Building consensus on common features and interoperability use cases for community health information systems: a Delphi study

INTRODUCTION

Information systems for community health have become increasingly sophisticated and evidence-based in the last decade and they are now the most widely used health information systems in many low-income and middle-income countries. This study aimed to establish consensus regarding key features and interoperability priorities for community health information systems (CHISs).

METHODS

A Delphi study was conducted among a systematically selected panel of CHIS experts. This impressive pool of experts represented a range of leading global health institutions, with gender and regional balance as well as diversity in their areas of expertise. Through five rounds of iterative surveys and follow-up interviews, the experts established a high degree of consensus. We supplemented the Delphi study findings with a series of focus group discussions with 10 community health worker (CHW) leaders.

RESULTS

CHISs today are expected to adapt to a wide range of local contextual requirements and to support and improve care delivery. While once associated with a single role type (CHWs), these systems are now expected to engage other end users, including patients, supervisors, clinicians and data managers. Of 30 WHO-classified digital health interventions for care providers, experts identified 23 (77%) as being important for CHISs. Case management and care coordination features accounted for more than one-third (14 of 37, 38%) of the core features expected of CHISs today, a higher proportion than any other category. The highest priority use cases for interoperability include CHIS to health management information system monthly reporting and CHIS to electronic medical record referrals.

CONCLUSION

CHISs today are expected to be feature-rich, to support a range of user roles in community health systems, and to be highly adaptable to local contextual requirements. Future interoperability efforts, such as CHISs in general, are expected not only to move data efficiently but to strengthen community health systems in ways that measurably improve care.

Effect of mobile application user interface improvements on minimum expected home visit coverage by community health workers in Mali: a randomised controlled trial

BACKGROUND

Proactive community case management (ProCCM) has shown promise to advance goals of universal health coverage (UHC). ProCCM community health workers (CHWs) face operational challenges when pursuing their goal of visiting every household in their service area at least twice monthly to proactively find sick patients. We developed a software extension (UHC Mode) to an existing CHW mobile application featuring user interface design improvements to support CHWs in planning daily home visits. We evaluated the effect of UHC Mode on minimum expected home visit coverage.

METHODS

We conducted a parallel-group, two-arm randomised controlled trial of ProCCM CHWs in two separate regions in Mali. CHWs were randomly assigned to UHC Mode or the standard mobile application (control) with a 1:1 allocation. Randomisation was stratified by health catchment area. CHWs and other programme personnel were not masked to arm allocation. CHWs used their assigned intervention for 4 months. Using a difference-in-differences analysis, we estimated the mean change in minimum expected home visit coverage from preintervention to postintervention between arms.

RESULTS

Enrolment occurred in January 2019. Of 199 eligible CHWs randomised to the intervention or control arm, 196 were enrolled and 195 were included in the analysis. Households whose CHW used UHC Mode had 2.41 times higher odds of minimum expected home visit coverage compared with households whose CHW used the control (95% CI 1.68 to 3.47; p<0.0005). Minimum expected home visit coverage in the UHC Mode arm increased 13.6 percentage points (95% CI 8.1 to 19.0) compared with the control arm.

CONCLUSION

Our findings suggest UHC Mode is an effective tool that can improve home visit coverage and promote progress towards UHC when implemented in the ProCCM context. User interface design of health information systems that supports health workers' daily practices and meets their requirements can have a positive impact on health worker performance and home visit coverage.

TRIAL REGISTRATION NUMBER

NCT04106921.

Cost-effectiveness analysis of two-way texting for post-operative follow-up in Zimbabwe's voluntary medical male circumcision program

Objective

Although adverse events (AEs) following voluntary medical male circumcision (VMMC) are rare, their prompt ascertainment and management is a marker of quality care. The use of two-way text messaging (2wT) for client follow-up after VMMC reduces the need for clinic visits (standard of care (SoC)) without compromising safety. We compared the cost-effectiveness of 2wT to SoC for post-VMMC follow-up in two, high-volume, public VMMC sites in Zimbabwe.

