Bridging the Human Resource Gap in Primary Health Care Delivery Systems of Developing Countries With mHealth: Narrative Literature Review

Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh

There is an unmet need for phototherapy treatment in low- and middle-income countries (LMICs) to prevent disability and death of newborns with neonatal hyperbilirubinemia. Home phototherapy deployed by community health workers (CHWs) in LMICs may help increase access to essential newborn postnatal care in a more acceptable way for families and lead to an increase in indicated treatment rates for newborns with hyperbilirubinemia. We aimed to investigate the operational feasibility and acceptability of a CHW-led home phototherapy intervention in a rural sub-district of Bangladesh for families and CHWs where home delivery was common and a treatment facility for neonatal hyperbilirubinemia was often more than two hours from households. We enrolled 23 newborns who were ≥ 2 kg in weight and ≥ 35 weeks gestational age, without clinical danger signs, and met the American Academy of Pediatric treatment criteria for phototherapy for hyperbilirubinemia. We employed a mixed-method investigation to evaluate the feasibility and acceptability of home phototherapy through surveys, in-depth interviews and focus group discussions with CHWs, mothers, and grandparents. Mothers and family members found home phototherapy worked well, saved them money, and was convenient and easy to operate. CHWs found it feasible to deploy home phototherapy and identified hands-on training, mHealth job aids, a manageable workload, and prenatal education as facilitating factors for implementation. Feasibility and acceptability concerns were limited amongst parents and included: a lack of confidence in CHWs' skills, fear of putting newborn infants in a phototherapy device, and unreliable home power supply. CHW-led home phototherapy was acceptable to families and CHWs in rural Bangladesh. Further investigation should be done to determine the impact of home phototherapy on treatment rates and on preventing morbidity associated with neonatal hyperbilirubinemia. Clinical Trial (CT) registration ID: NCT03933423, full protocol can be accessed at https://doi.org/10.1186/s13102-024-00824-6 . Name of the trial registry: clinicaltrials.gov. Clinical Trial (CT) registration Date: 01/05/2019.

Mhealth tools for community-based infectious disease surveillance in Africa: a scoping review protocol

INTRODUCTION

Countries in the WHO's African region have found community-based surveillance useful in ensuring the effectiveness of the Integrated Disease Surveillance and Response strategy. This approach encourages community participation in the surveillance system, in addition to early detection of outbreaks and other health threats. Thus, advancements in mobile health have the potential to improve community-based surveillance in Africa. The purpose of this review is to map evidence on available mhealth tools for community-based infectious disease surveillance in Africa.

METHODS AND ANALYSIS

The scoping review will follow a mixed-methods approach in line with the framework of Arksey and O'Malley amended by Levac and colleagues and the Joanna Briggs Institute. To retrieve published literature, PubMed, Scopus, Web of Science, Google Scholar and Google databases will be explored. Websites of organisations involved in surveillance activities across the African region will also be explored. Authors will be interested in published literature between 2000 and 2022 in any language. The primary investigator and a second author will independently review the retrieved titles according to the inclusion criteria, while a third reviewer will resolve conflicts that may arise. The review will map evidence according to the key concepts (mhealth, community-based surveillance and Africa) to inform stakeholders and mhealth designers on best practices to adopt involving mhealth approaches at the community level and mhealth tool designs, respectively. Results following the review will be presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: Extension for Scoping Review Guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required for scoping reviews as it does not involve the use of human subjects. This review is the first phase in an overall project on digital health. The findings of the review will be published in a peer-reviewed journal and disseminated at suitable forums and conferences.

The Health Impact of mHealth Interventions in India: Systematic Review and Meta-Analysis

Background

Considerable use of mobile health (mHealth) interventions has been seen, and these interventions have beneficial effects on health and health service delivery processes, especially in resource-limited settings. Various functionalities of mobile phones offer a range of opportunities for mHealth interventions.

Objective

This review aims to assess the health impact of mHealth interventions in India.

Methods

This systematic review and meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies conducted in India, and published between April 1, 2011, and March 31, 2021, were considered. A literature search was conducted using a combination of MeSH (Medical Subject Headings) terms in different databases to identify peer-reviewed publications. Thirteen out of 1350 articles were included for the final review. Risk of bias was assessed using the Risk of Bias 2 tool for RCTs and Risk Of Bias In Non-randomised Studies - of Interventions tool (for nonrandomized trials), and a meta-analysis was performed using RevMan for 3 comparable studies on maternal, neonatal, and child health.

Results

The meta-analysis showed improved usage of maternal and child health services including iron-folic acid supplementation (odds ratio [OR] 14.30, 95% CI 6.65-30.75), administration of both doses of the tetanus toxoid (OR 2.47, 95% CI 0.22-27.37), and attending 4 or more antenatal check-ups (OR 1.82, 95% CI 0.65-5.09). Meta-analysis for studies concerning economic evaluation and chronic diseases could not be performed due to heterogeneity. However, a positive economic impact was observed from a societal perspective (ReMiND [reducing maternal and newborn deaths] and ImTeCHO [Innovative Mobile Technology for Community Health Operation] interventions), and chronic disease interventions showed a positive impact on clinical outcomes, patient and provider satisfaction, app usage, and improvement in health behaviors.

