Identifying Barriers and Facilitators of 13 mHealth Projects in North America and Africa: Protocol for a 5-Year Implementation Science Study

Perceptions of tech-based mental health screening

Background

An estimated one-third of patients experience post-traumatic stress disorder (PTSD) or depression in the year following a traumatic injury. The American College of Surgeons requires postinjury PTSD and depression screening in trauma centers, although implementation has been limited. Tech-based solutions have been proposed to improve uptake of postinjury mental health screening. The goals of this pilot study were to assess the usability and acceptability of Blueprint, a tech-based mental health screening platform, and explore attitudes toward tech-based screening and intervention.

Methods

This pilot study included trauma patients (n=10) admitted to the trauma service. Participants completed the PTSD Checklist-5 and Patient Health Questionnaire-9 using Blueprint to test usability and acceptability of the platform. Participants completed the System Usability Scale (SUS) and a semi-structured interview to assess several domains including attitudes toward tech-based screening, potential barriers to implementation, and its usefulness in a postinjury context. Summative Template Analysis, a data abstraction procedure, was used to analyze qualitative data.

Results

Blueprint received an average SUS score of 93.25/100 suggesting participants found the interface to be an 'excellent' means to assess postinjury mental health concerns. Participants were supportive of universal screening and identified several benefits to engaging in tech-based routine monitoring of postinjury PTSD and depressive symptoms including convenience, personalization, and trauma-informed care. Regarding intervention, patients valued web-based psychoeducation on topics related to their overall care and local resources.

Conclusions

Tech-based mental health screening was highly usable and valuable to trauma patients at risk for postinjury PTSD and depression. Participants valued web-based psychoeducation and resources, but overall preferred Blueprint be used to facilitate access to in-person mental health services. Further evaluation of Blueprint as a means of assessment, intervention, and referral is needed.

Barriers and facilitators of implementing electronic monitors to improve adherence and health outcomes in tuberculosis patients: protocol for a systematic review based on the Consolidated Framework for Implementation Research

BACKGROUND

Tuberculosis (TB) has been regarded as 'a relentless scourge', increasing morbidity and mortality and burdening vulnerable populations. Poor adherence to TB treatment and ineffective traditional interventions hinders TB control. A novel TB approach called 'electronic monitors', equipping medication boxes with daily audio or visual reminders for electronically monitoring medication intake, seems promising in improving adherence and health outcomes and overcoming the weaknesses of traditional interventions. However, no review has systematically examined and synthesized the influencing factors of implementing electronic monitors. Implementation research offers the means to analyse the influencing factors of the implementation and its process, fitting well with the aim of this review. Therefore, the widely recognized Consolidated Framework for Implementation Research (CFIR), which offers a common taxonomy for evaluating intervention implementation, will be adopted to systematically identify barriers and facilitators of the electronic monitors for improving adherence and health outcomes in patients with TB.

METHODS AND ANALYSIS

The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Literature research will be conducted in five electronic databases (Ovid MEDLINE, CINAHL, EMBASE, Cochrane Library and Web of Science) to identify the barriers and facilitators of implementing electronic monitors in patients with TB. The CFIR will be used as a guide for categorizing and synthesizing the barriers and facilitators. Study screening, data extraction, quality appraisal and data analysis will be conducted by two independent reviewers. The use of additional reviewers will solve any disagreements between the two reviewers.

DISCUSSION

Given the increased prominence of TB epidemiology and the adherence problem of electronic monitors, there is a solid rationale for synthesizing the existing studies via the CFIR. The findings and conclusion of this review will lay bare the achievements and effectiveness of implementing electronic monitors, as well as the attendant gaps and limitations. Further strategies for facilitating the implementation of electronic monitors will also be explored. This review will be of essential significance for research and practice, supporting future academic research initiatives centred on patients with TB and aiding electronic monitor design in lowering the morbidity and mortality associated with TB disease.

TRIAL REGISTRATION NUMBER

PROSPERO: CRD42023395747.

SMS-based digital health intervention in Rwanda's home-based care program for remote management of COVID-19 cases and contacts: A qualitative study of sustainability and scalability

Background

COVID-19 pandemic resulted in unprecedented global health challenges. Rwanda identified its first COVID-19 case on March 14, 2020 and subsequently introduced Home-Base Care (HBC) Program in August 2020 following community transmission of the virus and to alleviate logistical and financial strain on the healthcare system. Cases and contacts eligible for HBC were remotely supported by WelTel, an SMS-based mHealth intervention that was successfully implemented before for HIV epidemic in Rwanda. Enrolled cases and contacts were supported and monitored daily via their cell and/or mobile phones until they complete isolation/quarantine period. This study explored the rationale, perspectives, and experiences of key informants (KIs) during the implementation WelTel's mHealth tool for HBC in Rwanda.