Materials and methods

We developed a decision-analytic (decision tree) model of post-VMMC client follow-up at two high-volume sites. We parameterized the model using data from both a randomized controlled study of 2wT vs. SoC and from the routine VMMC program. The perspective of analysis was the Zimbabwe government (payer). The time horizon covered the time from VMMC to wound healing. Costs included text messaging; both in-person and outreach follow-up; and AE management. Costs were estimated in 2018 U.S. dollars. The outcome of analysis was AE yield relative to the globally accepted safety standard of a 2% AE rate. We estimated the incremental cost per percentage increase in AE ascertainment and the incremental cost per additional AE identified. We conducted univariate and probabilistic sensitivity analyses.

Results

2wT increased the costs due to text messaging by $4.42 but reduced clinic visit costs by $2.92 and outreach costs by $3.61 –a net savings of $2.10. 2wT also increased AE ascertainment by 50% (92% AE yield in 2wT compared to 42% AE yield in SoC). Therefore, 2wT dominated SoC in the incremental analysis: 2wT was less costly and more effective. Results were generally robust to univariate and probabilistic sensitivity analysis.

Conclusions

2wT is cost-effective for post-VMMC follow-up in Zimbabwe. Countries in which VMMC is a high-priority HIV prevention intervention should consider this mHealth intervention to reduce overall cost per VMMC, increasing the likelihood of current and future VMMC program sustainability.

Usability and acceptability of a two-way texting intervention for post-operative follow-up for voluntary medical male circumcision in Zimbabwe

BACKGROUND

Voluntary medical male circumcision (MC) is safe and effective. Nevertheless, MC programs require multiple post-operative visits. In Zimbabwe, a randomized control trial (RCT) found that post-operative two-way texting (2wT) between clients and MC providers instead of in-person reviews reduced provider workload and safeguarded patient safety. A critical component of the RCT assessed usability and acceptability of 2wT among providers and clients. These findings inform scale-up of the 2wT approach to post-operative follow-up.

METHODS

The RCT assigned 362 adult MC clients with cell phones into 2wT; these men responded to 13 automated daily texts supported by interactive texting or in-person follow-up, when needed. A subset of 100 texting clients filled a self-administered usability survey on day 14. 2wT acceptability was ascertained via 2wT response rates. Among 2wT providers, eight key informant interviews focused on 2wT acceptability and usability. Influences of wage and age on response rates and client-reported potential AEs were explored using linear and logistic regression models, respectively.

RESULTS

Clients felt confident, comfortable, satisfied, and well-supported with 2wT-based follow-up; few noted texting challenges or concerns about healing. Clients felt 2wT saved them time and money. Response rates (92%) suggested 2wT acceptability. Both clients and providers felt 2wT was highly usable. Providers noted 2wT saved them time, empowered clients to engage in their healing, and closed gaps in MC service quality. For scale, providers reinforced good post-operative counseling on AEs and texting instructions. Wage and age did not influence text response rates or potential AE texts.

CONCLUSION

Results strongly suggest that 2wT is highly usable and acceptable for providers and patients. Men with concerns solicited provider guidance and reassurance offered via text. Providers noted that men engaged proactively in their healing. 2wT between providers and patients should be expanded for MC and considered for other short-term care contexts. The trial is registered on ClinicalTrials.gov, trial NCT03119337, and was activated on April 18, 2017. https://clinicaltrials.gov/ct2/show/NCT03119337.

Prioritising the role of community health workers in the COVID-19 response

COVID-19 disproportionately affects the poor and vulnerable. Community health workers are poised to play a pivotal role in fighting the pandemic, especially in countries with less resilient health systems. Drawing from practitioner expertise across four WHO regions, this article outlines the targeted actions needed at different stages of the pandemic to achieve the following goals: (1) PROTECT healthcare workers, (2) INTERRUPT the virus, (3) MAINTAIN existing healthcare services while surging their capacity, and (4) SHIELD the most vulnerable from socioeconomic shocks. While decisive action must be taken now to blunt the impact of the pandemic in countries likely to be hit the hardest, many of the investments in the supply chain, compensation, dedicated supervision, continuous training and performance management necessary for rapid community response in a pandemic are the same as those required to achieve universal healthcare and prevent the next epidemic.