Conclusions

This review provides a comprehensive overview of mHealth technology in all health sectors in India, analyzing both health and health care usage indicators for interventions focused on maternal and child health and chronic diseases.

Trial Registration

PROSPERO 2021 CRD42021235315; https://tinyurl.com/yh4tp2j7.

Mobile Health Access and Utilisation in Uganda: Knowledge, Attitudes and Perceptions of Health and Veterinary Workers

Background: Despite its strong growth in many parts of the world, mobile health access is still limited in low- and middle-income countries. Among the many factors restricting implementation are the lack of information security, insufficient evidence base, low sensitization, and user acceptance. Limited evidence has been obtained on current practices, perceptions, and user acceptability in such settings. The aim of this study was therefore to evaluate the knowledge, attitude, and perceptions on mobile health use among health workers and veterinary officers in Uganda. Materials and Methods: A cross-section study was carried out, targeting health practitioners in both hospitals and veterinary laboratories/clinics. A structured questionnaire was used to collect data from the Central, Eastern, Northern, and Western representative regions. Interviews with selected health workers were also conducted as well as a focused group discussion. Results: Of the 120 health practitioners that were targeted, a total of 80 health workers and 7 veterinary practitioners participated in the study of which 46% were men and 54% women. Majority of the health workers had encountered m-health but had never used it, whereas the 15 practitioners who had used it before the survey did not use it for disease diagnosis in hospitals but used it for ordering medicine online, for patient consultations with the doctors, result interpretation, tracking women menstrual cycles, tuberculosis assessment. Discussion and Conclusion: Participants expressed significant interest in mobile health as it addresses key challenges including challenges with management of patient data, and long patient queues, which would ultimately improve service delivery. However, there is some skepticism about access as many rural facilities lack access to smartphones and stable internet.

'I understood the texting process well'. Participant perspectives on usability and acceptability of SMS-based telehealth follow-up after voluntary medical male circumcision in South Africa

Background

Voluntary medical male circumcision (MC) is a biomedical HIV prevention method that requires post-operative follow-up for healing confirmation. Recent research found that a two-way texting (2wT) app providing SMS-based telehealth for MC patients was safe and reduced provider workload. We evaluated 2wT usability among MC clients in South Africa assigned the 2wT intervention within a larger randomized controlled trial (RCT) of 2wT safety and workload.

Methods

This quantitative usability study is within an RCT where 547 men used 2wT to interact with an MC provider via SMS. The sub-study involved the first 100 men assigned to 2wT who completed a usability survey 14 days after surgery. Acceptability was assessed through 2wT response rates of the 547 men. Regression models analyzed associations between age, wage, location, potential adverse events (AEs), and 2wT responses.

Results

Men assigned to 2wT found it safe, comfortable, and convenient, reporting time and cost savings. High response rates (88%) to daily messages indicated acceptability. Age, wage, and location didn't affect text responses or potential AEs.

Conclusion

2wT for post-MC follow-up was highly usable and acceptable, suggesting its viability as an alternative to in-person visits. It enhanced confidence in wound self-management. This SMS-based telehealth can enhance MC care quality and be adapted to similar contexts for independent healing support, particularly for men.

The impact of digital communication and data exchange on primary health service delivery in a small island developing state setting

Tuvalu is one of the smallest and most remote countries in the world. Due partly to its geography, the limited availability of human resources for health, infrastructure weaknesses, and the economic situation, Tuvalu faces many health systems challenges to delivering primary health care and achieving universal health coverage. Advancements in information communication technology are anticipated to change the face of health care delivery, including in developing settings. In 2020 Tuvalu commenced installation of Very Small Aperture Terminals (VSAT) at health facilities on remote outer islands to allow the digital exchange of data and information between facilities and healthcare workers. We documented the impact that the installation of VSAT has had on supporting health workers in remote locations, clinical decision-making, and delivering primary health more broadly. We found that installation of VSAT in Tuvalu has enabled regular peer-to-peer communication across facilities; supported remote clinical decision-making and reduced the number of domestic and overseas medical referrals required; and supported formal and informal staff supervision, education, and development. We also found that VSAT's stability is dependent on access to services (such as a reliable electricity supply) for which responsibility sits outside of the health sector. We stress that digital health is not a panacea for all health service delivery challenges and should be seen as a tool (not the solution) to support health service improvement. Our research provides evidence of the impact digital connectivity offers primary health care and universal health coverage efforts in developing settings. It provides insights into factors that enable and inhibit sustainable adoption of new health technologies in low- and middle-income countries.

Identifying Feasible Heart Failure Interventions Suitable for the Jordan Healthcare system: A Delphi Study

Interventions and strategies should align with the context and capacity of the health system. Identifying the most feasible and appropriate heart failure interventions in Jordan will improve heart failure management and clinical outcomes. Therefore, this study aimed to derive consensus from clinicians (using the Delphi method) regarding the most feasible and appropriate heart failure interventions in Jordan. A two-round Delphi study involving seven clinicians and policy makers were conducted. The Delphi results found consensus for the feasibility of the educational materials, follow up phone call, cardiac rehabilitation, group session, and training courses for staff. The components that were not feasible were: multidisciplinary team, individual session, and telemonitoring devices. The present study demonstrates the importance of utilizing interventions tailored to patients' characteristics and aligned with the capacity of healthcare system.