Methods

Semi-structured one-on-one virtual interviews were conducted with KIs in this qualitative study. The KIs were classified into 2 major categories: (A) Senior staff including policymakers, directors, and senior managers; (B) Technical teams including case managers, and other staff supporting the implementation of WelTel (e.g., IT staff). Interviews were audio-recorded, transcribed, and analyzed in NVivo. Thematic analysis was conducted using a hybrid approach. A topic guide was developed using the Modified Consolidated Framework for Implementation Research and feedback from local stakeholders.

Results

7 KIs were interviewed. Five themes emerged following thematic analysis including: SMS-Based mHealth for Home-Isolation; Facilitators for Intervention Adoption; Barriers for Intervention Adoption; Infection prevention and control for Home-Isolation; and SMS-Based mHealth for Future Pandemics and Epidemics. Based on interviews, strong political commitment and advanced digital infrastructure were major facilitators for adopting WelTel for HBC. A major barrier to adopting WelTel was identified as technical-based issues. This was followed by local communication culture. All participates agreed on the significance of using WelTel to improve access and adherence to infection prevention and control measures, understand transmission dynamics, and inform public health decision-making regarding HBC.

Conclusions

Rwanda successfully adopted WelTel for supporting and monitoring COVID-19 cases and contacts in home-isolation and the implementation was instrumental to the country's effort to manage the pandemic. Experiences and perspectives of cases and contacts enrolled into WelTel must be explored to understand the appropriateness and effectiveness of the intervention.

Using the Consolidated Framework for Implementation Research to Inform the Design of the Mobile Inspección Visual con Ácido Acético System: Mixed Methods Case Study

Background

There is growing evidence supporting the use of mobile health (mHealth) interventions in low- and middle-income countries to address resource limitations in the delivery of health information and services to vulnerable populations. In parallel, there is an increasing emphasis on the use of implementation science tools and frameworks for the early identification of implementation barriers and to improve the acceptability, appropriateness, and adoption of mHealth interventions in resource-limited settings. However, there are limited examples of the application of implementation science tools and frameworks to the formative phase of mHealth design for resource-limited settings despite the potential benefits of this work for enhancing subsequent implementation, scale-up, and sustainability.

Objective

We presented a case study on the use of an implementation science framework in mHealth design. In particular, we illustrated the usability of the Consolidated Framework for Implementation Research (CFIR) for organizing and interpreting formative research findings during the design of the mobile Inspección Visual con Ácido Acético (mIVAA) system in Lima, Peru.

Methods

We collected formative data from prospective users of the mIVAA intervention using multiple research methodologies, including structured observations, surveys, group and individual interviews, and discussions with local stakeholders at the partnering organization in Peru. These activities enabled the documentation of clinical workflows, perceived barriers to and facilitators of mIVAA, overarching barriers to cervical cancer screening in community-based settings, and related local policies and guidelines in health care. Using a convergent mixed methods analytic approach and the CFIR as an organizing framework, we mapped formative research findings to identify key implementation barriers and inform iterations of the mIVAA system design.

Results

In the setting of our case study, most implementation barriers were identified in the CFIR domains of intervention characteristics and inner setting. All but one barrier were addressed before mIVAA deployment by modifying the system design and adding supportive resources. Solutions involved improvements to infrastructure, including cellular data plans to avoid disruption from internet failure; improved process and flow, including an updated software interface; and better user role definition for image capture to be consistent with local health care laws.

Conclusions

The CFIR can serve as a comprehensive framework for organizing formative research data and identifying key implementation barriers during mHealth intervention design. In our case study of the mIVAA system in Peru, formative research contributing to the CFIR domains of intervention characteristics and inner setting elicited the most key barriers to implementation. The early identification of barriers enabled design iterations before system deployment. Future efforts to develop mHealth interventions for low- and middle-income countries may benefit from using the approach presented in this case study as well as prioritizing the CFIR domains of intervention characteristics and inner setting.

