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mHealth4Afrika-Supporting Primary Healthcare Delivery in Resource Constrained Environments

Authors:

Abstract

mHealth4Afrika is co-designing and validating a modular, multilingual, state of the art health information system to address primary healthcare requirements in resource constrained environments. This platform has been co-designed in partnership with Ministries of Health, district health officers, clinic managers and primary healthcare workers from urban, rural and deep rural clinics in Ethiopia, Kenya, Malawi and South Africa. This paper provides insights into the motivation for this work, the co-design process followed to develop and validate the mHealth4Afrika platform to date, ongoing research and lessons learnt to date. The expected outcome is a multi-country proof of concept that can be adapted to address the requirements of different national health systems. mHealth4Afrika has the potential to make a significant contribution to strengthening primary health delivery in resource constrained environments.
mHealth4Afrika - Supporting Primary Healthcare Delivery
in Resource Constrained Environments
Miriam Cunningham, Paul Cunningham, IIMC / IST-Africa Institute / mHealth4Afrika
miriam@iimg.com, paul@iimg.com, secretariat@IST-Africa.org
(353) - 1 - 8170607
Docklands Innovation Park, 128 East Wall Road, Dublin 3
Ireland
Abstract
mHealth4Afrika is co-designing and validating a modular, multilingual, state of the art
health information system to address primary healthcare requirements in resource
constrained environments. This platform has been co-designed in partnership with
Ministries of Health, district health officers, clinic managers and primary healthcare
workers from urban, rural and deep rural clinics in Ethiopia, Kenya, Malawi and South
Africa. This paper provides insights into the motivation for this work, the co-design
process followed to develop and validate the mHealth4Afrika platform to date, ongoing
research and lessons learnt to date. The expected outcome is a multi-country proof of
concept that can be adapted to address the requirements of different national health
systems. mHealth4Afrika has the potential to make a significant contribution to
strengthening primary health delivery in resource constrained environments.
1. Introduction
1.1 Context
mHealth4Afrika is specifically focused on supporting achievement of Sustainable
Development Goal 3 (SDG3) - Ensure healthy lives and promote well-being for all at all
age. The SDG3 targets include: reduce global maternal mortality ratio to less then 70 per
100,000 live births; end preventable deaths of newborns and children under 5 years of
age; reduce premature mortality from non-communicable diseases through prevention
and treatment by one third and end the epidemics of AIDs, tuberculosis, malaria and
neglected tropical diseases by 2030 (Sustainable Development Goals, UN). While these
are very ambitious targets when compared for example, to the average maternal
mortality ratio in Sub-Saharan Africa (initial focus of mHealth4Afrika) in 2015 of 546 per
100,000 live births (Cunningham et al, 2017), the objectives of mHealth4Afrika are well
aligned with the SDG3 targets.
mHealth4Afrika intervention countries (Ethiopia, Kenya, Malawi, South Africa) have
strong policy commitments in place to support healthcare delivery. They are focused on
increasing access to healthcare including offering free access to maternal healthcare
(antenatal and postnatal care), leveraging technology to increase the efficiency of
primary healthcare delivery more efficiently and address shortfalls in experienced
healthcare professionals in rural and deep rural areas where large populations are
based (Cunningham et al, 2016; African Union Commission, 2014; Federal Democratic
Republic of Ethiopia National Planning Commission, 2015; NESC, 2007; National
Economic Council, 1998; National Planning Commission, South Africa, 2013).
In the context of supporting Universal Health Coverage, there is a growing awareness of
the critical role technological innovation can play in supporting people-centred health
services (Cunningham et al, 2018a, 2018b; WHO, 2016; European Commission, 2014).
The current default data capture method in resource constrained urban, rural and deep
Cunningham, M., Cunningham, P. (2018) mHealth4Afrika - Supporting Primary Healthcare Delivery in Resource Constrained Environments,
Proceedings of 2018 International Conference on Sustainable Development (ICSD)
rural health centres in Ethiopia, Kenya, Malawi and South Africa is paper-based
registries (Cunningham et al, 2016; Cunningham et al, 2018b). The level of detail
captured is constrained based on the physical nature of the registry. It can be
challenging to create a comprehensive medical history for patients who have engaged
with multiple services or attended different health facilities. Data can inadvertently be
duplicated across different program registries. This can create significant problems for
primary healthcare facilities, especially in cases of medical emergency (Cunningham et
al, 2018a). All of these issues have a direct impact on the quality and continuity of care.