Evaluation of community health worker's performance at home-based newborn assessment supported by mHealth in rural Bangladesh

BACKGROUND

In low to middle-income countries where home births are common and neonatal postnatal care is limited, community health worker (CHW) home visits can extend the capability of health systems to reach vulnerable newborns in the postnatal period. CHW assessment of newborn danger signs supported by mHealth have the potential to improve the quality of danger sign assessments and reduce CHW training requirements. We aim to estimate the validity (sensitivity, specificity, positive and negative predictive value) of CHW assessment of newborn infants aided by mHealth compared to physician assessment.

METHODS

In this prospective study, ten CHWs received five days of theoretical and hands-on training on the physical assessment of newborns including ten danger signs. CHWs assessed 273 newborn infants for danger signs within 48 h of birth and then consecutively for three days. A physician repeated 20% (n = 148) of the assessments conducted by CHWs. Both CHWs and the physician evaluated newborns for ten danger signs and decided on referral. We used the physician's danger sign identification and referral decision as the gold standard to validate CHWs' identification of danger signs and referral decisions.

RESULTS

The referrals made by the CHWs had high sensitivity (93.3%), specificity (96.2%), and almost perfect agreement (K = 0.80) with the referrals made by the physician. CHW identification of all the danger signs except hypothermia showed moderate to high sensitivity (66.7-100%) compared to physician assessments. All the danger signs assessments except hypothermia showed moderate to high positive predictive value (PPV) (50-100%) and excellent negative predictive value (NPV) (99-100%). Specificity was high (99-100%) for all ten danger signs.

CONCLUSION

CHW's identification of neonatal danger signs aided by mHealth showed moderate to high validity in comparison to physician assessments. mHealth platforms may reduce CHW training requirements and while maintaining quality CHW physical assessment performance extending the ability of health systems to provide neonatal postnatal care in low-resource communities.

TRIAL REGISTRATION

clinicaltrials.gov NCT03933423 , January 05, 2019.

Reaching Patients With Noncommunicable Diseases in Rural Tanzania Using Mobile Devices and Community Trust: Qualitative Study

Background

A health service using mobile devices, mobile health (mHealth), has been widely applied to programs focusing on maternal and child health and communicable diseases in sub-Saharan African countries. However, mHealth apps for noncommunicable disease (NCD) services remain limited.

Objective

This study aimed to explore the acceptability and potential usability of SMS text messaging for patients and health care providers for the management of NCDs as part of an implementation research in rural Tanzania.

Methods

Nine focus group discussions were conducted with 56 participants (21 community health workers [CHWs], 17 patients, and 18 health care professionals [HPs]) in 3 districts in the Dodoma region, Tanzania. The interview guides were prepared in Swahili, and each session was recorded, transcribed, and translated into English. The focus group discussions consisted of the following topics: (1) perceptions of the participants about the possible use of mobile devices and SMS text messages as an mHealth platform in community health services; and (2) experiences of mobile device use in health activities or receiving health services via a mobile phone in the past.

Results

CHWs and HPs reported having familiarity using mobile devices to provide health services, especially for reaching or tracing patients in remote settings; however, patients with NCDs were less familiar with the use of mobile devices compared with the other groups. Hesitation to receive health services via SMS text messaging was seen in the patient group, as they wondered who would send health advice to them. Some patients expected services beyond what mHealth could do, such as aiding in recovery from a disease or sending notifications about the availability of prescription medications. CHWs showed interest in using text messaging to provide health services in the community; however, the concerns raised by CHWs included the cost of using their own mobile devices. Moreover, they demanded training about NCD management before engaging in such an activity.

Conclusions

This study explored views and experiences regarding the possible installation of an mHealth intervention for managing NCDs in rural Tanzania. Although HPs and CHWs had experience using mobile devices to provide health services in non-NCD projects, only a few patients (3/17, 17%) had heard about the use of mobile devices to receive health services. To improve the suitability and acceptability of the intervention design for patients with NCDs, their trust must be earned. Involving CHWs in the intervention is recommended because they have already been appointed in the community and already know how to communicate effectively with patients in the area.

Protocol of a parallel group Randomized Control Trial (RCT) for Mobile-assisted Medication Adherence Support (Ma-MAS) intervention among Tuberculosis patients

BACKGROUND

Non-adherence to Tuberculosis (TB) medication is a serious threat to TB prevention and control programs, especially in resource-limited settings. The growth of the popularity of mobile phones provides opportunities to address non-adherence, by facilitating direct communication more frequently between healthcare providers and patients through SMS texts and voice phone calls. However, the existing evidence is inconsistent about the effect of SMS interventions on TB treatment adherence. Such interventions are also seldom developed based on appropriate theoretical foundations. Therefore, there is a reason to approach this problem more rigorously, by developing the intervention systematically with evidence-based theory and conducting the trial with strong measurement methods.

