Assessing the perspectives of users and beneficiaries of a community health worker mHealth tracking system for mothers and children in Rwanda

Healthcare workers' perspectives on the availability and use of mobile health technologies for disease diagnosis and treatment support in the Ashanti Region of Ghana

INTRODUCTION

Considering the usefulness of mobile health (mHealth) technologies in healthcare delivery in low- and middle-income countries, including Ghana; there is a need to explore healthcare professionals' perspectives on the availability and use of mHealth for disease screening and treatment of patients' conditions. The study's main aim is to explore healthcare professionals' perspectives regarding the availability and use of mHealth applications for disease screening and management at point-of-care in Ghana's Ashanti Region.

MATERIALS AND METHODS

We conducted in-depth interviews with healthcare professionals who use mHealth applications daily between July and September 2020. A purposive sampling strategy was employed to select healthcare professionals who have been using mobile health application tools to support healthcare delivery. The researchers conducted 14 in-depth interviews with healthcare professionals on the availability and use of mHealth applications to support disease diagnosis and treatment of patients' conditions. Data were transcribed, coded, arranged, and analyzed to determine categories and themes.

RESULTS

The study results demonstrated that healthcare workers had positive perceptions towards mHealth applications. Healthcare professionals identified significant challenges concerning mHealth applications: the high cost of data; lack of education or limited awareness; poor mobile networks; unstable internet connectivity; erratic power supply; and unavailability of logistics. Healthcare professionals identified the following prerequisite strategies to strengthen the use and scale-up of mHealth applications: stable internet connectivity; creating awareness; supplying logistics; reducing the cost of data; and developing local mobile apps.

CONCLUSIONS

The study results revealed the availability of mHealth applications at the individual level for disease screening and treatment support of patients' conditions. The study also showed several significant challenges facing mHealth applications which need to be addressed to guarantee the successful implementation and scaling-up of mHealth activities at all levels of healthcare delivery. Hence, future research should incorporate healthcare professionals' perspectives to completely understand mHealth implementation and scaling-up challenges and measures to inform policy regulations.

Types, reporting and acceptability of community-based interventions for stillbirth prevention in sub-Saharan Africa (SSA): a systematic review

Background

Community-based interventions are increasingly being implemented in Sub-Saharan Africa (SSA) for stillbirth prevention, but the nature of these interventions, their reporting and acceptability are poorly assessed. In addition to understanding their effectiveness, complete reporting of the methods, results and intervention acceptability is essential as it could potentially reduce research waste from replication of inadequately implemented and unacceptable interventions. We conducted a systematic review to investigate these aspects of community-based interventions for preventing stillbirths in SSA.

Methods

In this systematic review, eight databases (MEDLINE(OvidSP), Embase (OvidSP), Cochrane Central Register of Controlled Trials, Global Health, Science Citation Index and Social Science Citation index (Web of Science Core Collection), CINAHL (EBSCOhost) and Global Index Medicus) and four grey literature sources were searched from January 1, 2000 to July 7, 2023 for relevant quantitative and qualitative studies from SSA (PROSPERO-CRD42021296623). Following deduplication, abstract screening and full-text review, studies were included if the interventions were community-based with or without a health facility component. The main outcomes were types of community-based interventions, completeness of intervention reporting using the TIDier (Template for Intervention Description and replication) checklist, and themes related to intervention acceptability identified using a theoretical framework. Study quality was assessed using the Cochrane risk of bias and National Heart, Lung and Blood Institute's tools.

Findings

Thirty-nine reports from thirty-four studies conducted in 18 SSA countries were eligible for inclusion. Four types of interventions were identified: nutritional, infection prevention, access to skilled childbirth attendants and health knowledge/behaviour of women. These interventions were implemented using nine strategies: mHealth (defined as the use of mobile and wireless technologies to support the achievement of health objectives), women's groups, community midwifery, home visits, mass media sensitisation, traditional birth attendant and community volunteer training, community mobilisation and transport vouchers. The completeness of reporting using the TIDier checklist varied across studies with a very low proportion of the included studies reporting the intervention intensity, dosing, tailoring and modification. The quality of the included studies were graded as poor (n = 6), fair (n = 14) and good (n = 18). Though interventions were acceptable, only 4 (out of 7) studies explored women's perceptions, mostly focusing on perceived intervention effects and how they felt, omitting key constructs like ethicality, opportunity cost and burden of participation.