Electronic records can include personal health records, electronic medical records and
electronic health records (Moster-Phipps et al, 2012). There is a move towards personal
health records in developing countries where individuals take a more active role in their
health care, leveraging a range of technological applications to monitor health conditions
(e.g., fitness levels, diabetes, blood pressure, heart conditions) as well as interacting
with professional healthcare providers. Electronic medical records (EMR) are digital
versions of the paper-based registries within a specific health facility, while electronic
health records (EHR) are patient-centred records that include past medical history,
allergies, immunisations, radiology images, laboratory results, diagnoses and treatments
(WHO, 2016). WHO highlights that electronic health records enhance patient diagnosis
and treatment through access to accurate and timely patient data (WHO, 2016).
As part of the initial interaction with target intervention health centres identified by
Ministries of Health, mHealth4Afrika identified that none of them had access to a
complete electronic patient record system or electronic medical devices to record patient
data at the point of care (Cunningham et al, 2018a). Based on identifying this gap,
mHealth4Afrika has co-designed an integrated solution to address the health service
delivery needs based on requirements in the initial partner countries (Ethiopia, Kenya,
Malawi, South Africa). This solution is being validated by the intervention health centres.
1.2 mHealth4Afrika Objectives
mHealth4Afrika is co-designing and validating a modular, multilingual, state of the art
health information system to address primary healthcare requirements in resource
constrained environments. This platform has been co-designed in partnership with
Ministries of Health, district health officers, clinic managers and health workers from
urban, rural and deep rural environments in Ethiopia, Kenya, Malawi and South Africa
since November 2015 (Cunningham et al, 2017; Cunningham et al, 2018a). It supports
the adoption of technology at the point of care by integrating electronic medical record
and electronic health record functionality with medical sensors and data visualisation
tools to facilitate the interpretation and monitoring of patient results.
The overall objectives (Cunningham et al, 2017; Cunningham et al, 2018a) include to:
research end-user requirements for rural and deep rural communities in developing
country contexts;
research and evaluate the challenges and potential benefits associated with co-
designing a common multilingual patient record framework that integrates readings
and clinical data from tablets and medical sensors used at the point of care;
train healthcare workers in urban, rural and deep rural clinics on the coordinated,
integrated use of medical sensors and electronic patient records to support more
efficient, high quality healthcare delivery in resource constrained environments and
Cunningham, M., Cunningham, P. (2018) mHealth4Afrika - Supporting Primary Healthcare Delivery in Resource Constrained Environments,
Proceedings of 2018 International Conference on Sustainable Development (ICSD)
pilot and validate an integrated solution addressing the health system requirements
of primary healthcare clinics in Ethiopia, Kenya, Malawi and South Africa to assess
usability, user acceptance and functional and interface related modifications required
to facilitate wider adoption at national, regional and continental level.
mHealth4Afrika aims to provide both direct and indirect contributions to primary
healthcare delivery at health centre level by supporting improvements in: (a) the quality
and impact of primary healthcare delivery through timely capture of information,
systematic storage of important data points in the patient electronic record, and
improved follow up; (b) data quality (by reducing human error); (c) frequency of contact
with a focus on prevention through adoption of state-of-the-art technologies at the point
of care, (d) accuracy, quality and timeliness of monthly aggregate program indicators
and (e) access to educational materials for clinic staff and patients to strengthen digital
literacy and health skills and support preventative care (Cunningham et al, 2018a).
1.3 Insight into Intervention Health Centres
Traditionally validation of technological innovation has taken place in environments with
access to good physical and electronic infrastructure, using a model clinic approach.
mHealth4Afrika took a deliberate approach to engage with resource constrained
intervention health facilities in semi-urban, rural and deep rural locations. The objective
is to gain true insight into real environments where this platform could be adopted by
healthcare professionals. The intervention clinics are based in Northern Ethiopia,
Western Kenya, Southern Malawi and Eastern Cape in South Africa. They were agreed
with the Ministries of Health and district health offices (Cunningham et al, 2018a).
