A Patient-Held Smartcard With a Unique Identifier and an mHealth Platform to Improve the Availability of Prenatal Test Results in Rural Nigeria: Demonstration Study

Comparative effectiveness of implementation strategies for Accelerating Cervical Cancer Elimination through the integration of Screen-and-treat Services (ACCESS study): protocol for a cluster randomized hybrid type III trial in Nigeria

BACKGROUND

Despite the increased risk of cervical cancer (CC) among women living with HIV (WLHIV), CC screening and treatment (CCST) rates remain low in Africa. The integration of CCST services into established HIV programs in Africa can improve CC prevention and control. However, the paucity of evidence on effective implementation strategies (IS) has limited the success of integration in many countries. In this study, we seek to identify effective IS to enhance the integration of CCST services into existing HIV programs in Nigeria.

METHODS

Our proposed study has formative and experimental activities across the four phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Through an implementation mapping conducted with stakeholders in the exploration phase, we identified a core package of IS (Core) and an enhanced package of IS (Core+) mostly selected from the Expert Recommendations for Implementing Change. In the preparation phase, we refined and tailored the Core and Core+ IS with the implementation resource teams for local appropriateness. In the implementation phase, we will conduct a cluster-randomized hybrid type III trial to assess the comparative effectiveness of Core versus Core+. HIV comprehensive treatment sites (k = 12) will be matched by region and randomized to Core or Core+ in the ratio of 1:1 stratified by region. In the sustainment phase, we will assess the sustainment of CCST at each site. The study outcomes will be assessed using RE-AIM: reach (screening rate), adoption (uptake of IS by study sites), IS fidelity (degree to which the IS occurred according to protocol), clinical intervention fidelity (delivery of CC screening, onsite treatment, and referral according to protocol), clinical effectiveness (posttreatment screen negative), and sustainment (continued integrated CCST service delivery). Additionally, we will descriptively explore potential mechanisms, including organizational readiness, implementation climate, CCST self-efficacy, and implementation intentions.

DISCUSSION

The assessment of IS to increase CCST rates is consistent with the global plan of eliminating CC as a public health threat by 2030. Our study will identify a set of evidence-based IS for low-income settings to integrate evidence-based CCST interventions into routine HIV care in order to improve the health and life expectancy of WLHIV.

TRIAL REGISTRATION

Prospectively registered on November 7, 2023, at ClinicalTrials.gov no. NCT06128304. https://classic.

CLINICALTRIALS

gov/ct2/show/study/NCT06128304.

Potential risk factors for cardiovascular diseases and associated sociodemographic characteristics: A cross-sectional evaluation of a large cohort of women living with HIV in north-central Nigeria

Males have a higher prevalence of cardiovascular (CVD) risk factors such as alcohol use, hypercholesterolemia, hypertension, obesity, and smoking based on limited data available from two tertiary health centers in Nigeria. Increasing age and lower educational level influence smoking among the same population in northeastern and northwestern Nigeria. Specifically in women living with HIV (WLHIV), the association between demographic characteristics and CVD risk factors has not been described. In a multi-center cross-sectional study, we documented the association of sociodemographic characteristics with potential CVD risk factors among a large cohort of WLHIV attending five treatment sites in north-central Nigeria. This was a cross-sectional study among 5430 women of reproductive age who received antiretrovirals at five selected treatment sites in Benue State, Nigeria. We performed multivariable regression of sociodemographic characteristics on potential cardiovascular risk factors, namely, smoking, alcohol consumption, and contraceptive use. We found participants' mean age was 33.2 (standard deviation: 6.1) years. Prevalence of smoking, alcohol consumption, and contraceptive use were 0.6%, 11%, and 7% respectively. Older WLHIV (≥ 40 years) had a negative association with contraceptive use (aOR: 0.58, 95%CI: 0.42-0.81). Being educated WLHIV had a positive association with contraceptive use (aOR: 1.34, 95%CI: 1.02-1.76) and a negative association with tobacco smoking (aOR: 0.37, 95%CI: 0.16-0.83). Being a farmer had a negative association with alcohol consumption (aOR: 0.43, 95%CI: 0.35-0.52) and contraceptive use (aOR: 0.61, 95%CI: 0.48-0.76). Compared to being married, being in a single relationship had positive association with alcohol consumption (aOR: 1.30, 95%CI: 1.08-1.56) while parenting was associated with 165% higher odds of contraceptive use (aOR: 2.65, 95%CI: 1.73-4.06). In conclusion, the low prevalence of smoking exists among women living with HIV on antiretroviral treatment. Older age, farming and being married are potential deterrents to lifestyle risk factors for cardiovascular diseases among this population. To improve HIV-related treatment efforts and outcomes, implementing interventions aimed at lifestyle behavioral modification among this population has the potential to reduce cardiovascular disease risks.