Interpretation

Different community-based interventions have been tried and evaluated for stillbirth prevention in SSA. The reproducibility and implementation scale-up of these interventions may be limited by incomplete intervention descriptions in the published literature. To strengthen impact, it is crucial to holistically explore the acceptability of these interventions among women and their families.

Funding

Clarendon/Balliol/NDPH DPhil scholarship for UGA. MN is funded by a Medical Research Council Transition Support Award (MR/W029294/1).

Understanding community health workers' activities in a community-based child health promotion project in Kyrgyzstan

BACKGROUND

Community health workers (CHWs) have strong potential for conducting health initiatives in vulnerable countries. Their continuing activities are essential for positive outcomes. The purpose of this study is to understand CHW activities in Kyrgyzstan migrant villages and their impact on individuals and communities.

METHODS

This study used a mixed-method design. All active CHWs were invited to participate in the survey and the first reflection note regarding their experience and satisfaction with CHW activities. Respondents who agreed to participate in the second reflection notes wrote additional reflection notes. Participatory observational CHW activity report meeting data was collected for additional qualitative analysis. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed thematically.

RESULTS

CHWs started their activities with altruistic and personal motives, such as social recognition and knowledge acquisition. Job-related satisfaction after the activity tended to be high. After performing home visits and resident participatory events, they experienced intrinsic motivation, resource mobilization efforts, increased autonomy, and social recognition. Although the material rewards were small as volunteers, they recognized their positive impact on individuals and communities and gained pride and happiness.

CONCLUSIONS

CHWs participating in health promotion projects had training and CHW-nurse network activities and were gradually empowered in the process. When considering the sustainability of CHW activities, it is important to increase self-confidence and strengthen social recognition through empowerment.

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

BACKGROUND

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

METHODS

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

RESULTS AND DISCUSSION

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

CONCLUSIONS

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

Use of mHealth tools to register birth outcomes in low-income and middle-income countries: a scoping review

OBJECTIVE

Accurate reporting of birth outcomes in low-income and middle-income countries (LMICs) is essential. Mobile health (mHealth) tools have been proposed as a replacement for conventional paper-based registers. mHealth could provide timely data for individual facilities and health departments, as well as capture deliveries outside facilities. This scoping review evaluates which mHealth tools have been reported to birth outcomes in the delivering room in LMICs and documents their reported advantages and drawbacks.

DESIGN

A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Joanna Briggs Institute guidelines for scoping reviews and the mHealth evidence reporting and assessment checklist for evaluating mHealth interventions.

DATA SOURCES

PubMed, CINAHL and Global Health were searched for records until 3 February 2022 with no earliest date limit.

ELIGIBILITY CRITERIA

Studies were included where healthcare workers used mHealth tools in LMICs to record birth outcomes. Exclusion criteria included mHealth not being used at the point of delivery, non-peer reviewed literature and studies not written in English.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened studies and extracted data. Common themes among studies were identified.

RESULTS

640 records were screened, 21 of which met the inclusion criteria, describing 15 different mHealth tools. We identified six themes: (1) digital tools for labour monitoring (8 studies); (2) digital data collection of specific birth outcomes (3 studies); (3) digital technologies used in community settings (6 studies); (4) attitudes of healthcare workers (10 studies); (5) paper versus electronic data collection (3 studies) and (6) infrastructure, interoperability and sustainability (8 studies).

CONCLUSION

Several mHealth technologies are reported to have the capability to record birth outcomes at delivery, but none were identified that were designed solely for that purpose. Use of digital delivery registers appears feasible and acceptable to healthcare workers, but definitive evaluations are lacking. Further assessment of the sustainability of technologies and their ability to integrate with existing health information systems is needed.