Testing mHealth solutions at the last mile: insights from a study of technology-assisted community health referrals in rural Kenya

BACKGROUND

mHealth technologies are already disrupting conventional healthcare delivery by making innovative solutions more accessible in terms of reach and price across reach and price across the developing world. However, much less has been documented on the process of mHealth innovation introduction in the context of rural communities of Africa. Pending still is the widespread adoption of standards and the removal of barriers to introduction, testing and scale. This paper documents the innovation process of technology introduction, results and lessons learned through a case study of two mHealth initiatives: closed-loop referrals for maternal and child health; and HIV self-testing. Both initiatives were implemented and evaluated in Kisii County, Kenya by Living Goods.

METHODS

Living Goods applied an innovation framework to introduce and evaluate two interventions integrated into the Living Goods Smart Health app, a smartphone-based digital health application designed to carry out household registration, assessment, and diagnosis at community level. Community health workers (CHWs) used digitally assisted, standardized Ministry of Health algorithms to assess and refer clients to the nearest health facility for diagnosis confirmation and treatment as appropriate. Routine data as well as periodic household surveys were captured to incorporate performance data and outcomes into activity management. A quasi-experimental evaluation was carried out using a Propensity Score Matching (PSM) methodology to evaluate intervention arms for each intervention.

RESULTS

Findings suggest that the initiatives increased the frequency of visits to households with participants in the treatment groups being more likely to have been visited more than six times within the last six months. The interventions contributed in part to an increase in the frequency of CHW follow-up visits within the treatment group. Attitudes of trust and confidence in CHWs were high but limited to referral services and not to diagnostic and curative services.

CONCLUSIONS

The innovation process effectively positioned and tested at community level the two interventions to address key barriers to service delivery acceptance and uptake. Despite extensive pre-testing and field iterations to adapt the solutions to the local context, behavioral and technology barriers persisted. The study highlights important implications for both innovators and service providers: technology introduction and adaptation at community level requires multiple, rapid iteration loops to ensure product refinement and user-acceptance; behavioral assessments of acceptability require a wholistic approach to ensure effective alignment of senders, receivers and trusted intermediaries of novel services.

Human-centered design for global health equity

As digital technologies play a growing role in healthcare, human-centered design is gaining traction in global health. Amid concern that this trend offers little more than buzzwords, our paper clarifies how human-centered design matters for global health equity. First, we contextualize how the design discipline differs from conventional approaches to research and innovation in global health, by emphasizing craft skills and iterative methods that reframe the relationship between design and implementation. Second, while there is no definitive agreement about what the 'human' part means, it often implies stakeholder participation, augmenting human skills, and attention to human values. Finally, we consider the practical relevance of human-centered design by reflecting on our experiences accompanying health workers through over seventy digital health initiatives. In light of this material, we describe human-centered design as a flexible yet disciplined approach to innovation that prioritizes people's needs and concrete experiences in the design of complex systems.

Improving Community Health Worker performance by using a personalised feedback dashboard for supervision: a randomised controlled trial

BACKGROUND

Countries across sub-Saharan Africa are scaling up Community Health Worker (CHW) programmes, yet there remains little high-quality research assessing strategies for CHW supervision and performance improvement. This randomised controlled trial aimed to determine the effect of a personalised performance dashboard used as a supervision tool on the quantity, speed, and quality of CHW care.

METHODS

We conducted a randomised controlled trial in a large health catchment area in peri-urban Mali. One hundred forty-eight CHWs conducting proactive case-finding home visits were randomly allocated to receive individual monthly supervision with or without the CHW Performance Dashboard from January to June 2016. Randomisation was stratified by CHW supervisor, level of CHW experience, and CHW baseline performance for monthly quantity of care (number of household visits). With regression analysis, we used a difference-in-difference model to estimate the effect of the intervention on monthly quantity, timeliness (percentage of children under five treated within 24 hours of symptom onset), and quality (percentage of children under five treated without protocol error) of care over a six-month post-intervention period relative to a three-month pre-intervention period.

RESULTS

Use of the Dashboard during monthly supervision significantly increased the mean number of home visits by 39.94 visits per month (95% CI = 3.56-76.3; P = 0.031). Estimated effects on secondary outcomes of timeliness and quality were positive but not statistically significant. Across both study arms, CHW quantity, timeliness, and quality of care significantly improved over the study period, during which time all CHWs received dedicated monthly supervision, although effects plateaued over time.

CONCLUSIONS

Our findings suggest that dedicated monthly supervision and personalised feedback using performance dashboards can increase CHW productivity. Further operational research is needed to understand how to sustain the performance improvements over time.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03684551).