METHODS

This study is a single-blind parallel-group design individual randomized control trial. A total of 186 participants (93 per group) will be individually randomized into one of the two groups with a 1:1 allocation ratio by a computer-generated algorithm. Group one (intervention) participants will receive daily SMS texts and weekly phone calls concerning their daily medication intake and medication refill clinic visit reminder and group two (control) participants will receive the same routine standard treatment care as the intervention group, but no SMS text and phone calls. All participants will be followed for two months of home-based self-administered medication during the continuation phases of the standard treatment period. Urine test for the presence of isoniazid (INH) drug metabolites in urine will be undertaken at the random point at the fourth and eighth weeks of intervention to measure medication adherence. Medication adherence will also be assessed by self-report measurements using the AIDS Clinical Trial Group adherence (ACTG) and Visual Analogue Scales (VAS) questionnaires, and clinic appointment attendance registration. Multivariable regression model analysis will be employed to assess the effect of the Ma-MAS intervention at a significance level of P-value < 0.05 with a 95% confidence interval.

DISCUSSION

For this trial, a mobile-assisted medication adherence intervention will first be developed systematically based on the Medical Research Council framework using appropriate behavioural theory and evidence. The trial will then evaluate the effect of SMS texts and phone calls on TB medication adherence. Evidence generated from this trial will be highly valuable for policymakers, program managers, and healthcare providers working in Ethiopia and beyond.

TRIAL REGISTRATION

The trial is registered in the Pan-Africa Clinical Trials Registry with trial number PACTR202002831201865.

Foldscope as a primary diagnostic tool for oral and urinary tract infections and its effectiveness in oral health education

Due to its speed, accuracy and cost-effectiveness, microscopy has become an integral part of clinical examination for disease diagnosis. However, modern microscopes are very costly and require skilled personnel for their operation and maintenance, and specimen processing and analysis is labour-intensive. Further, lack of such expensive diagnostic tools in remote areas is a serious concern. Affordable point-of-care diagnostic tools are the most useful for timely disease diagnosis and management. The Foldscope is an affordable origami-based microscopy device composed of a series of paper clippings, which, upon assembly, can hold a specimen slide for observation, and this specimen can be viewed via a mobile phone camera attached to it. The present study evaluated the use of the Foldscope in the clinical diagnosis of oral and urinary tract infections and evaluated its efficacy as a motivational tool for improving oral health among school children in India. We qualitatively compared the Foldscope to a clinical microscope by examining five different types of clinical samples. Of the different types of clinical samples, the Foldscope was effective in detecting infection in dental plaque samples and urine samples. Thus, we further analysed 31 dental plaque samples of patients aged 3-13 years and 25 urine samples of patients aged 11-62 years. We also evaluated the use of the Foldscope as an educational tool for motivating oral hygiene among 80 school children aged 12 years and found that students in the Foldscope intervention group had better measures of oral hygiene than did students in the nonintervention group. In summary, our study indicated that the Foldscope is useful in detecting urinary tract infections and kidney stones in urine samples and is a useful motivational tool for oral health education among school-aged children. Furthermore, it may also be useful in oral health monitoring in resource poor settings. LAY DESCRIPTION: Poor and remote population often suffers due to lack of capacity to buy products or avail services which are expensive. In such a society people are not able to afford even the basic detection of diseases. Foldscope may come to rescue here! Foldscope is a paper-based, use-and-throw, affordable microscope. This study explores the use of Foldscope in clinics and diseases diagnosis using patient samples. Preliminary detection of disease associated symptoms in dental and urinary infections and digital record keeping via storage in mobile phone memory and hospital OPD records for monitoring patient's health are some of the advantages of Foldscope for clinical use in resource poor settings. It identifies that Foldscope not only can be used by students or teachers for educational purposes but it can also pave a path for promotion of dental hygiene among young children. The study also suggests that further improvement in design or resolution of Foldscope will broaden the scope of its application, in future.

The Utility of SMS to Report Male Partner HIV Self-testing Outcomes Among Women Seeking Reproductive Health Services in Kenya: Cohort Study

Background

Use of SMS for data collection is expanding, but coverage, bias, and logistical constraints are poorly described.

Objective

The aim of this study is to assess the use of SMS to capture clinical outcomes that occur at home and identify potential biases in reporting compared to in-person ascertainment.

Methods

In the PrEP Implementation in Young Women and Adolescents program, which integrated pre-exposure prophylaxis (PrEP) into antenatal care, postnatal care, and family planning facilities in Kisumu County, Kenya, HIV-negative women 14 years of age or older were offered oral HIV self-tests (HIVSTs) to take home to male partners. Women that brought a phone with a Safaricom SIM to the clinic were offered registration in an automated SMS system (mSurvey) to collect information on HIVST outcomes. Women were asked if they offered the test to their male partners, and asked about the test process and results. HIVST outcomes were collected via SMS (sent 2.5 weeks later), in-person (if women returned for a follow-up scheduled 1 month later), or using both methods (if women initiated PrEP, they also had scheduled follow-up visits). The SMS prompted women to reply at no charge. HIVST outcomes were compared between women with scheduled follow-up visits and those without (follow-up visits were only scheduled for women who initiated PrEP). HIVST outcomes were also compared between women reporting via SMS and in-person.