In terms of infrastructure the semi-urban health centres and some of the rural health
centres are connected to the electricity grid. However, some have only intermittent
supply, particularly during the rainy season. Since initial interaction with the other clinics
there have been some positive infrastructure developments in terms of being connected
to the grid or installing solar infrastructure. Most of the health centres now have access
to a 2G or 3G mobile signal. None of the initial participating health centres had a local
area network, WiFi network or Internet access (Cunningham et al, 2017).
Historically, there has been limited use of technology to support healthcare delivery in
participating intervention clinics (Cunningham et al, 2016). Prior to engaging with
mHealth4Afrika, intervention clinics were not using electronic medical devices or an
electronic system to record patient data at the point of care (Cunningham et al, 2017).
Where computers had been installed they were typically used by the clinic manager for
administrative issues including reporting, or used to capture a sub-set of data or monthly
indicators related to a specific program (such as TB or HIV). None of the computers
were networked and there was limited awareness that existing computers could be used
for more than one purpose (Cunningham et al, 2016). Most health facility staff had not
received any on the job formal computer literacy training. Some were self-taught or
received limited training as part of their studies. Nurses in Bungoma Country (Kenya)
and Eastern Cape (South Africa) indicated that they use their personal mobile phones to
communicate with peers via WhatsApp Groups or search for clinical information the on
the Internet (Cunningham et al, 2016). Based on findings captured during the needs
assessment and baseline study, it was necessary to install basic electronic infrastructure
and provide digital literacy training in intervention clinics and ensure that user interfaces
were intuitive and easy to use (Cunningham et al, 2016; Cunningham et al, 2017).
Cunningham, M., Cunningham, P. (2018) mHealth4Afrika - Supporting Primary Healthcare Delivery in Resource Constrained Environments,
Proceedings of 2018 International Conference on Sustainable Development (ICSD)
Most health facilities provide a range of services including antenatal care, postnatal care,
family planning, child under 5 programs (growth and nutrition, immunisation),
tuberculosis, antiretroviral therapy (ART) and general out patient department (OPD).
Some of the larger facilities also provide delivery and cervical cancer screening services.
Most of the intervention health centres in Ethiopia, Kenya and Malawi support large
catchment areas (populations of 25,000 to 50,000) with constrained staffing. As is
normal outside hospitals, none of the intervention health centres have doctors on staff.
Clinic managers are typically either a clinical officer (three year diploma in clinical
medicine) or a degree nurse. Other clinical staff are either degree or diploma nurses.
Larger facilities may also have a pharmacy or laboratory technician on staff
(Cunningham et al, 2016). Health Information Technicians in Ethiopia have a diploma in
health informatics and are responsible for preparing clinic level monthly aggregate
program indicators to be sent to the district health office. All clinics have community-
based healthcare workers (Health Extension Workers in Ethiopia, Community
Healthcare Workers in Kenya and South Africa, Health Surveillance Assistants in
Malawi). In some countries, they may have a certificate. Most have limited formal
training and are supervised by clinic nurses (Cunningham et al, 2016).
1.4 Paper Focus
This paper shares insight into the co-design process followed to date to develop and
validate the mHealth4Afrika platform. Section 2 describes the methodology applied,
while Section 3 provides insights into activities to date and ongoing research. Section 4
presents conclusions and lessons learnt.
2. Methodology
mHealth4Afrika is applying an experimental research strategy, carrying out “an empirical
investigation under controlled conditions designed to examine the properties of, and
relationship between, specific factors" (Denscombe, 2010).
mHealth4Afrika has a number of research threads:
a) researching end-user requirements to inform data sets for programs, workflow and
initial functional requirements in the four beneficiary countries;
b) researching medical sensors appropriate for use in participating health centres;
c) researching the minimum technological infrastructure and minimal level of digital
literacy required to effectively use the platform;
d) technical development of a platform based on the requirements identified; and
e) validating the platform to assess usability, user acceptance and any modifications
required to support wider adoption for primary healthcare service delivery.