Digital Health Technologies for Maternal and Child Health in African and other LMICs: A Cross-disciplinary Scoping Review with Stakeholder Consultation (Preprint)

BACKGROUND

Maternal and child health (MCH) is a global health concern, especially impacting low- and middle-income countries (LMIC). Digital health technologies are creating opportunities to address the social determinants of MCH by facilitating access to information and providing other forms of support throughout the maternity journey. Previous reviews in different disciplines have synthesized digital health intervention outcomes in LMIC. However, contributions in this space are scattered across publications in different disciplines and lack coherence in what digital MCH means across fields.

OBJECTIVE

This cross-disciplinary scoping review synthesized the existing published literature in 3 major disciplines on the use of digital health interventions for MCH in LMIC, with a particular focus on sub-Saharan Africa.

METHODS

We conducted a scoping review using the 6-stage framework by Arksey and O'Malley across 3 disciplines, including public health, social sciences applied to health, and human-computer interaction research in health care. We searched the following databases: Scopus, PubMed, Google Scholar, ACM Digital Library, IEEE Xplore, Web of Science, and PLOS. A stakeholder consultation was undertaken to inform and validate the review.

RESULTS

During the search, 284 peer-reviewed articles were identified. After removing 41 duplicates, 141 articles met our inclusion criteria: 34 from social sciences applied to health, 58 from public health, and 49 from human-computer interaction research in health care. These articles were then tagged (labeled) by 3 researchers using a custom data extraction framework to obtain the findings. First, the scope of digital MCH was found to target health education (eg, breastfeeding and child nutrition), care and follow-up of health service use (to support community health workers), maternal mental health, and nutritional and health outcomes. These interventions included mobile apps, SMS text messaging, voice messaging, web-based applications, social media, movies and videos, and wearable or sensor-based devices. Second, we highlight key challenges: little attention has been given to understanding the lived experiences of the communities; key role players (eg, fathers, grandparents, and other family members) are often excluded; and many studies are designed considering nuclear families that do not represent the family structures of the local cultures.

CONCLUSIONS

Digital MCH has shown steady growth in Africa and other LMIC settings. Unfortunately, the role of the community was negligible, as these interventions often do not include communities early and inclusively enough in the design process. We highlight key opportunities and sociotechnical challenges for digital MCH in LMIC, such as more affordable mobile data; better access to smartphones and wearable technologies; and the rise of custom-developed, culturally appropriate apps that are more suited to low-literacy users. We also focus on barriers such as an overreliance on text-based communications and the difficulty of MCH research and design to inform and translate into policy.

Multilevel determinants of community health workers for an effective maternal and child health programme in sub-Saharan Africa: a systematic review

Background

Countries in sub-Saharan Africa (SSA) continue to have the highest maternal and under-five child deaths in the world. The ongoing COVID-19 pandemic is amplifying the problems and overwhelming already fragile health systems. Community health workers (CHWs) are increasingly being acknowledged as crucial members of the healthcare workforce in improving maternal and child health (MCH). However, evidence is limited on multilevel determinants of an effective CHWs programme using CHWs’ perspective. The objective of this systematic review is to examine perceived barriers to and enablers of different levels of the determinants of the CHWs’ engagement to enhance MCH equity and a resilient community health system in SSA.

Methods

We systematically conducted a literature search from inception in MEDLINE complete, EMBASE, CINAHL complete and Global Health for relevant studies. Qualitative studies that presented information on perceived barriers to and facilitators of effectiveness of CHWs in SSA were eligible for inclusion. Quality appraisal was conducted according to the Critical Appraisal Skills Programme qualitative study checklist. We used a framework analysis to identify key findings.

Findings

From the database search, 1561 articles were identified. Nine articles met the inclusion criteria and were included in the final review. Using socio-ecological framework, we identified the determinants of CHWs’ effectiveness at 4 levels: individual/CHWs, interpersonal, community and health system logistics. Under each level, we identified themes of perceived barriers such as competency gaps, lack of collaboration, fragmentation of empowerment programmes. In terms of facilitators, we identified themes such as CHW empowerment, interpersonal effectiveness, community trust, integration of CHWs into health systems and technology.