Changes and gaps of global and regional disease burden of hepatitis B infection in children younger than 5 years old between 2015 and 2019: A real-world data review

Hepatitis B virus (HBV) infection has been declared an ongoing health threat, especially infections among children. We compared and updated the disease burden of HBV infection and the effectiveness of vaccination among children younger than 5 years to offer indications for hepatitis B prevention across the world. The country-level data on the prevalence of hepatitis B surface antigen (HBsAg), the coverages of hepatitis B vaccine birth-dose (HepB-BD), three-dose series (HepB3), income level, population density/size, and human development index were collected from open access databases including WHO, UNICEF, and World Bank. Comparison of the prevalence of HBsAg under 5 years old between 2015 and 2019 based on vaccination coverages was conducted by the gamma generalized linear mixed model. Globally, more than 6.3 million HBV infections were estimated in children under 5 years in 2019, compared to 10.1 million in 2015 within the 179 countries involved. The pooled average prevalence of HBsAg among children younger than 5 years decreased from 1.4% (95% confidence interval [CI]: 1.1-1.8) to 0.9% (95% CI: 0.7-1.2). The rate difference or rate ratio was -0.5% (95% CI: -0.6% to -0.3%) or 0.51(95% CI: 0.44-0.58), respectively. Countries from the African region or with lower income/population density/human development indexes bore the most significant disease burden of hepatitis B. Higher coverages of hepatitis B vaccine birth-dose or primary series correlated with significant HBsAg prevalence decreases and much-decreased ratio, independently. Hepatitis B prevention among children under 5 years has significantly been achieved while remaining the most life-threatening disease burden, unequally distributed worldwide. The hepatitis B vaccination should be prioritized for all newborns, especially in those resource-constrained countries or regions.

Developing the Speaking Out and Allying Relationships Intervention on Videoconference for HIV-Positive GBMSM in Eastern Cape, South Africa

In South Africa, HIV prevalence for gay, bisexual, and men who have sex with men (GBMSM) is as high as 49.5%, yet only 25.7% are taking treatment, resulting in transmission risk between partners and the need for dyadic interventions for men in relationships. Through our preliminary research, we identified the evidence-based intervention Healthy Relationships (HR)-an HIV risk assessment and status disclosure intervention for those in relationships-to be tailored into videoconference format for partnered HIV-positive GBMSM in South Africa. The HR adaptation, called SOAR (Speaking Out & Allying Relationships), applied a human-centered design approach. In-depth interviews were conducted with HIV-positive GBMSM (N = 15) to refine intervention preferences with results used to establish a beta SOAR. A trained interventionist conducted SOAR functionality (n = 6) and usability (n = 7) tests with separate invited groups composed of the original participants interviewed. Field logs, focus group discussions, and a study-specific preference survey were administered. Thematic analysis and descriptive statistics were completed with a convergent analytical approach used to understand usability. Overall experience of GBMSM in SOAR was good (69%) or excellent (31%). More than half of the participants (61%) rated using videoconferencing for SOAR as good, with 38% rating it as fair. All participants stated that SOAR was understandable and satisfactory with willingness to recommend it to other GBMSM. This adaptation approach was effective, and the resultant SOAR intervention has the potential to improve individual coping and HIV communication skills with partners to engage with biomedical prevention and in turn support GBMSM couples.

Rapid implementation mapping to identify implementation determinants and strategies for cervical cancer control in Nigeria

Background

Cervical cancer constitutes a huge burden among women in Nigeria, particularly HIV-infected women. However, the provision and uptake of cervical cancer screening and treatment is limited in Nigeria. Understanding implementation determinants is essential for the effective translation of such evidence-based interventions into practice, particularly in low-resource settings. COVID-19 pandemic necessitated online collaboration making implementation mapping challenging in some ways, while providing streamlining opportunities. In this study, we describe the use of a virtual online approach for implementation mapping (steps 1-3) to identify implementation determinants, mechanisms, and strategies to implement evidence-based cervical cancer screening and treatment in existing HIV infrastructure in Nigeria.