Evaluation of the implementation process of the mobile health platform 'WelTel' in six sites in East Africa and Canada using the modified consolidated framework for implementation research (mCFIR)

BACKGROUND

Health systems globally are investing in integrating secure messaging platforms for virtual care in clinical practice. Implementation science is essential for adoption, scale-up, spread and maintenance of complex evidence-based solutions in clinics with evolving priorities. In response, the mobile Health (mHealth) Research Group modified the existing consolidated framework for implementation research (CFIR) to evaluate implementation of virtual health tools in clinical settings. WelTel® is an evidence-based digital health platform widely deployed in various geographical and health contexts. The objective is to identify the facilitators and barriers for implementing WelTel and to assess the application of the mCFIR tool in facilitating focus groups in different geographical and health settings.

METHODS

Both qualitative and descriptive quantitative approaches were employed. Six mCFIR sessions were held in three countries with 51 key stakeholders. The mCFIR tool consists of 5 Domains and 25 constructs and was distributed through Qualtrics Experience Management (XM). "Performance" and "Importance" scores were valued on a scale of 0 to 10 (Mean ± SD). Descriptive analysis was conducted using R computing software. NVivo 12 Pro software was used to analyze mCFIR responses and to generate themes from the participants' input.

RESULTS

We observed a parallel trend in the scores of Importance and Performance. Of the five Domains, Domain 4 (End-user Characteristics) and Domain 3 (Inner Settings) scored highest in Importance (8.9 ± 0.5 and 8.6 ± 0.6, respectively) and Performance (7.6 ± 0.7 and 7.2 ± 1.3, respectively) for all sites. Domain 2 (Outer Setting) scored the lowest in both Importance and Performance for all sites (7.6 ± 0.4 and 5.6 ± 1.8). The thematic analysis produced the following themes: for areas of strengths, the themes brought up were timely diagnosis and response, cost-effectiveness, and user-friendliness. As for areas for improvement, the themes discussed were training, phone accessibility, stakeholder engagement, and literacy.

CONCLUSION

The mCFIR tool allowed for a comprehensive understanding of the barriers and facilitators to the implementation, reach, and scale-up of digital health tools. Amongst several important findings, we observed the value of bringing the perspectives of both end users (HCPs and patients) to the table across Domains.

TRIAL REGISTRATION

NCT02603536 - November 11, 2015: WelTelOAKTREE: Text Messaging to Support Patients With HIV/AIDS in British Columbia (WelTelOAKTREE). NCT01549457 - March 9, 2012: TB mHealth Study-Use of Cell Phones to Improve Compliance in Patients on LTBI Treatment.

A national intervention to support frail older adults in primary care: a protocol for an adapted implementation framework

BACKGROUND

Older Canadians are high users of health care services, however the health care system is not well-designed to meet the complex needs of many older adults. Older persons often look to their primary care practitioners to assess their needs and coordinate their care. The intervention seeks to improve primary care for older persons living with frailty and will be implemented in six primary care clinics in three Canadian provinces. Presently, more than 1.6 million older Canadians are living with frailty, and this is projected to increase to 2.5 million within a decade (Canadian Frailty Network, Frailty Matters, 2020). The model will include frailty screening, an online portal to expedite referrals and improve coordination with community services, and several tools and techniques to support patient and family engagement and shared decision-making. Our project is guided by the Consolidated Framework for Implementation Research (CFIR) (Damschroder LJ, et al. Implement Scil, 4, 50, 2009). As others have done, we adapted the CFIR for our work. Our adapted framework combines elements of the socio-ecological model, key concepts from the CFIR, and elements from other implementation science frameworks. Nested within a broader mixed-method implementation study, the focus of this paper is to outline our guiding conceptual framework and qualitative methods protocol.

METHODS

We will use the adapted CFIR framework to inform the data we collect and our analytic approach. Our work is divided into three phases: (1) baseline assessment of 'usual care'; (2) tailoring and implementing a new primary care model; and (3) evaluation. In each of these phases we will engage in qualitative data collection, including clinical observations, focus groups, in-depth interviews and extensive field notes. At each site we will collect data with health care providers, key informants (e.g., executive directors), and rostered patients ≥ 70 years. We will engage in team-based analysis across multiple sites, three provinces and two languages through regular telephone conferences, a comprehensive analysis codebook, leadership from our Qualitative Working Group and a collective appreciation that "science is a team sport" (Clinical Orthopaedics and Related Research 471, 701-702, 2013).

DISCUSSION

Outcomes of this research may be used by other research teams who chose to adapt the CFIR framework to reflect the unique contexts of their work, and clinicians seeking to implement our model, or other models of care for frail older patients in primary care.