Results

Among 2123 women offered HIVSTs and mSurvey registration, 486 (23.89%) accepted HIVSTs, of whom 359 (73.87%) were eligible for mSurvey. Additionally, 76/170 (44.7%) women with scheduled follow-up visits and 146/189 (77.3%) without scheduled follow-up visits registered in mSurvey. Among the 76 women with scheduled follow-ups, 62 (82%) had HIVST outcomes collected: 19 (31%) in-person, 20 (32%) by SMS, and 23 (37%) using both methods. Among the 146 women without scheduled visits, 87 (59.6%) had HIVST outcomes collected: 3 (3%) in-person, 82 (94%) by SMS, and 2 (2%) using both methods. SMS increased the collection of HIVST outcomes substantially for women with scheduled follow-up visits (1.48-fold), and captured 82 additional reports from women without scheduled follow-up visits. Among 222 women with reported HIVST outcomes, frequencies of offering partners the HIVST (85/95, 89% in-person vs 96/102, 94% SMS; P=.31), partners using the HIVST (83/85, 98% vs 92/96, 96%; P=.50), women using HIVST with partners (82/83, 99% vs 91/92, 99%; P=.94), and seeing partner’s HIVST results (82/83, 99% vs 89/92, 97%; P=.56) were similar between women reporting in-person only versus by SMS only. However, frequency of reports of experiencing harm or negative reactions from partners was more commonly reported in the SMS group (17/102, 16.7% vs 2/85, 2%; P=.003). Barriers to the SMS system registration included not having a Safaricom SIM or a functioning phone.

Conclusions

Our results suggest that the use of SMS substantially improves completeness of outcome data, does not bias reporting of nonsensitive information, and may increase reporting of sensitive information.  

Sustainability of 'mHealth' interventions in sub- Saharan Africa: a stakeholder analysis of an electronic community case management project in Malawi

Background

The global health community and funding agencies are currently engaged in ensuring that worthwhile research-based programmes are sustainable. Despite its importance, few studies have analysed the sustainability of global health interventions. In this paper, we aim to explore barriers and facilitators for the wider implementation and sustainability of a mobile health (mHealth) intervention (Supporting LIFE Community Case Management programme) in Malawi, Africa.

Methods

Between January and March 2017, a qualitative approach was used to carry out and analyse 13 in-depth semi-structured interviews with key stakeholders across all levels of healthcare provision in Malawi to explore their perceptions with regards to the implementation and sustainability of the mHealth programme. Data were analysed thematically by two reviewers.

Results

Overall, our analysis found that the programme was successful in achieving its goals. However, there are many challenges to the wider implementation and sustainability of this programme, including the absence of monetary resources, limited visibility outside the healthcare sector, the lack of integration with community-based and nationwide programmes, services and information and communication technologies, and the limited local capacity in relation to the maintenance, further development, and management.

Conclusions

Future developments should be aligned with the strategic goals and interests of the Ministry of Health and engage with national and international stakeholders to develop shared goals and strategies for nationwide scale-up. These developments should also focus on building local capacity by educating trainers and ensuring that training methods and guidelines are appropriately accredited based on national policies. Our findings provide a framework for a variety of stakeholders who are engaged in sustaining mHealth programmes in resource-poor settings and can be used to develop an evidence-based policy for the utilization of technology for healthcare delivery across developing countries.

Using mHealth to Deliver a Home-Based Testing and Counseling Program to Improve Linkage to Care and ART Adherence in Rural South Africa

Community-based HIV testing and counseling (HTC) programs have become an important part of the healthcare system in South Africa and other low- and middle-income countries with a high HIV prevalence and strained primary healthcare system. Current HTC programs excel at identifying people living with HIV (PLH) but leave gaps in linkage to care and antiretroviral therapy (ART) as most HTC programs do not have the capacity to ensure that linkage has occurred. This article presents the protocol for an mHealth study, that is, pilot testing a mobile platform in KwaZulu-Natal (KZN), South Africa, to improve linkage to care and ART adherence after home-based HTC. Testing data are shared with designated clinics. PLH are identified using fingerprint scans, mobile numbers, or South African IDs. If PLH do not present at a designated clinic after testing HIV positive, study field staff are sent SMS alerts to prompt follow-up visits. Similarly, if PLH do not refill ART prescriptions after their initial 1-month dose runs out, SMS alerts that are sent to field staff. This paper presents the mHealth study protocol and baseline sample characteristics (N = 101 PLH). Analyses will summarize rates of linkage to care and ART prescription refills. Cost-effectiveness analyses will examine the costs and benefits of linkage and ART adherence using our mHealth system. Linkage to care rates will be compared between our study and a historical control, that is, provided by a prior HTC program that was conducted in KZN without our mHealth system (n = 615).

Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017

INTRODUCTION

The 2018 Astana Declaration reaffirmed global commitment to primary healthcare (PHC) as a core strategy to achieve universal health coverage. To meet this potential, PHC in low-income and middle-income countries (LMIC) needs to be strengthened, but research is lacking and fragmented. We conducted a scoping review of the recent literature to assess the state of research on PHC in LMIC and understand where future research is most needed.

METHODS

Guided by the Primary Healthcare Performance Initiative (PHCPI) conceptual framework, we conducted searches of the peer-reviewed literature on PHC in LMIC published between 2010 (the publication year of the last major review of PHC in LMIC) and 2017. We also conducted country-specific searches to understand performance trajectories in 14 high-performing countries identified in the previous review. Evidence highlights and gaps for each topic area of the PHCPI framework were extracted and summarised.