Methods

This study used a mixed methods study design with a virtual modified nominal group technique (NGT) process aligning with Implementation Mapping steps 1-3. Eleven stakeholders (six program staff and five healthcare providers and administrators) participated in a virtual NGT process which occurred in two phases. The first phase utilized online surveys, and the second phase utilized an NGT and implementation mapping process. The Exploration, Preparation, Implementation and Sustainment (EPIS) framework was used to elicit discussion around determinants and strategies from the outer context (i.e., country and regions), inner organizational context of existing HIV infrastructure, bridging factors that relate to bi-directional influences, and the health innovation to be implemented (in this case cervical cancer screening and treatment). During the NGT, the group ranked implementation barriers and voted on implementation strategies using Mentimeter.

Results

Eighteen determinants to integrating cervical cancer screening and treatment into existing comprehensive HIV programs were related to human resources capacity, access to cervical cancer services, logistics management, clinic, and client-related factors. The top 3 determinants included gaps in human resources capacity, poor access to cervical cancer services, and lack of demand for services resulting from lack of awareness about the disease and servicesA set of six core implementation strategies and two enhanced implementation strategies were identified.

Conclusions

Rapid Implementation Mapping is a feasible and acceptable approach for identifying and articulating implementation determinants, mechanisms, and strategies for complex healthcare interventions in LMICs.

Acceptability and user experiences of a patient-held smart card for antenatal services in Nigeria: a qualitative study

BACKGROUND

Poor maternal, newborn and child health outcomes remain a major public health challenge in Nigeria. Mobile health (mHealth) interventions such as patient-held smart cards have been proposed as effective solutions to improve maternal health outcomes. Our objectives were to assess the acceptability and experiences of pregnant women with the use of a patient-held smartcard for antenatal services in Nigeria.

METHODS

Using focus group discussions, qualitative data were obtained from 35 pregnant women attending antenatal services in four Local Government Areas (LGAs) in Benue State, Nigeria. The audio-recorded data were transcribed and analyzed using framework analysis techniques such as the PEN-3 cultural model as a guide.

RESULTS

The participants were 18-44 years of age (median age: 24 years), all were married and the majority were farmers. Most of the participants had accepted and used the smartcards for antenatal services. The most common positive perceptions about the smartcards were their ability to be used across multiple health facilities, the preference for storage of the women's medical information on the smartcards compared to the usual paper-based system, and shorter waiting times at the clinics. Notable facilitators to using the smartcards were its provision at the "Baby showers" which were already acceptable to the women, access to free medical screenings, and ease of storage and retrieval of health records from the cards. Costs associated with health services was reported as a major barrier to using the smartcards. Support from health workers, program staff and family members, particularly spouses, encouraged the participants to use the smartcards.

CONCLUSION

These findings revealed that patient-held smart card for maternal health care services is acceptable by women utilizing antenatal services in Nigeria. Understanding perceptions, barriers, facilitators, and supportive systems that enhance the use of these smart cards may facilitate the development of lifesaving mobile health platforms that have the potential to achieve antenatal, delivery, and postnatal targets in a resource-limited setting.

Scoping review of health information technology usability methods leveraged in Africa

OBJECTIVE

The aim of this study was to explore the state of health information technology (HIT) usability evaluation in Africa.

MATERIALS AND METHODS

We searched three electronic databases: PubMed, Embase, and Association for Computing Machinery. We categorized the stage of evaluations, the type of interactions assessed, and methods applied using Stead's System Development Life Cycle (SDLC) and Bennett and Shackel's usability models.

RESULTS

Analysis of 73 of 1002 articles that met inclusion criteria reveals that HIT usability evaluations in Africa have increased in recent years and mainly focused on later SDLC stage (stages 4 and 5) evaluations in sub-Saharan Africa. Forty percent of the articles examined system-user-task-environment (type 4) interactions. Most articles used mixed methods to measure usability. Interviews and surveys were often used at each development stage, while other methods, such as quality-adjusted life year analysis, were only found at stage 5. Sixty percent of articles did not include a theoretical model or framework.

DISCUSSION

The use of multistage evaluation and mixed methods approaches to obtain a comprehensive understanding HIT usability is critical to ensure that HIT meets user needs.

