, streamlined care and improved outcomes. Attention is also drawn, however, to specifics of the environment which would demand further and careful consideration for success - time pressure, intensity and the wide range of subspecialties to be considered.

Mobile health and the performance of maternal health care workers in low- and middle-income countries: A realist review

Introduction

Maternal health and the performance of health workers is a key concern in low- and middle-income countries. Mobile health technologies are reportedly able to improve workers' performance. However, how this has been achieved for maternal health workers in low-resource settings is not fully substantiated. To address this gap by building theoretical explanations, two questions were posed: How does mobile health influence the performance of maternal health care workers in low- and middle-income countries? What mechanisms and contextual factors are associated with mobile health use for maternal health service delivery in low- and middle-income countries?

Methods

Guided by established guidelines, a realist review was conducted. Five databases were searched for relevant English language articles published between 2009 and 2016. A three-stage framework was developed and populated with explanatory configurations of Intervention-Context-Actors-Mechanism-Outcome. Articles were analyzed retroductively, with identified factors grouped into meaningful clusters.

Results

Of 1254 records identified, 23 articles representing 16 studies were retained. Four main mechanisms were identified: usability and empowerment explaining mobile health adoption, third-party recognition explaining mobile health utilization, and empowerment of health workers explaining improved competence. Evidence was skewed toward the adoption and utilization stage of the framework, with weak explanations for performance outcomes.

Conclusions

Findings suggest that health workers can be empowered to adopt and utilize mobile health in contexts where it is aligned to their needs, workload, training, and skills. In turn, mobile health can empower health workers with skills and confidence when it is perceived as useful and easy to use, in contexts that foster recognition from clients, peers, or supervisors.

Species identification of adult African blowflies (Diptera: Calliphoridae) of forensic importance

Necrophagous blowflies can provide an excellent source of evidence for forensic entomologists and are also relevant to problems in public health, medicine, and animal health. However, access to useful information about these blowflies is constrained by the need to correctly identify the flies, and the poor availability of reliable, accessible identification tools is a serious obstacle to the development of forensic entomology in the majority of African countries. In response to this need, a high-quality key to the adults of all species of forensically relevant blowflies of Africa has been prepared, drawing on high-quality entomological materials and modern focus-stacking photomicroscopy. This new key can be easily applied by investigators inexperienced in the taxonomy of blowflies and is made available through a highly accessible online platform. Problematic diagnostic characters used in previous keys are discussed.

A survey of mobile phone use in the provision of palliative care services in the African region and priorities for future development

INTRODUCTION

Palliative care (PC) services in the African region need to adapt to manage rising numbers of patients with cancer or other life-limiting conditions. Mobile phone use in healthcare delivery (mHealth) is at an early stage of development for PC, but may provide new approaches to supporting patients regionally, particularly those with non-communicable diseases.

METHODS

We conducted an online survey of 51 PC providers across 21 countries in the African region to identify: (i) current mHealth use in PC service delivery; (ii) potential barriers to mHealth use; and (iii) provider priorities for research development.

RESULTS

mHealth approaches were reported across 71.4% of services in which respondents were based. Barriers to mHealth research include patients not having access to phones, mobile network access, and limited access to expertise and hardware required for mHealth. Research priorities were identified which included exploring ways of incorporating mHealth into patient care and ensuring access and relevance of mHealth for patients and health professionals.

DISCUSSION

mHealth approaches are present across PC services in the African region, but so too are barriers to their use. Further work is required to explore how existing mHealth activities might be further developed and aligned with priority areas for PC development. Crucially, user engagement that seeks to understand the preferences and priorities of patients with PC needs, their caregivers, and those involved in the provision of PC should remain central to these efforts.