RESULTS

We retrieved 5219 articles, 207 of which met final inclusion criteria. Many PHC system inputs such as payment and workforce are well-studied. A number of emerging service delivery innovations have early evidence of success but lack evidence for how to scale more broadly. Community-based PHC systems with supportive governmental policies and financing structures (public and private) consistently promote better outcomes and equity. Among the 14 highlighted countries, most maintained or improved progress in the scope of services, quality, access and financial coverage of PHC during the review time period.

CONCLUSION

Our findings revealed a heterogeneous focus of recent literature, with ample evidence for effective PHC policies, payment and other system inputs. More variability was seen in key areas of service delivery, underscoring a need for greater emphasis on implementation science and intervention testing. Future evaluations are needed on PHC system capacities and orientation toward social accountability, innovation, management and population health in order to achieve the promise of PHC.

Patients' Perceptions of mHealth Apps: Meta-Ethnographic Review of Qualitative Studies

BACKGROUND

Mobile phones and tablets are being increasingly integrated into the daily lives of many people worldwide. Mobile health (mHealth) apps have promising possibilities for optimizing health systems, improving care and health, and reducing health disparities. However, health care apps often seem to be underused after being downloaded.

OBJECTIVE

The aim of this paper is to reach a better understanding of people's perceptions, beliefs, and experience of mHealth apps as well as to determine how highly they appreciate these tools.

METHODS

A systematic review was carried out on qualitative studies published in English, on patients' perception of mHealth apps between January 2013 and June 2018. Data extracted from these articles were synthesized using a meta-ethnographic approach and an interpretative method.

RESULTS

A total of 356 articles were selected for screening, and 43 of them met the inclusion criteria. Most of the articles included populations inhabiting developed countries and were published during the last 2 years, and most of the apps on which they focused were designed to help patients with chronic diseases. In this review, we present the strengths and weaknesses of using mHealth apps from the patients' point of view. The strengths can be categorized into two main aspects: engaging patients in their own health care and increasing patient empowerment. The weaknesses pointed out by the participants focus on four main topics: trustworthiness, appropriateness, personalization, and accessibility of these tools.

CONCLUSIONS

Although many of the patients included in the studies reviewed considered mHealth apps as a useful complementary tool, some major problems arise in their optimal use, including the need for more closely tailored designs, the cost of these apps, the validity of the information delivered, and security and privacy issues. Many of these issues could be resolved with more support from health providers. In addition, it would be worth developing standards to ensure that these apps provide patients accurate evidence-based information.

Multistakeholder Perspectives on Maternal Text Messaging Intervention in Uganda: Qualitative Study

Background

Despite continued interest in the use of mobile health for improving maternal health outcomes, there have been limited attempts to identify relevant program theories.

Objectives

This study had two aims: first, to explicate the assumptions of program designers, which we call the program theory and second, to contrast this program theory with empirical data to gain a better understanding of mechanisms, facilitators, and barriers related to the program outcomes.

Methods

To achieve the aforementioned objectives, we conducted a retrospective qualitative study of a text messaging (short message service) platform geared at improving individual maternal health outcomes in Uganda. Through interviews with program designers (n=3), we elicited 3 main designers’ assumptions and explored these against data from qualitative interviews with primary beneficiaries (n=26; 15 women and 11 men) and health service providers (n=6), as well as 6 focus group discussions with village health team members (n=50) who were all involved in the program.

Results

Our study results highlighted that while the program designers’ assumptions were appropriate, additional mechanisms and contextual factors, such as the importance of incentives for village health team members, mobile phone ownership, and health system factors should have been considered.

Conclusions

Our results indicate that text messages could be an effective part of a more comprehensive maternal health program when context and system barriers are identified and addressed in the program theories.

A Participatory System for Preventing Pandemics of Animal Origins: Pilot Study of the Participatory One Health Disease Detection (PODD) System

Background

Aiming for early disease detection and prompt outbreak control, digital technology with a participatory One Health approach was used to create a novel disease surveillance system called Participatory One Health Disease Detection (PODD). PODD is a community-owned surveillance system that collects data from volunteer reporters; identifies disease outbreak automatically; and notifies the local governments (LGs), surrounding villages, and relevant authorities. This system provides a direct and immediate benefit to the communities by empowering them to protect themselves.

Objective

The objective of this study was to determine the effectiveness of the PODD system for the rapid detection and control of disease outbreaks.

Methods

The system was piloted in 74 LGs in Chiang Mai, Thailand, with the participation of 296 volunteer reporters. The volunteers and LGs were key participants in the piloting of the PODD system. Volunteers monitored animal and human diseases, as well as environmental problems, in their communities and reported these events via the PODD mobile phone app. LGs were responsible for outbreak control and provided support to the volunteers. Outcome mapping was used to evaluate the performance of the LGs and volunteers.