CONCLUSIONS

Developing and enhancing usable HIT is critical to promoting equitable health service delivery and high-quality care in Africa. Early-stage evaluations (stages 1 and 2) and interactions (types 0 and 1) should receive special attention to ensure HIT usability prior to implementing HIT in the field.

Awareness of HIV serostatus by sex partners of women living with HIV in North-Central Nigeria: correlates and predictive analyses

Non-communication of HIV status among sex partners is a notable hurdle in halting transmission, largely due to socio-cultural factors. This study aimed to predict the determinants of male partners' awareness of women's serostatus. A total of 8825 women of reproductive age living with HIV who were clients at five comprehensive HIV treatment centres in Benue State, North-Central Nigeria were surveyed between June and December 2017, and 6655 reported having a sexual partner at the time of the survey selected for analysis. A regression model was used to estimate the determinants of male partner awareness of serostatus from the perspective of women. Conditional marginal analyses were conducted to evaluate the marginal effects of identified predictors on the probability of outcomes. Partners of married women were found to have greater odds of being aware of their spouse's serostatus (adjusted OR (aOR): 3.20; 95%CI: 2.13-4.81) than non-married partners. Similarly, the odds of male partner awareness increased with the years women had been on antiretroviral therapy (aOR: 1.13; 95%CI: 1.07-1.20). The probability of partners of married respondents being aware of their spouse's HIV serostatus was 97%. The conditional marginal effects of being educated to primary or higher level were 1.2 (95% CI: -0.2 to 2.7) and 1.8 (95% CI: 0.09-3.4) percentage points higher respectively when compared with women with no formal education. Being unemployed or being a trader significantly decreased the probability of partners being aware of respondents' serostatus when compared with farmers; conditional marginal effects of -6.7 (95% CI: -12.0 to -1.4) and -3.9 (95% CI: -5.7 to -2.2) percentage points, respectively. The study found that relationship status and girl-child education are factors that can improve communication of HIV status to sex partners. Policies and interventions aimed at improving the social determinants of health, and social support for healthy communications in relationships, are recommended to reduce HIV transmission between sex partners.

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

Background

Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

Methods

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Results

Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Using Mobile Phone Apps to Deliver Rural General Practitioner Services: Critical Review Using the Walkthrough Method

Background

The widespread use of mobile phones represents new frontiers for improving access to health care. This includes using mobile apps to deliver general practitioner (GP) services in rural areas. However, the wider adoption of apps for increasing access to rural GP services relies on understanding how they might intersect with the rural health system context.

Objective

This research aims to critically review mobile apps for delivering GP services in a rural health service context using the walkthrough method.

Methods

The sample comprised 3 GP service apps under the top 100 list in the medical category in the Apple App Store (also available via the Google Play Store) in Australia as of June 2020. The walkthrough method was applied to extract data and critique the explicit factors, such as the app interface elements, and implicit factors, such as the embedded cultural features related to use for people in rural settings. Data analysis was undertaken between 3 researchers over 6 months applying the walkthrough method and using critical reflection.

Results

There were 3 main themes: improving rural access, addressing rural health care needs, and providing quality of care. App-based GP services may improve rural GP service availability. However, this may be at a relatively superficial level that does not encompass the scope and intensity of the services needed in rural areas (including relevant chronic and emergency care) at a cost that rural patients can afford. The apps showed signs of limited tailoring to the cultural dimensions of rural health care as a barrier to rural use. Patients generally self-selected to use GP service apps with limited support, potentially leading to inappropriate uptake especially by disadvantaged groups with lower health literacy. Although the apps claimed to avail most GP services (70%-80% in some cases), it emerged after enrollment that emergency, complex, and serious conditions might be excluded, potentially imposing more complex caseloads on in-person rural GPs. Apps provided limited information about continuity and coordination of care and sharing information with rural GPs, potentially leading to fragmented and low-quality care. There was commonly no assurance of rural skills and experience of physicians staffing apps despite the wider scope of skills needed to be effective in rural general practice.

Conclusions

GP apps may increase the availability of GP services, but they may require clearer exclusions, appropriate use through decision-making tools, more rural-tailored interfaces, and capacity to align appointment times and costs with patients with complex needs to engage and be useful in a rural context. It is also important to consider how these app-based services could share information with local health care staff for safety and continuity of rural primary care. Finally, information about the physicians’ rural training and experience is critical for quality.