Conclusion

Evidence from this review revealed that effectiveness of CHW/MCH programme is determined by multilevel contextual factors. The socio-ecological framework can provide a lens of understanding diverse context that impedes or enhances CHWs’ engagement and effectiveness at different levels. Hence, there is a need for health programme policy makers and practitioners to adopt a multilevel CHW/MCH programme guided by the socio-ecological framework to transform CHW programmes. The framework can help to address the barriers and scale up the facilitators to ensuring MCH equity and a resilient community health system in SSA.

Application of primary healthcare principles in national community health worker programmes in low-income and middle-income countries: a scoping review

OBJECTIVE

To identify which primary healthcare (PHC) principles are reflected in the implementation of national community health worker (CHW) programmes and how they may contribute to the outcomes of these programmes in the context of low-income and middle-income countries (LMICs).

DESIGN

Scoping review.

DATA SOURCES

A systematic search was conducted through PubMed, CINAHL, EMBASE and Scopus databases.

ELIGIBILITY CRITERIA

The review considered published primary studies on national programmes, projects or initiatives using the services of CHWs in LMICs focused on maternal and child health. We included only English language studies. Excluded were programmes operated by non-government organisations, study protocols, reviews, commentaries, opinion papers, editorials and conference proceedings.

DATA EXTRACTION AND SYNTHESIS

We reviewed the application of four PHC principles (universal health coverage, community participation, intersectoral coordination and appropriateness) in the CHW programme's objectives, implementation and stated outcomes. Data extraction was undertaken systematically in an excel spreadsheet while the findings were synthesised in a narrative manner. The quality appraisal of the selected studies was not performed in this scoping review.

RESULTS

From 1280 papers published between 1983 and 2019, 26 met the inclusion criteria. These 26 papers included 14 CHW programmes from 13 LMICs. Universal health coverage and community participation were the two commonly reported PHC principles, while intersectoral coordination was generally missing. Similarly, the cultural acceptability aspect of the principle of appropriateness was present in all programmes as these programmes select CHWs from within the communities. Other aspects, particularly effectiveness, were not evident.

CONCLUSION

The implementation of PHC principles across national CHW programmes in LMICs is patchy. For comprehensiveness and improved health outcomes, programmes need to incorporate all attributes of PHC principles. Future research may focus on how to incorporate more attributes of PHC principles while implementing national CHW programmes in LMICs. Better documentation and publications of CHW programme implementation are also needed.

Explaining the impact of mHealth on maternal and child health care in low- and middle-income countries: a realist synthesis

Background

Despite the growing global application of mobile health (mHealth) technology in maternal and child health, contextual factors, and mechanisms by which interventional outcomes are generated, have not been subjected to a systematic examination. In this study, we sought to uncover context, mechanisms, and outcome elements of various mHealth interventions based on implementation and evaluation studies to formulate theories or models explicating how mHealth interventions work (or not) both for health care providers and for pregnant women and mothers.

Method

We undertook a realist synthesis. An electronic search of five online databases (PubMed/Medline, Google Scholar, Scopus, Academic Search Premier and Health Systems Evidence) was performed. Using appropriate Boolean phrases terms and selection procedures, 32 articles were identified. A theory-driven approach, narrative synthesis, was applied to synthesize the data. Thematic content analysis was used to delineate elements of the intervention, including its context, actors, mechanisms, and outcomes. Abduction and retroduction were applied using a realist evaluation heuristic tool to formulate generative theories.