Qualitative data collection (incorporating a mix of semi-structured interviews and focus
groups) and ethnographic observations have been used during the needs requirements
and base line study (November 2015 - January 2016, 40 informants from 19 health
centres in the four intervention countries), alpha validation (November - December 2016,
49 participants from 14 health clinics in the intervention countries) and validation of the
first iteration of the beta platform (November - December 2017, 36 participants from 11
health clinics in the intervention countries) (Cunningham et al, 2016; Cunningham et al,
2017; Cunningham et al, 2018). Intensity sampling was the most appropriate approach
Cunningham, M., Cunningham, P. (2018) mHealth4Afrika - Supporting Primary Healthcare Delivery in Resource Constrained Environments,
Proceedings of 2018 International Conference on Sustainable Development (ICSD)
based on the use of purposive sampling techniques (Creswell, 2007; Collins et al, 2007).
Desk research, analysis of World Health Organisation standards, national protocols and
qualitative data collection were used to determine the breadth of data sets across the
four beneficiary countries and workflow required for specific programs and to research
those medical sensors deemed most appropriate based on the requirements of the
health centres and the readings prioritised during the needs requirements study.
Design science research techniques are applied for the technical development whereby
the problem is identified, artefact requirements defined, and the artefact is designed,
developed, demonstrated and evaluated (Johannesson et al, 2012). The regular platform
iterations are implemented using an agile development process. This supports regular
interaction with policy makers, district and clinic managers and healthcare workers as
part of the co-design process to validate the current iteration and prioritise functionality
and data sets for subsequent iteration(s) (Cunningham et al, 2018a).
mHealth4Afrika secured the necessary ethical approval required in each country
(Cunningham et al, 2016; Cunningham et al, 2017; Cunningham et al, 2018a;
Cunningham et al, 2018b). There are no risks to participants based on their contribution
to this study, which is voluntary. Participants are all adults and either nursing school or
university graduates. They are generally fluent in English, and no vulnerable people
were targeted. As highlighted earlier, the intervention clinics/health centres are identified
by the Ministries of Health and district health offices. This study is taking place at a mix
of semi-urban, rural and deep rural health centres in the Amhara Region, Northwest
Ethiopia, Bungoma County, Western Kenya, Zomba and Machinga Districts, Southern
Malawi and Eastern Cape, South Africa. Clinic management signed an Informed
Consent form during Q4 2015 agreeing that data collected throughout the project
duration could be used for the purposes of research, informing policy and associated
publications. To ensure anonymity, each transcript per health facility was allocated a
unique numerical code. With the consent of participants, interviews were audio recorded
to facilitate creating transcripts to complement field notes taken during interviews, which
were analysed leveraging Creswell's Data Analysis Spiral (Creswell, 2007).
3. mHealth4Afrika Activities to Date
3.1 Determining End User Requirements and Designing Programs
As part of the co-design methodology, an extensive consultation was undertaken with
key stakeholders at national level in Ethiopia, Malawi, Kenya and South Africa between
October 2015 and January 2016 to inform the needs requirements and carry out a base
line study. Leveraging a mix of semi-structured interviews, focus groups and analysis of
national protocols, an analysis of the patient record system, user interface, sensor,
linguistic, work flow, privacy and infrastructure requirements was undertaken to inform
the development of the alpha version of the mHealthAfrika platform. The needs
assessment analysed end user profiles, usability and user experience requirements,
health data elements to be captured, and the overall clinical workflows and reporting
requirements related to maternal healthcare delivery (Cunningham et al, 2017).
The baseline study (Cunningham et al, 2016) examined the overall health centre
environment to determine how best to integrate the platform into day-to-day operations
and healthcare workers’ work practices. It also took account of previous exposure to and
Cunningham, M., Cunningham, P. (2018) mHealth4Afrika - Supporting Primary Healthcare Delivery in Resource Constrained Environments,
Proceedings of 2018 International Conference on Sustainable Development (ICSD)
use of technology to determine the potential impact of the adoption of the
mHealth4Afrika platform on the working life of healthcare workers and clinics in different
settings. It provided valuable insights into human resource capacity, practical and
technical challenges, and both equipment and infrastructure related deficits. It also
identified constraints and digital literacy and platform training requirements of healthcare
workers to be considered during the co-design of the mHealth4Afrika platform.
One of the aims of mHealth4Afrika is to design a multi-country proof of concept based
on the needs of four beneficiary countries, that can be adapted to address the
requirements of different national health systems in other intervention countries. Based
on these requirements, it is necessary that the programs incorporate both mandatory
data sets required under national protocols as well as additional data healthcare
professionals wish to capture as part of holistic monitoring of a patient's well being.