TRIAL REGISTRATION

U.S. National Library of Medicine, NCT03442426 . Registered 22 February 2018- Retrospectively registered.

[Acceptability and satisfaction with pregnancy and newborn diagnostic assessment (PANDA) system providing prenatal care in Burkina Faso]

Introduction

les technologies mobiles en santé sont de plus en plus utilisées comme solutions innovantes pour améliorer les services de soins prénatals (SPN) dans les soins de première ligne. Cette étude a évalué l´acceptabilité et la satisfaction de l´utilisation du système Pregnancy and Newborn Diagnostic Assessment (PANDA) lors des SPN au Burkina Faso.

Méthodes

une étude transversale utilisant une approche mixte a été menée auprès de 35 utilisatrices des SPN et de 35 agents de santé dans le district sanitaire de Koupéla, dans la région du Centre-Est du Burkina Faso en septembre 2017. Des entretiens et 4 focus groups ont été réalisés auprès des utilisatrices des SPN et des d´entretiens semi-structurés auprès des professionnels de soin. Une analyse descriptive des données quantitatives a été effectuée avec le logiciel SPSS et les données qualitatives ont fait l’objet d´une analyse thématique avec NVivo 10.

Résultats

le système PANDA a été très bien accepté et très apprécié par les utilisatrices et les prestataires de soins. Les motifs de satisfaction chez les utilisatrices étaient l´amélioration des échanges avec les prestataires de soin et l´accès à des soins de meilleure qualité à moindre coût. Les agents de santé ont apprécié la pertinence du système PANDA et l´amélioration des prestations fournies, du suivi et de la prise en charge des femmes enceintes.

Conclusion

le système PANDA est très bien accepté et apprécié au niveau des soins primaires aussi bien par les prestataires de soins que par les utilisatrices de services de soins prénataux au Burkina Faso.

Mobile Phone Access and Willingness Among Mothers to Receive a Text-Based mHealth Intervention to Improve Prenatal Care in Northwest Ethiopia: Cross-Sectional Study

BACKGROUND

Maternal mortality remains high in many low- and middle-income countries where limited access to health services is linked to low antenatal care utilization. Effective communication and engagement with care providers are vital for the delivery and receipt of sufficient health care services. There is strong evidence that simple text-based interventions can improve the prenatal care utilization, but most mobile health (mHealth) interventions are not implemented on a larger scale owing to the lack of context and preliminary evidence on how to make the transition.

OBJECTIVE

The objective of this study was to determine access to mobile phones by pregnant women attending antenatal care as well as willingness to receive a text message (short message service, SMS)-based mHealth intervention for antenatal care services and identify its associated factors among pregnant women attending an antenatal care clinic in Gondar Town Administration, Northwest Ethiopia, Africa.

METHODS

A cross-sectional quantitative study was conducted among 422 pregnant women attending antenatal care from March 27 to April 28, 2017. Data were collected using structured questionnaires. Data entry and analysis were performed using Epi-Info version 7 and SPSS version 20, respectively. In addition, descriptive statistics and bivariable and multivariable logistic regression analyses were performed. Furthermore, odds ratio with 95% CI was used to identify factors associated with the willingness to receive a text message-based mHealth intervention.

RESULTS

A total of 416 respondents (response rate 98.6%, 416/422) were included in the analysis. About 76.7% (319/416) of respondents owned a mobile phone and 71.2% (296/416) were willing to receive an SMS text message. Among the mobile phone owners, only 37.6% (120/319) were having smartphones. Of all women with mobile phones, 89.7% (286/319) described that they are the primary holders of these phones and among them, 85.0% (271/319) reported having had the same phone number for more than a year. Among the phone owners, 90.0% (287/319) described that they could read and 86.8% (277/416) could send SMS text messages using their mobile phones in their day-to-day activities. Among pregnant women who were willing to receive SMS text messages, about 96.3% (285/296) were willing to receive information regarding activities or things to avoid during pregnancy. Factors associated with willingness were youth age group (adjusted odds ratio [AOR] 2.869, 95% CI 1.451-5.651), having attained secondary and higher educational level (AOR 4.995, 95% CI 1.489-14.773), and the frequency of mobile phone use (AOR 0.319, 95% CI 0.141-0.718).

CONCLUSIONS

A high proportion of pregnant women in an antenatal care clinic in this remote setting have a mobile phone and are willing to receive an SMS text message-based mHealth intervention. Age, educational status, and the frequency of mobile phone use are significantly associated with the willingness to receive SMS text message-based mHealth interventions.