Results

We formulated two configurational models illustrating how and why mHealth impacts implementation and uptake of maternal and child health care. Implementation-related mechanisms include buy-in from health care providers, perceived support of health care providers’ motivation and perceived ease of use and usefulness. These mechanisms are influenced by adaptive health system conditions including organization, resource availability, policy implementation dynamics, experience with technology, network infrastructure and connectivity. For pregnant women and mothers, mechanisms that trigger mHealth use and consequently uptake of maternal and child health care include perceived satisfaction, motivation and positive psychological support. Information overload was identified as a potential negative mechanism impacting the uptake of maternal and child health care. These mechanisms are influenced by health system conditions, socio-cultural characteristics, socio-economic and demographics characteristics, network infrastructure and connectivity and awareness.

Conclusion

Models developed in this study provide a detailed understanding of implementation and uptake of mHealth interventions and how and why they impact maternal and child health care in low- and middle-income countries. These models provide a foundation for the ‘white box’ of theory-driven evaluation of mHealth interventions and can improve rollout and implementation where required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03684-x.

Combining the theory of change and realist evaluation approaches to elicit an initial program theory of the MomConnect program in South Africa

Background

One of the Sustainable Development Goals is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. In South Africa, the flagship National Department of Health MomConnect program was launched in 2014 to strengthen the quality of maternal and child health (MCH) services and improve mortality outcomes. MomConnect was rapidly rolled out with a limited understanding of how and why the program was expected to work even though studies had shown the effectiveness of the MomConnect program in improving the uptake of MCH services. This study aimed to unearth the initial program theory of the MomConnect program based on explicit and implicit assumptions of how the program was organized and expected to work.

Methods

We conducted a document analysis using design- and implementation-related documents of the MomConnect program guided by the principles of Theory of Change (ToC) and Realist Evaluation (RE). Content and thematic analysis approaches were deductively applied to analyze the documents toward constructing ToC and RE-informed models. Abductive thinking and retroduction were further applied to the realist-informed approach to link program context, mechanisms, and outcomes to construct the initial program theory.

Results

ToC and RE-informed models illustrated how the MomConnect program was organized and expected to work. The process of constructing the ToC provided the platform for the development of the initial program theory, which identified three critical elements: (1) the central modalities of the MomConnect program; (2) the intended outcomes; and (3) the tentative causal links indicating, in a stepwise manner of, how the outcomes were intended to be achieved. The RE approach ‘enhanced’ the causal links by identifying relevant programmatic contexts and linking the postulated mechanisms of action (empowerment, encouragement, motivation, and knowledge acquisition) to program outcomes.

Conclusion

The application of ToC and RE provided an explicitly cumulative approach to knowledge generation in unveiling the initial program theory of MomConnect rather than delivering answers to questions of program effectiveness.

Using an ethics of care lens to understand the place of community health workers in Rwanda's maternal healthcare system

This study explores the informal care roles involved in the delivery of maternal health services by Rwanda's elected maternal community health workers. We conducted semi-structured interviews with 20 such workers in five Rwandan districts to explore their understandings of why they were elected for this voluntary position; what motivates them to fulfill their responsibilities; and their experiences of providing maternal health services in a resource-limited context. Thematically exploring the findings using an ethics of care lens, we highlight how responsibility, vulnerability and mutuality inform the place of these workers' roles in the maternal care system and their villages. We conclude by acknowledging the significant responsibilities assigned by these works and that the burden that may result from taking on such care may negatively affect the sustainability of this initiative.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effects of scaling up various community-level interventions on child mortality in Burundi, Kenya, Rwanda, Uganda and Tanzania: a modeling study

Background

Improving child health remains one of the most significant health challenges in sub-Saharan Africa, a region that accounts for half of the global burden of under-five mortality despite having approximately 13% of the world population and 25% of births globally. Improving access to evidence-based community-level interventions has increasingly been advocated to contribute to reducing child mortality and, thus, help low-and middle-income countries (LMICs) achieve the child health related Sustainable Development Goal (SDG) target. Nevertheless, the coverage of community-level interventions remains suboptimal. In this study, we estimated the potential impact of scaling up various community-level interventions on child mortality in five East African Community (EAC) countries (i.e., Burundi, Kenya, Rwanda, Uganda and the United Republic of Tanzania).