The initial use case / program focus was on Antenatal Care including Medical History, as
this is a free service in beneficiary countries with a large data set and complex workflow
(Cunningham et al, 2018a). A detailed analysis was undertaken of the standard paper-
based registries for the four countries to create a super set of data elements. These
were then grouped into relevant program stages and sections (General Examination,
Systemic Examination, Screening, Immunisations and Supplements) to support a useful
workflow. The mandatory data sets identified were compared with the WHO Essential
Interventions for Maternal, newborn and child health (Cunningham et al, 2017). This
analysis identified significant additions required beyond the WHO Essential
Interventions, which were incorporated into the program design of the alpha prototype.
This significantly expanded the datasets to be collected, to create the necessary basic
superset of data points required to validate the mHealth4Afrika alpha prototype. The
alpha validation was very productive, validating data sets and workflow and identifying
additional data sets to include in the first beta iteration (Cunningham et al, 2017).
The programs configured for Beta v1 extended maternal health to cover Antenatal Care,
Delivery and Postnatal Care and the initial Child Under 5 Program structure. The initial
data points in the Child Under 5 program were based on analysis of mandatory national
data sets from child health booklets in the four countries addressing growth and nutrition,
immunisations, vitamin A and deworming. The initial data sets were positively validated
during the beta v1 validation, with the data sets extended to include childhood illnesses
(including cough, fever, diarrhoea, measles, ear problems, sore throat and anaemia).
The program structure and workflow was adjusted based on feedback received for
inclusion in beta v2.
Based on interdependent programs to facilitate holistic monitoring of the patient's well
being, programs prioritised for inclusion in beta v3 included Family Planning, Cervical
Cancer Screening, Tuberculosis (TB), Antiretroviral therapy (ART) and General Out
Patient Department (OPD) consultations. There was extensive interaction with
healthcare staff in the intervention health centres while designing these programs.
3.2 Introducing Medical Sensors at the Point of Care
Medical sensors are primarily used in referral hospitals in the beneficiary countries.
Blood pressure readings in a health centre are typically taken using a traditional arm
blood pressure cuff. As part of the needs requirements, the health centres were asked to
prioritise sensor readings that would be beneficial to take at the point of care. The
Cunningham, M., Cunningham, P. (2018) mHealth4Afrika - Supporting Primary Healthcare Delivery in Resource Constrained Environments,
Proceedings of 2018 International Conference on Sustainable Development (ICSD)
sensors prioritised by the health centres in the four countries included: blood pressure
sensor (Sphygmomanometer); pulse and oxygen in blood sensor (SPO2); Glucometer
sensor; Body temperature sensor (thermometer), haemoglobin and fetoscope (Foetal
activity including pulse rate). Based on agreeing the readings and environmental factors
to be considered, IIMC engaged with a number of European, American and Chinese
sensor manufacturers focused on Sp02, blood pressure, body temperature, glucose and
weight during December 2016 - February 2017. The objective was to identify CE
approved sensors at different price points that would be appropriate for use in semi-
urban, rural and deep rural clinic environments. Sensor manufacturers short listed for
validation purposes included Hemocue (Sweden), Nonin (US) and Visiomed (France).
mHealth4Afrika intervention clinics have access to an oximeter (SpO2, pulse),
glucometer (sugar levels), blood pressure, contactless thermometer, weighing scales
and the HemoCue Hb 201 (haemoglobin). mHealth4Afrika has developed a custom
Android application to support the transfer of sensor readings from BLE CE approved
devices to populate the electronic patient record using proprietary standards. This
Android application is integrated with the mHealth4Afrika database via a Web API and
Oauth2 API to authenticate the user, retrieve up to-date patient records from the
mHealth4Afrika database, search for the patient, capture the sensor reading from
Bluetooth Low Energy sensors, associate sensor readings with a specific patient and
transfer the data using the secure Health Level 7 Fast Healthcare Interoperability
Resources (FHIR)® data communication standard to the electronic patient record
(Cunningham et al, 2018a). The readings are visualised and compared with similar
readings from previous program visits within the mHealth4Afrika platform to facilitate
comparative monitoring of the patient's condition.