Results

LGs were categorized into one of the 3 groups based on performance: A (good), B (fair), and C (poor), with the majority (46%,34/74) categorized into group B. Volunteers were similarly categorized into 4 performance groups (A-D), again with group A showing the best performance, with the majority categorized into groups B and C. After 16 months of implementation, 1029 abnormal events had been reported and confirmed to be true reports. The majority of abnormal reports were sick or dead animals (404/1029, 39.26%), followed by zoonoses and other human diseases (129/1029, 12.54%). Many potentially devastating animal disease outbreaks were detected and successfully controlled, including 26 chicken high mortality outbreaks, 4 cattle disease outbreaks, 3 pig disease outbreaks, and 3 fish disease outbreaks. In all cases, the communities and animal authorities cooperated to apply community contingency plans to control these outbreaks, and community volunteers continued to monitor the abnormal events for 3 weeks after each outbreak was controlled.

Conclusions

By design, PODD initially targeted only animal diseases that potentially could emerge into human pandemics (eg, avian influenza) and then, in response to community needs, expanded to cover human health and environmental health issues.

Mobile microscopy as a screening tool for oral cancer in India: A pilot study

Oral cancer is the most common type of cancer among men in India and other countries in South Asia. Late diagnosis contributes significantly to this mortality, highlighting the need for effective and specific point-of-care diagnostic tools. The same regions with high prevalence of oral cancer have seen extensive growth in mobile phone infrastructure, which enables widespread access to telemedicine services. In this work, we describe the evaluation of an automated tablet-based mobile microscope as an adjunct for telemedicine-based oral cancer screening in India. Brush biopsy, a minimally invasive sampling technique was combined with a simplified staining protocol and a tablet-based mobile microscope to facilitate local collection of digital images and remote evaluation of the images by clinicians. The tablet-based mobile microscope (CellScope device) combines an iPad Mini with collection optics, LED illumination and Bluetooth-controlled motors to scan a slide specimen and capture high-resolution images of stained brush biopsy samples. Researchers at the Mazumdar Shaw Medical Foundation (MSMF) in Bangalore, India used the instrument to collect and send randomly selected images of each slide for telepathology review. Evaluation of the concordance between gold standard histology, conventional microscopy cytology, and remote pathologist review of the images was performed as part of a pilot study of mobile microscopy as a screening tool for oral cancer. Results indicated that the instrument successfully collected images of sufficient quality to enable remote diagnoses that show concordance with existing techniques. Further studies will evaluate the effectiveness of oral cancer screening with mobile microscopy by minimally trained technicians in low-resource settings.

mHealth Interventions for Health System Strengthening in China: A Systematic Review

Background

With rapidly expanding infrastructure in China, mobile technology has been deemed to have the potential to revolutionize health care delivery. There is particular promise for mobile health (mHealth) to positively influence health system reform and confront the new challenges of chronic diseases.

Objective

The aim of this study was to systematically review existing mHealth initiatives in China, characterize them, and examine the extent to which mHealth contributes toward the health system strengthening in China. Furthermore, we also aimed to identify gaps in mHealth development and evaluation.

Methods

We systematically reviewed the literature from English and Chinese electronic database and trial registries, including PubMed, EMBASE, Cochrane, China National Knowledge of Infrastructure (CNKI), and World Health Organization (WHO) International Clinical Trials Registry Platform. We used the English keywords of mHealth, eHealth, telemedicine, telehealth, mobile phone, cell phone, text messaging, and China, as well as their corresponding Chinese keywords. All articles using mobile technology for health care management were included in the study.

Results

A total of 1704 articles were found using the search terms, and eventually 72 were included. Overall, few high quality interventions were identified. Most interventions were found to be insufficient in scope, and their evaluation was of inadequate rigor to generate scalable solutions and provide reliable evidence of effectiveness. Most interventions focused on text messaging for consumer education and behavior change. There were a limited number of interventions that addressed health information management, health workforce issues, use of medicines and technologies, or leadership and governance from a health system perspective.

Conclusions

We provide four recommendations for future mHealth interventions in China that include the need for the development, evaluation and trials examining integrated mHealth interventions to guide the development of future mHealth interventions, target disadvantaged populations with mHealth interventions, and generate appropriate evidence for scalable and sustainable models of care.

Exploring the ambivalent evidence base of mobile health (mHealth): A systematic literature review on the use of mobile phones for the improvement of community health in Africa

BACKGROUND

Africa is labelled the world's fastest-growing 'mobile region'. Considering such growth and the fragility of the continent's healthcare, mHealth has flourished. This review explores mHealth for community health in Africa in order to assess its still ambivalent evidence base.

METHODS

Using PubMed, Web of Science, OvidSP and Google Scholar, a systematic review was conducted of one decade (2005-2015) of peer-reviewed literature on mHealth in Africa. Data analysis focused on qualifications of success and failure. Impact evaluations of project assessments (n = 65) were complemented with general analyses/overviews of mHealth's effectiveness (n = 35).

RESULTS

Review of these texts reveals ambivalence in the appraisal of mHealth; essentially, the critical stance in general analyses/overviews is absent from project assessments. Especially weak evidence concerning sustainability and scalability is stressed in overviews. Project assessments are more optimistic. Their analysis suggests a causal connection between simplicity and success. Effective interventions are thus characterized by straightforward design and modest objectives. Greatest impediments of impact are general technology-related issues and intervention inappropriateness due to insufficient understanding of beneficiaries and specific context of use (circumstantial complications).