Community based screening for sickle haemoglobin among pregnant women in Benue State, Nigeria: I-Care-to-Know, a Healthy Beginning Initiative

Background

Haemoglobin genotype screening at prenatal care offers women an opportunity to be aware of their genotype, receive education on sickle cell disease (SCD) and may increase maternal demand for SCD newborn screening. In developed countries, most pregnant women who access prenatal care and deliver at the hospital receive haemoglobin genotype screening. In settings with low prenatal care attendance and low hospital deliveries, community-based screening may provide similar opportunity for pregnant women. We assessed the feasibility and acceptability of integrating haemoglobin genotype screening into an existing community-based HIV program.

Methods

Onsite community-based integrated testing for HIV, hepatitis B virus and haemoglobin electrophoresis, were conducted for pregnant women and their male partners. Community Health Advisors implementing the NIH and PEPFAR-supported Healthy Beginning Initiative (HBI) program provided education on SCD, collected blood sample for haemoglobin electrophoresis and provided test results to participants enrolled into the HBI program. We concurrently conducted a cross-sectional study using a pretested, semi-structured, interviewer administered questionnaire to collect demographic data and assess awareness of individual haemoglobin “genotype” among HBI pregnant women participants.

Results

In this study, 99.9% (10,167/10,168) of pregnant women who received education on SCD accepted and completed the survey, had blood drawn for haemoglobin electrophoresis and received their results. A majority of participating pregnant women (97.0%) were not aware of their haemoglobin “genotype”. Among the participants who were incorrect about their haemoglobin “genotype”, 41.1% (23/56) of women who reported their haemoglobin “genotype” as AA were actually AS. The odds of haemoglobin “genotype” awareness was higher among participants who were in younger age group, completed tertiary education, had less number of pregnancies, and attended antenatal care. Overall prevalence of sickle cell trait (AS) was 18.7%.

Conclusions

It is feasible to integrate haemoglobin “genotype” testing into an existing community-based maternal-child program. Most pregnant women who were unaware of their haemoglobin “genotype” accepted and had haemoglobin genotype testing, and received their test results. Increasing parental awareness of their own haemoglobin “genotype” could increase their likelihood of accepting newborn screening for SCD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03974-4.

Ethical Implications of eHealth Tools for Delivering STI/HIV Laboratory Results and Partner Notifications

Purpose of Review

eHealth tools are increasingly utilized for communication with patients. Although efficacious and cost-effective, these tools face several barriers that challenge their ethical use in sexual health. We reviewed literature from the past decade to pick illustrative studies of eHealth tools that deliver results of laboratory tests for sexually transmitted infections, including the human immunodeficiency virus, as well as partner notifications. We describe ethical implications for such technologies.

Recent Findings

Our review found that despite widespread research on the use of eHealth tools in delivering laboratory results and partner notifications, these studies rarely measured or reported on the ethical implications. Such implications can be organized according to the four major principles in bioethics: beneficence, patient autonomy, non-maleficence, and justice. The beneficence of eHealth typically measures efficacy in comparison to existing standards of care. Patient autonomy includes the ability to opt in or out of eHealth tools, right-based principles of consent, and sovereignty over healthcare data. To adhere to the principle of non-maleficence, relevant harms must be identified and measured—such as unintentional disclosure of illness, sexual orientation, or sexual activity. Justice must also be considered to accommodate all users equally, irrespective of their literacy level, with easy-to-use platforms that provide clear messages.

Summary

Based on case studies from this review, we developed a list of recommendations for the ethical development and evaluation of eHealth platforms to deliver STI/HIV results to patients and notifications to partners.

Sero-prevalence and determinants of Hepatitis B among a cohort of HIV-infected women of reproductive age in Nigeria

INTRODUCTION

Sub-Saharan Africa houses over two-thirds of the 37 million people living with human immunodeficiency virus (HIV) globally and of this, 5-20% are co-infected with Hepatitis B virus (HBV). This is double jeopardy, especially for women of reproductive age in these settings, who can transmit both viruses vertically as well as horizontally to their children. The objectives of this study were to investigate the prevalence and determinants of HBV among women of reproductive age living with HIV.

METHODS

This was a cross-sectional study of HIV-infected women of reproductive age in Benue State, Nigeria. Participants were eligible for the study if they were HIV-infected women (ages 18-45 years) receiving care from any of the selected study sites. A global rapid hepatitis B surface antigen (HBsAg) antibody test strip was used to test for HBsAg in plasma. A pretested questionnaire was used to collect data on sociodemographic, clinical and lifestyle characteristics of participants. We estimated prevalence of HBV infection and used multivariable logistic regression to determine factors associated with the infection at a significance level of <0.05.