The research is focused on determining: a) user acceptance to use medical sensors at
the point of care; b) if this supports preventive care through quicker identification of non-
communicable diseases (such as diabetes and hypertension); c) if sensors can facilitate
adoption of triage and d) if comparative visualisation of the readings captured across
visits support better holistic monitoring of the patient's overall well-being.
3.3 Infrastructure and Training
As outlined previously the initial intervention clinics did not have existing computer
technology to validate the mHealth4Afrika platform during pilot phases. As part of the
needs requirement, the basic hardware required was identified: laptop to be used as
server for storage and retrieval of the patient records; tablets to be used for data
collection and search at the point of care, and WiFi router to support data exchange
between the devices used at the point of care and the server hosting the database.
While traditionally desktop computers are installed in health facilities, mHealth4Afrika
decided to provide a high specification laptop because of the impact of intermittent
electricity,. Some of the more recent intervention clinics in Kenya have some existing
infrastructure in place (server, LAN, thin clients). This will allow us to compare findings
and test the impact of the platform being hosted on a different technical configuration.
The SSIT IST-Africa SIGHT secured a Projects Grant from the IEEE Humanitarian
Activities Committee (HAC) to procure necessary equipment (touch screen laptops, 10-
inch tablets, routers and back up drives) for the initial intervention health centres in
Ethiopia, Malawi and Kenya. This grant also supported the procurement of solar systems
Cunningham, M., Cunningham, P. (2018) mHealth4Afrika - Supporting Primary Healthcare Delivery in Resource Constrained Environments,
Proceedings of 2018 International Conference on Sustainable Development (ICSD)
for several health centres in Malawi and one health centre in Ethiopia, which are
currently not connected to the public grid (Cunningham et al, 2016).
While setting up the technical infrastructure in the health centres, digital literacy training
was undertaken with clinical staff around their clinical responsibilities. Undertaken both
on a one-on-one basis and in small groups, this training focused on how to use the
devices (laptops, tablets) provided and becoming familiar using a computer keyboard as
well as a touch screen. Bluetooth keyboards were provided with the tablets. Valuable
lessons were learnt during the initial digital literacy training, which informed how we
approach digital literacy training with new intervention health centres, to encourage self-
directed learning while staff are not working. To use a health information system, clinical
staff must be trained to type sufficiently confidently and quickly that they have the option
to collect patient data in real time during a consultation (Cunningham et al, 2018a).
Following basic digital literacy training, application training was provided, both in small
groups and on a one-on-one basis as required. Initially clinical staff requested an
electronic application training manual with one printed hard copy per facility as a back up
to the face-to-face training. We have found through experience that supplementing such
manuals with a series of short videos focused on different functionality sets and
programs, is very well received by staff. Tool Tips are also included within the program
data collection forms to support online learning (Cunningham et al, 2018b).
3.4 mHealth4Afrika Platform Iterations
mHealth4Afrika is applying an agile development process. This supports regular
interaction with policy makers, district and clinic managers and healthcare workers as
part of the co-design process to validate the current iteration and prioritise functionality
and data sets to be added to subsequent iteration(s) (Cunningham et al, 2018a).
During Q4 2016, the alpha prototype focused on a use case focused around antenatal
care. This facilitated validation of a common workflow to register patients, set up
healthcare worker access rights, manage patients and capture and retrieve medical data
associated with medical history, obstetric history and ANC1 stages (Cunningham et al,
2017). Based on feedback received during the alpha validation, the first beta iteration
ncluded a more comprehensive functional set, refined user interface, extended program
for maternal health (antenatal care, delivery, postnatal care), first iteration of the Child
under 5 Program and integration of sensor readings in the electronic patient record.
The validation of Beta v1 was undertaken over a longer time period during Q4 2017, with
some of the health centres using the platform on a day-to-day basis for several weeks
prior to the formal validation. They found the Beta v1 functionality to be comprehensive
and intuitive, facilitating setting up system users, assigning access rights, managing
clinic appointments, searching and retrieving patient electronic health records, viewing a
patient overview page with visualisation of vital sign readings over the different ANC
visits, capturing and retrieving patient data related to different visits and capturing vital
sign readings using medical sensors (Cunningham et al, 2018a). The revised program
structure was appreciated, with a number of participants noting that grouping data into
sections provided a de-facto high level check list nurses could use while undertaking a
consultation. They indicated that while using the paper-based registries, clinicians and
nurses mostly take summaries during consultations that may not be sufficiently
methodical or complete due to lack of time. They noted that providing such a checklist
Cunningham, M., Cunningham, P. (2018) mHealth4Afrika - Supporting Primary Healthcare Delivery in Resource Constrained Environments,
Proceedings of 2018 International Conference on Sustainable Development (ICSD)
would help avoid missing capturing necessary details (Cunningham et al, 2018a).