CONCLUSION

Distinguishing between these two categories of complications helps to break the deadlock that marks the mHealth debate and add nuance to claims that mHealth's evidence base is weak. Constructive realism - rather than unfounded optimism or pessimism without nuance - should guide the design of interventions. Besides anticipative of technology-related complications, such realism must lead to either basic interventions or to smart mHealth shaped by deep understanding of the context of implementation.

What's Past is Prologue: A Scoping Review of Recent Public Health and Global Health Informatics Literature

OBJECTIVE

To categorize and describe the public health informatics (PHI) and global health informatics (GHI) literature between 2012 and 2014.

METHODS

We conducted a semi-systematic review of articles published between January 2012 and September 2014 where information and communications technologies (ICT) was a primary subject of the study or a main component of the study methodology. Additional inclusion and exclusion criteria were used to filter PHI and GHI articles from the larger biomedical informatics domain. Articles were identified using MEDLINE as well as personal bibliographies from members of the American Medical Informatics Association PHI and GHI working groups.

RESULTS

A total of 85 PHI articles and 282 GHI articles were identified. While systems in PHI continue to support surveillance activities, we identified a shift towards support for prevention, environmental health, and public health care services. Furthermore, articles from the U.S. reveal a shift towards PHI applications at state and local levels. GHI articles focused on telemedicine, mHealth and eHealth applications. The development of adequate infrastructure to support ICT remains a challenge, although we identified a small but growing set of articles that measure the impact of ICT on clinical outcomes.

DISCUSSION

There is evidence of growth with respect to both implementation of information systems within the public health enterprise as well as a widening of scope within each informatics discipline. Yet the articles also illuminate the need for more primary research studies on what works and what does not as both searches yielded small numbers of primary, empirical articles.

CONCLUSION

While the body of knowledge around PHI and GHI continues to mature, additional studies of higher quality are needed to generate the robust evidence base needed to support continued investment in ICT by governmental health agencies.

SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India

Background

Cardiovascular disease (CVD) is the major cause of premature death and disability in India and yet few people at risk of CVD are able to access best practice health care. Mobile health (mHealth) is a promising solution, but very few mHealth interventions have been subjected to robust evaluation in India.

Objective

The objectives were to develop a multifaceted, mobile clinical decision support system (CDSS) for CVD management and evaluate it for use by public nonphysician health care workers (NPHWs) and physicians in a rural Indian setting.

Methods

Plain language clinical rules were developed based on standard guidelines and programmed into a computer tablet app. The algorithm was validated and field-tested in 11 villages in Andhra Pradesh, involving 11 NPHWs and 3 primary health center (PHC) physicians. A mixed method evaluation was conducted comprising clinical and survey data and in-depth patient and staff interviews to understand barriers and enablers to the use of the system. Then this was thematically analyzed using NVivo 10.

Results

During validation of the algorithm, there was an initial agreement for 70% of the 42 calculated variables between the CDSS and SPSS software outputs. Discrepancies were identified and amendments were made until perfect agreement was achieved. During field testing, NPHWs and PHC physicians used the CDSS to screen 227 and 65 adults, respectively. The NPHWs identified 39% (88/227) of patients for referral with 78% (69/88) of these having a definite indication for blood pressure (BP)-lowering medication. However, only 35% (24/69) attended a clinic within 1 month of referral, with 42% (10/24) of these reporting continuing medications at 3-month follow-up. Physicians identified and recommended 17% (11/65) of patients for BP-lowering medications. Qualitative interviews identified 3 interrelated interview themes: (1) the CDSS had potential to change prevailing health care models, (2) task-shifting to NPHWs was the central driver of change, and (3) despite high acceptability by end users, actual transformation was substantially limited by system-level barriers such as patient access to doctors and medicines.

Conclusions

A tablet-based CDSS implemented within primary health care systems has the potential to help improve CVD outcomes in India. However, system-level barriers to accessing medical care limit its full impact. These barriers need to be actively addressed for clinical innovations to be successful.

Trial Registration

Clinical Trials Registry of India: CTRI/2013/06/003753; http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=6259&EncHid=51761.70513&userName=CTRI/2013/06/003753 (Archived by WebCite at http://www.webcitation.org/6UBDlrEuq).

Use of mHealth systems and tools for non-communicable diseases in low- and middle-income countries: a systematic review

With the rapid adoption of mobile devices, mobile health (mHealth) offers the potential to transform health care delivery, especially in the world's poorest regions. We systematically reviewed the literature to determine the impact of mHealth interventions on health care quality for non-communicable diseases in low- and middle-income countries and to identify knowledge gaps in this rapidly evolving field. Overall, we found few high-quality studies. Most studies narrowly focused on text messaging systems for patient behavior change, and few studies examined the health systems strengthening aspects of mHealth. There were limited literature reporting clinical effectiveness, costs, and patient acceptability, and none reporting equity and safety issues. Despite the bold promise of mHealth to improve health care, much remains unknown about whether and how this will be fulfilled. Encouragingly, we identified some registered clinical trial protocols of large-scale, multidimensional mHealth interventions, suggesting that the current limited evidence base will expand in coming years.