Methods

We identified ten preventive and curative community-level interventions that have been reported to reduce child mortality: Breastfeeding promotion, complementary feeding, vitamin A supplementation, Zinc for treatment of diarrhea, hand washing with soap, hygienic disposal of children’s stools, oral rehydration solution (ORS), oral antibiotics for treatment of pneumonia, treatment for moderate acute malnutrition (MAM), and prevention of malaria using insecticide-treated nets and indoor residual spraying (ITN/IRS). Using the Lives Saved Tool, we modeled the impact on child mortality of scaling up these 10 interventions from baseline coverage (2016) to ideal coverage (99%) by 2030 (ideal scale-up scenario) relative to business as usual (BAU) scenario (forecasted coverage based on prior coverage trends). Our outcome measures include number of child deaths prevented.

Results

Compared to BAU scenario, ideal scale-up of the 10 interventions could prevent approximately 74,200 (sensitivity bounds 59,068–88,611) child deaths by 2030 including 10,100 (8210–11,870) deaths in Burundi, 10,300 (7831–12,619) deaths in Kenya, 4350 (3678–4958) deaths in Rwanda, 20,600 (16049–25,162) deaths in Uganda, and 28,900 (23300–34,002) deaths in the United Republic of Tanzania. The top four interventions (oral antibiotics for pneumonia, ORS, hand washing with soap, and treatment for MAM) account for over 75.0% of all deaths prevented in each EAC country: 78.4% in Burundi, 76.0% in Kenya, 81.8% in Rwanda, 91.0% in Uganda and 88.5% in the United Republic of Tanzania.

Conclusions

Scaling up interventions that can be delivered at community level by community health workers could contribute to substantial reduction of child mortality in EAC and could help the EAC region achieve child health-related SDG target. Our findings suggest that the top four community-level interventions could account for more than three-quarters of all deaths prevented across EAC countries. Going forward, costs of scaling up each intervention will be estimated to guide policy decisions including health resource allocations in EAC countries.

Effect of a community health worker mHealth monitoring system on uptake of maternal and newborn health services in Rwanda

Background

In an effort to improve access to proven maternal and newborn health interventions, Rwanda implemented a mobile phone (mHealth) monitoring system called RapidSMS. RapidSMS was scaled up across Rwanda in 2013. The objective of this study was to evaluate the impact of RapidSMS on the utilization of maternal and newborn health services in Rwanda.

Methods

Using data from the 2014/15 Rwanda demographic and health survey, we identified a cohort of women aged 15–49 years who had a live birth that occurred between 2010 and 2014. Using interrupted time series design, we estimated the impact of RapidSMS on uptake of maternal and newborn health services including antenatal care (ANC), health facility delivery and vaccination coverage.

Results

Overall, the coverage rate at baseline for ANC (at least one visit), health facility delivery and vaccination was very high (> 90%). The baseline rate was 50.30% for first ANC visit during the first trimester and 40.57% for at least four ANC visits. We found no evidence that implementing RapidSMS was associated with an immediate increase in ANC (level change: -1.00% (95% CI: -2.30 to 0.29) for ANC visit at least once, -1.69% (95% CI: -9.94 to 6.55) for ANC (at least 4 visits), -3.80% (95% CI: -13.66 to 6.05) for first ANC visit during the first trimester), health facility delivery (level change: -1.79, 95% CI: -6.16 to 2.58), and vaccination coverage (level change: 0.58% (95%CI: -0.38 to 1.55) for BCG, -0.75% (95% CI: -6.18 to 4.67) for polio 0). Moreover, there was no significant trend change across the outcomes studied.

Conclusion

Based on survey data, the implementation of RapidSMS did not appear to increase uptake of the maternal and newborn health services we studied in Rwanda. In most instances, this was because the existing level of the indicators we studied was very high (ceiling effect), leaving little room for potential improvement. RapidSMS may work in contexts where improvement remains to be made, but not for indicators that are already very high. As such, further research is required to understand why RapidSMS had no impact on indicators where there was enough room for improvement.