RESULTS

A total of 6577 women were screened for HBsAg. The prevalence of HBV was 10.3% (95% CI: 9.5-10.9%). Age, parity and male partner's HIV status were found to be associated with having HBV infection. Compared to women older than 40 years, the odds of HBV infection increased significantly with increasing age until age 35 years and decreased significantly with increasing parity (versus no parity). Women with HIV-infected partners and those without a partner had higher odds of HBV infection compared to women with HIV-negative partners.

CONCLUSION

HBV is hyperendemic among HIV-infected women of reproductive age in North Central Nigeria. Specific programs targeting HBV testing, vaccination and treatment of all women of reproductive age need to be developed in this resource-limited, high-need setting.

Towards the elimination of mother-to-child transmission of HIV in Nigeria: a health system perspective of the achievements and challenges

Despite its scaled-up response for prevention of mother-to-child transmission of HIV (PMTCT), Nigeria still contributes the greatest number of infants infected with HIV worldwide. Drawing on our knowledge, and review of policy documents and research papers, we explored the achievements and challenges in the elimination of mother-to-child transmission of HIV in Nigeria using the WHO's health systems framework. We found that Nigeria has increased the number of PMTCT sites, decentralized and integrated PMTCT care for expanded service delivery, adopted task-shifting to address the shortage of skilled healthcare providers, explored alternative sources of domestic funding to bridge the funding gap and harmonized the health management information system to improve data quality. Some of the challenges we identified included: difficulty in identifying HIV-infected pregnant women because of low uptake of antenatal care; interrupted supplies of medical commodities; knowledge gaps among healthcare workers; and lack of a national unique identifying system to enhance data quality. While there have been some achievements in the PMTCT program, gaps still exist in the different blocks of the health system. Elimination of mother-to-child transmission of HIV in Nigeria will require the implementation of feasible, culturally acceptable and sustainable interventions to address the health system-related challenges.

Implementation of eHealth Interventions Across the HIV Care Cascade: a Review of Recent Research

PURPOSE OF REVIEW

We review recent implementation science focusing on eHealth interventions to improve outcomes along the HIV care cascade. We highlight several gaps in the eHealth implementation literature and propose areas for future study.

RECENT FINDINGS

We identified 17 studies conducted in North America, Europe, and sub-Saharan Africa assessing the acceptability, appropriateness, adoption, cost, feasibility, fidelity, penetration, or sustainability of eHealth interventions targeting the HIV care cascade. Most interventions used SMS messages to improve cascade outcomes. Feasibility research has demonstrated the importance of adaptability for intervention scale-up and delivery. Key gaps in the literature remain related to predictors of the adoption of eHealth interventions by health facilities and staff. In addition, no studies explored sustainability and few used theoretical frameworks for implementation research or validated measures of implementation outcomes. We propose next steps for the future of eHealth implementation research to inform the delivery, scale-up, and maintenance of eHealth interventions in the real world.

Viability of diagnostic decision support for antenatal care in rural settings: findings from the Bliss4Midwives Intervention in Northern Ghana

Background

Antenatal screening is useful for early identification and management of high-risk pregnancies. In low-resource settings, provision of the full complement of tests is limited and diagnostic referrals incure additional costs for pregnant women. We assessed the viability of Bliss4Midwives (B4M) - a point-of-care diagnostic decision support device for decentralized screening of pre-eclampsia, gestational diabetes and anaemia during antenatal care (ANC).

Methods

The device was piloted in seven health facilities across two districts in Northern Ghana over a ten-month period. Health workers were expected to screen women at each ANC visit till delivery. All screening records from the device were automatically archived digitally and later downloaded. After removing duplicates or invalid entries, descriptive quantitative analysis was carried out with IBM SPSS Statistics (version 23). B4M usage behavior, diagnostic and referral outcome were analyzed.

Results

Health workers conducted 1323 partial or full antenatal screening on 940 women, resulting in decision support for 835 (88.8%) B4M beneficiaries. Diagnostic referral was eliminated for 708 (84.7%) beneficiaries, with 335 (40.1%) of these from facilities without on-site diagnostic alternatives. Of visits with complete data, 92/559 (16.4%) women were screened in their first trimester, 28/940 (2.9%) had 4+ B4M visits and 107/835 (12.8%) women were recommended for urgent referral to a higher-level facility on the first visit. Follow-up screenings flagged an additional 17 women for urgent referral with 10 cases of repeated alerts in five women. Wide variations between high (9 months use) and low adopting (1.5 months use) facilities were observed, with some similarities in usage trend.

