"Now You Have Become Doctors": Lady Health Workers' Experiences Implementing an mHealth Application in Rural Pakistan

Efficacy of a Personalized mHealth App in Improving Micronutrient Supplement Use Among Pregnant Women in Karachi, Pakistan: Parallel-Group Randomized Controlled Trial

BACKGROUND

Micronutrient deficiencies in folate, ferritin, calcium, and vitamin D are common during pregnancy in low- and middle-income countries, often due to inadequate diets. Micronutrient supplementation can address this need, whereas innovative awareness strategies in antenatal practices could enhance supplement use compliance.

OBJECTIVE

We evaluated the efficacy of a personalized mobile health (mHealth) intervention, hypothesizing a 30% improvement in supplement use in the intervention group compared to a conventional face-to-face counseling group.

METHODS

In an unblinded randomized controlled trial, we enrolled 306 first-trimester pregnant women from Aga Khan University Hospital between January 2020 and September 2021 who owned smartphones with internet connection. Women on regular medications or with dietary restrictions or critical illnesses were excluded. The intervention group received personalized micronutrient supplement use coaching through an mHealth app (PurUmeed Aaghaz) as thrice-a-week push messages and tailored recommendations over a 24-week period. The comparison group received standard face-to-face counseling at 6, 12, 18, and 24 weeks after enrollment. Baseline sociodemographic, obstetrics, anthropometric, dietary, and lifestyle data were collected through face-to-face interviews. At each follow-up, participants reported their weekly use of folic acid, iron, calcium, and vitamin D supplements, scored as 0 (daily), 1.5 (4-6 times weekly), and 3 (≤3 times weekly). Scores were summed to calculate the cumulative supplement use score (CSUS; 0-12), with higher scores indicating greater inadequacy. Every fourth woman was invited for biochemical micronutrient assessment. Data were analyzed using Stata (version 14), with random-effects linear and logistic panel regression to compare CSUS and supplement use between the 2 groups from baseline to endline.

RESULTS

Of 153 participants per group, 107 (69.9%) in the intervention and 125 (81.7%) in the nonintervention group completed the study. After 24 weeks, the intervention group showed a greater but insignificant reduction in mean CSUS compared to the nonintervention group (β=-.27, 95% CI -0.65 to 0.12; P=.17). Daily supplement use improved by 20% versus 22.4% for folic acid, 11.2 times versus 2.1 times for iron, 1.2 times versus 14.2 times for calcium, and 3 times versus 1.3 times for vitamin D in the intervention versus nonintervention group, respectively. Multivariable analysis showed higher, though insignificant, odds of sufficient folic acid (adjusted odds ratio [aOR] 1.26, 95% CI 0.68-2.36; P=.46) and iron (aOR 1.31, 95% CI 0.95-1.81; P=.10) use in the intervention group, whereas vitamin D use was significantly higher (aOR 1.88, 95% CI 1.43-2.47; P<.001). Calcium intake improved in the nonintervention group (aOR 0.59, 95% CI 0.44-0.79; P<.001). Anemia decreased in the intervention group, whereas ferritin, calcium, and vitamin D deficiencies persisted or worsened, particularly in the nonintervention group.

CONCLUSIONS

An appropriately implemented mHealth intervention can improve antenatal vitamin D supplementation. Affordable, accessible, and personalized counseling through mHealth could ameliorate micronutrient status during pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04216446; https://clinicaltrials.gov/study/NCT04216446.

A qualitative study assessing acceptability and appropriateness of a technology-assisted mental health intervention by community frontline workers: mPareshan implementation research in rural Pakistan

BACKGROUND

With a shortage of mental health specialists and a significant rural population in Pakistan, leveraging community-based healthcare workers becomes crucial to address mental health needs. Equipping the healthcare workers with digital tools such as mobile applications have the potential to increase access to mental health support in low-resource areas. This study examines the acceptability, appropriateness, barriers, and facilitators to implementing a technology-assisted mental health intervention (mPareshan) delivered by Lady Health Workers (LHWs) in rural Pakistan.

METHODS

This is a qualitative study embedded within a larger implementation research trial assessing the feasibility of an mHealth intervention aimed at improving anxiety and depression. 8 focus group discussions and 18 in-depth interviews were conducted. Perceptions were sought before and after intervention from stakeholders comprising of policymakers, LHWs, Lady Health Supervisors (LHSs), and community participants. Data underwent thematic analysis using the RE-AIM framework.