During the pre-beta validation in June 2017 and the Beta v1 validation (November -
December 2017) it became clear that the health centres require a health information
system that allows a patient to be registered once and then enrolled in multiple programs
over a period of time depending on changes in health conditions. This informed a re-
architecture of Beta v2, while v1 was being validated (Cunningham et al, 2018a).
Beta v3, which is now being validated with the health centres, includes a significantly
refined user interface, additional clinic related functionality to support management of
healthcare workers as system users, additional patient and appointments and patient
related functionality supporting access to a range of interdependent programs,
appointments, risk factors, visualisation of program specific readings and reports to
assist in monitoring the patient's condition (Cunningham et al, 2018b).
4. Conclusions and Lessons Learnt
This paper provides insights into the co-design process followed to design programs,
develop and validate the mHealth4Afrika platform on a cross border basis to date.
4.1 Lessons Learnt
Importance of Active Engagement with End Users
Too often in the past eHealth/mHealth projects have primarily been technology push. To
meet the overall goal of mHealth4Afrika it is necessary to take a User-centered Design,
Collaborative Open Innovation based approach (Cunningham et al, 2016). A
combination of the co-design and agile development process has been very beneficial to
inform different iterations and facilitate active engagement. The objective was to ensure
the platform meets the day-to-day requirements of the health centres in terms of
usability, functionality and programs. The importance of interventions taking account of
information needs at different stages in the continuum of care is well documented in
literature (e.g. Bhutta et al, 2010; Cooper, 2013; Kerber et al, 2007; Obasola et al, 2015).
Importance of Being Reactive
A co-design approach also requires the research team to be responsive to feedback
received and willing to make necessary modifications to reflect user requirements.
mHealth4Afrika's initial focus was on addressing maternal and newborn healthcare
delivery. However, during the pre-beta validation and Beta v1 validation the health
centres indicated that while they appreciated the comprehensive programs being
developed, they needed a platform that supported a range of interdependent programs
to facilitate holistic monitoring of a patient's well being (Cunningham et al, 2018a).
Family planning and cervical cancer screening were seen to be natural extensions of
maternal health. TB and ART programs were prioritised based on the number of clients
who may initially visit the health centre for antenatal care and subsequently be enrolled
in these programs. The functionality required to support single enrolment and adding
multiple programs required a re-architecture of the platform. While it required
reallocation of resources to prioritise this technical work and program design, the net
result is that the platform is more useful to the health centres. It is important to be willing
to reallocate project resources to have the best overall impact.
Cunningham, M., Cunningham, P. (2018) mHealth4Afrika - Supporting Primary Healthcare Delivery in Resource Constrained Environments,
Proceedings of 2018 International Conference on Sustainable Development (ICSD)
Value to Taking a Cross-Border Approach
While it was considered ambitious for mHealth4Afrika to take a cross border approach
and to target non-conventional validation sites, this has been very valuable. Designing
programs that address the requirements of four national protocols has helped identify
common aspects that may be beneficial to other health centres in monitoring patient's
conditions, while still addressing country specific requirements. Developing a health
information system that simply replicates a paper-based registry often designed a long
time ago is short sighted. The amount of data that can be captured in a paper-based
registry is restricted by the size of the registries and the prioritisation of data sets based
on best practice at a point in time. The program design in mHealth4Afrika provides the
ability to capture all mandatory data sets as well as capturing additional data for more
complicated cases. We leverage conditional rendering / skip logic to facilitate additional
information to be collected based on responses to prioritised questions. When all the
programs have been fully validated in the beneficiary countries, we welcome the
opportunity to also validate them with countries that did not participate in the initial co-
design to get inputs on usability, functionality and program designs.