Conclusions

B4M helped decentralize ANC screening and decrease unnecessary referrals. Project outcomes were influenced by implementation strategy, technical features and behavioural dispositions of users and beneficiaries.

Improving Linkage to and Retention in Care in Newly Diagnosed HIV-Positive Patients Using Smartphones in South Africa: Randomized Controlled Trial

Background

South Africa provides free antiretroviral therapy for almost 5 million people living with HIV, but only 71% of the eligible people are on treatment, representing a shortfall in the care cascade, especially among men and youth. Many developing countries have expanded access to smartphones; success in health apps raises the possibility of improving this cascade.

Objective

SmartLink is a health app for Android smartphones providing HIV-related laboratory results, information, support, and appointment reminders to engage and link patients to care. This study aimed to evaluate the ability of SmartLink to improve linkage to care for HIV-positive smartphone owners.

Methods

This study was a multisite randomized controlled trial in Johannesburg. The intervention arm received the app (along with referral to a treatment site) and the control arm received the standard of care (referral alone). Linkage to care was confirmed by an HIV-related blood test reported on the National Health Laboratory Service database between 2 weeks and 8 months after initiation.

Results

A total of 345 participants were recruited into the study; 64.9% (224/345) of the participants were female and 44.1% (152/345) were aged less than 30 years. In addition, 46.7% (161/345) were employed full time, 95.9% (331/345) had at least secondary school education, and 35.9% (124/345) were from Zimbabwe. Linkage to care between 2 weeks and 8 months was 48.6% (88/181) in the intervention arm versus 45.1% (74/164) in the control (P=.52) and increased to 64.1% (116/181) and 61.0% (100/164) (P=.55), respectively, after the initial 8-month period. Moreover, youth aged 18 to 30-years showed a statistically significant 20% increase in linkage to care for the intervention group.

Conclusions

Youth aged less than 30 years have been historically difficult to reach with traditional interventions, and the SmartLink app provides a proof of concept that this population reacts to mobile health interventions that engage patients in HIV care.

Trial Registration

ClinicalTrials.gov NCT02756949; https://clinicaltrials.gov/ct2/show/NCT02756949 (Archived by WebCite at http://www.webcitation.org/6z1GTJCNW)

Pregnant women's experiences with an integrated diagnostic and decision support device for antenatal care in Ghana

Background

Quality antenatal care (ANC) is recognised as an opportunity for screening and early identification of pregnancy-related complications. In rural Ghana, challenges with access to diagnostic services demotivate women from ANC attendance and referral compliance, leading to absent or late identification and management of high-risk women. In 2016, an integrated diagnostic and clinical decision support system tagged ‘Bliss4Midwives’ (B4M), was piloted in Northern Ghana. The device facilitated non-invasive screening of pre-eclampsia, gestational diabetes and anaemia at the point-of-care. This study aimed to explore the experiences of pregnant women with B4M, and its influence on service utilisation (“pull effect”) and woman-provider relationships (“woman engagement”).

Methods

Through an embedded study design, qualitative methods including individual semi-structured interviews and non-participant observation were employed. Interviews were conducted with 20 pregnant women and 10 health workers, supplemented by ANC observations in intervention facilities. Secondary data on ANC registrations over a one-year period were extracted from health facility records to support findings on the perceived influence of B4M on service utilisation.

Results

Women’s first impressions of the device were mostly emotive (excitement, fear), but sometimes neutral. Although it is inconclusive whether B4M increased ANC registration, pregnant women generally valued the availability of diagnostic services at the point-of-care. Additionally, by fostering some level of engagement, the intervention made women feel listened to and cared for. Process outcomes of the B4M encounter also showed that it was perceived as improving the skills and knowledge of the health worker, which facilitated trust in diagnostic recommendations and was therefore believed to motivate referral compliance.

Conclusions

This study suggests that mHealth diagnostic and decision support devices enhance woman engagement and trust in health workers skills. There is need for further inquiry into how these interventions influence maternal health service utilization and women’s expectations of pregnancy care.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1853-7) contains supplementary material, which is available to authorized users.