RESULTS

Six main themes emerged from the data. All participants had realization of rising burden of mental illnesses and identified key determinants for mental ill-health. Delivery of mental health counselling by LHWs through a technology-assisted intervention was deemed acceptable and appropriate. LHWs were considered capable and trustworthy by the community to deliver a home-based mHealth intervention, given their easy accessibility as residents of the same community. The technology demonstrated potential for easy adoption as these frontline health workers were already familiar with smartphone technology. Some barriers identified during implementation roll-out included heavy workload of LHWs and difficulty in internet connectivity. Use of videos for counselling, and supportive supervision by LHSs emerged as key facilitators for implementation.

CONCLUSION

This study highlights that a technology-focused mental health intervention is feasible, acceptable, and appropriate to be implemented by community frontline workers in resource-constrained rural Pakistani settings. The mPareshan intervention can be easily adopted within the LHW-P. Further research should investigate how implementation barriers can be addressed for successful delivery.

Global inequities in adverse pregnancy outcomes: what can we do?

The Health Equity Leadership & Exchange Network states that "health equity exists when all people, regardless of race, sex, sexual orientation, disability, socioeconomic status, geographic location, or other societal constructs, have fair and just access, opportunity, and resources to achieve their highest potential for health." It is clear from the wide discrepancies in maternal and infant mortalities, by race, ethnicity, location, and social and economic status, that health equity has not been achieved in pregnancy care. Although the most obvious evidence of inequities is in low-resource settings, inequities also exist in high-resource settings. In this presentation, based on the Global Pregnancy Collaboration Workshop, which addressed this issue, the bases for the differences in outcomes were explored. Several different settings in which inequities exist in high- and low-resource settings were reviewed. Apparent causes include social drivers of health, such as low income, inadequate housing, suboptimal access to clean water, structural racism, and growing maternal healthcare deserts globally. In addition, a question is asked whether maternal health inequities will extend to and be partially due to current research practices. Our overview of inequities provides approaches to resolve these inequities, which are relevant to low- and high-resource settings. Based on the evidence, recommendations have been provided to increase health equity in pregnancy care. Unfortunately, some of these inequities are more amenable to resolution than others. Therefore, continued attention to these inequities and innovative thinking and research to seek solutions to these inequities are encouraged.

Contrasting the Expectations and Experiences of Mobile Health Use on Chronic Pain: A Questionnaire Study (Preprint)

Background

Chronic pain is a prolonged condition that deteriorates one's quality of life. Treating chronic pain requires a multicomponent approach, and in many cases, there are no “silver bullet” solutions. Mobile health (mHealth) is a rapidly expanding category of solutions in digital health with proven potential in chronic pain management.

Objective

This study aims to contrast the viewpoints of 2 groups of people with chronic pain concerning mHealth: people who have adopted the use of mHealth and those who have not. We highlight the benefits of mHealth solutions for people with chronic pain and the perceived obstacles to their increased adoption. We also provide recommendations to encourage people to try mHealth solutions as part of their self-care.

Methods

The Prolific crowdsourcing platform was used to collect crowdsourced data. A prescreening questionnaire was released to determine what type of pain potential participants have and whether they are currently using mHealth solutions for chronic pain. The participants were invited based on their experience using mHealth to manage their pain. Similar questions were presented to mHealth users and nonusers. Qualitative and quantitative analyses were performed to determine the outcomes of this study.

Results

In total, 31 responses were collected from people (aged 19-63 years, mean 31.4, SD 12.1) with chronic pain who use mHealth solutions. Two-thirds (n=20, 65%) of the users identified as female and 11 (35%) as male. We matched these mHealth users with an equal number of nonusers: 31 responses from the pool of 361 participants in the prescreening questionnaire. The nonusers’ ages ranged from 18 to 58 years (mean 30.8, SD 11.09), with 15 (50%) identifying as female and 15 (50%) as male. Likert-scale questions were analyzed using the Mann-Whitney-Wilcoxon (MWW) test. Results showed that the 2 groups differed significantly on 10 (43%) of 23 questions and shared similar views in the remaining 13 (57%). The most significant differences were related to privacy and interactions with health professionals. Of the 31 mHealth users, 12 (39%) declared that using mHealth solutions has made interacting with health or social care professionals easier (vs n=22, 71%, of nonusers). The majority of the nonusers (n=26, 84%) compared with about half of the users (n=15, 48%) expressed concern about sharing their data with, for example, third parties.

Conclusions

This study investigated how mHealth is currently used in the context of chronic pain and what expectations mHealth nonusers have for mHealth as a future chronic pain management tool. Analysis revealed contrasts between mHealth use expectations and actual usage experiences, highlighting privacy concerns toward mHealth solutions. Generally, the results showed that nonusers are more concerned about data privacy and expect mHealth to facilitate interacting with health professionals. The users, in contrast, feel that such connections do not exist.