The Case for Community Health Innovation Networks

This commentary1 outlines the rationale for building community health innovation networks in settings of poverty and high burdens of disease. These networks integrate deep research expertise and sustained implementation infrastructure, with the aim of streamlining the design, building and scale up of evidence-based technical innovations for community health. Drawing on our experiences establishing such networks in Mali and Kenya, we discuss the importance of: 1) sustaining operational capacity to strengthen health systems; 2) being strategic about how we embed design research within ongoing implementation efforts; and 3) institutional partnerships that invest in infrastructure to support a series of studies and innovation efforts over time. Without claiming to offer any ‘quick and easy’ solutions, we argue that this approach has real potential to address the gap between research and practice in technical innovation for global health and sustainable development.

Using Mobile Phones to Improve Vaccination Uptake in 21 Low- and Middle-Income Countries: Systematic Review

Background

The benefits of vaccination have been comprehensively proven; however, disparities in coverage persist because of poor health system management, limited resources, and parental knowledge and attitudes. Evidence suggests that health interventions that engage local parties in communication strategies improve vaccination uptake. As mobile technology is widely used to improve health communication, mobile health (mHealth) interventions might be used to increase coverage.

Objective

The aim of this study was to conduct a systematic review of the available literature on the use of mHealth to improve vaccination in low- and middle-income countries with large numbers of unvaccinated children.

Methods

In February 2017, MEDLINE (Medical Literature Analysis and Retrieval System Online), Scopus, and Web of Science, as well as three health organization websites—Communication Initiative Network, TechNet-21, and PATH—were searched to identify mHealth intervention studies on vaccination uptake in 21 countries.

Results

Ten peer-reviewed studies and 11 studies from white or gray literature were included. Nine took place in India, three in Pakistan, two each in Malawi and Nigeria, and one each in Bangladesh, Zambia, Zimbabwe, and Kenya. Ten peer-reviewed studies and 7 white or gray studies demonstrated improved vaccination uptake after interventions, including appointment reminders, mobile phone apps, and prerecorded messages.

Conclusions

Although the potential for mHealth interventions to improve vaccination coverage seems clear, the evidence for such interventions is not. The dearth of studies in countries facing the greatest barriers to immunization impedes the prospects for evidence-based policy and practice in these settings.

Digital technology for health sector governance in low and middle income countries: a scoping review

BACKGROUND

Poor governance impedes the provision of equitable and cost-effective health care in many low- and middle-income countries (LMICs). Although systemic problems such as corruption and inefficiency have been characterized as intractable, "good governance" interventions that promote transparency, accountability and public participation have yielded encouraging results. Mobile phones and other Information and Communication Technologies (ICTs) are beginning to play a role in these interventions, but little is known about their use and effects in the context of LMIC health care.

METHODS

Multi-stage scoping review: Research questions and scope were refined through a landscape scan of relevant implementation activities and by analyzing related concepts in the literature. Relevant studies were identified through iterative Internet searches (Google, Google Scholar), a systematic search of academic databases (PubMed, Web of Science), social media crowdsourcing (targeted LinkedIn and Twitter appeals) and reading reference lists and websites of relevant organizations. Parallel expert interviews helped to verify concepts and emerging findings and identified additional studies for inclusion. Results were charted, analyzed thematically and summarized.

RESULTS

We identified 34 articles from a wide range of disciplines and sectors, including 17 published research articles and 17 grey literature reports. Analysis of these articles revealed 15 distinct ways of using ICTs for good governance activities in LMIC health care. These use cases clustered into four conceptual categories: 1) gathering and verifying information on services to improve transparency and auditability 2) aggregating and visualizing data to aid communication and decision making 3) mobilizing citizens in reporting poor practices to improve accountability and quality and 4) automating and auditing processes to prevent fraud. Despite a considerable amount of implementation activity, we identified little formal evaluative research.

CONCLUSION

Innovative digital approaches are increasingly being used to facilitate good governance in the health sectors of LMICs but evidence of their effectiveness is still limited. More empirical studies are needed to measure concrete impacts, document mechanisms of action, and elucidate the political and sociotechnical dynamics that make designing and implementing ICTs for good governance so complex. Many digital good governance interventions are driven by an assumption that transparency alone will effect change; however responsive feedback mechanisms are also likely to be necessary.