4.2 Ongoing Research
Functionality prioritised for inclusion in Beta v4 includes automatic counting of
aggregated monthly program indicators and SMS notifications for patient appointments.
Research is ongoing on integration of medical sensor readings from across all programs.
Acknowledgements
This research was co-funded by the European Commission under the Horizon 2020
Research and Innovation Framework Programme (mHealth4Afrika, Grant Agreement
No. 688015). The interpretation of the results is the sole responsibility of the primary
researchers. The researchers would like to thank representatives of Ministries of Health,
district health offices, clinic managers and healthcare staff in resource constrained
health facilities in Ethiopia, Kenya, Malawi and South Africa who participated in the
project activities, for their invaluable contributions and insight. The researchers would
like to thank the mHealth4Afrika partners for their ongoing activities.
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Cunningham, M., Cunningham, P. (2018) mHealth4Afrika - Supporting Primary Healthcare Delivery in Resource Constrained Environments,
Proceedings of 2018 International Conference on Sustainable Development (ICSD)
... This platform has been co-designed in partnership with Ministries of Health, district health officers, clinic managers and health workers from urban, rural and deep rural environments in Ethiopia, Kenya, Malawi and South Africa since November 2015 [1,6]. It supports the adoption of technology at the point of care by integrating electronic medical record and electronic health record functionality with medical sensors and data visualisation tools to facilitate the interpretation and monitoring of patient results [3] Its initial focus was supporting timely capture and systemic storage of patient data for maternal and child programs in primary healthcare facilities in Ethiopia, Kenya, Malawi and South Africa. This focus reflects two issues -the dramatic divergence between the Sustainable Development Goal 3 (SDG3) target of reducing global maternal mortality ratio to less then 70 per 100,000 live births [13] and the 2015 average of 546 per 100,000 live births in Sub-Saharan Africa [3,6] and that in response to this crisis, African governments provide free ante-natal care. ...
... It supports the adoption of technology at the point of care by integrating electronic medical record and electronic health record functionality with medical sensors and data visualisation tools to facilitate the interpretation and monitoring of patient results [3] Its initial focus was supporting timely capture and systemic storage of patient data for maternal and child programs in primary healthcare facilities in Ethiopia, Kenya, Malawi and South Africa. This focus reflects two issues -the dramatic divergence between the Sustainable Development Goal 3 (SDG3) target of reducing global maternal mortality ratio to less then 70 per 100,000 live births [13] and the 2015 average of 546 per 100,000 live births in Sub-Saharan Africa [3,6] and that in response to this crisis, African governments provide free ante-natal care. A free healthcare service is likely to experience higher levels of take-up and influence whether families will then use paid services. ...
... The overall objectives of mHealth4Afrika [1,3,6] include to: • research and evaluate the challenges and potential benefits associated with co-designing a common multilingual patient record framework that integrates readings and clinical data from tablets and medical sensors used at the point of care; • research end-user requirements for resource constrained communities in developing country contexts to inform data sets for programs, workflow and initial functional requirements in the four beneficiary countries; • train healthcare workers on the coordinated, integrated use of medical sensors and electronic patient records to support more efficient, high quality healthcare delivery, and • pilot and validate an integrated solution addressing health system requirements of primary healthcare centres in Ethiopia, Kenya, Malawi and South Africa to assess usability, user acceptance and functional and interface adaptation required to facilitate wider national and international adoption. mHealth4Afrika aims to provide direct and indirect contributions to primary healthcare delivery in resource constrained environments by supporting improvements in: (a) the quality and impact of primary healthcare delivery through timely capture of information, systematic storage of important data points in the patient electronic record, and improved follow up; (b) data quality (by reducing human error); (c) frequency of contact with a focus on prevention through adoption of state-of-the-art technologies at the point of care, (d) accuracy, quality and timeliness of monthly aggregate program indicators and (e) access to educational materials for health centre staff and patients to strengthen digital literacy and health skills and support preventative care [1,3]. ...
Conference Paper
Full-text available
Supported by the European Commission, mHealth4Afrika is co-designing and validating a modular, multilingual, state of the art health information system to address primary healthcare requirements in resource constrained environments. This platform has been co-designed in partnership with Ministries of Health, district health officers, clinic managers and primary healthcare workers from urban, rural and deep rural health centres in Ethiopia, Kenya, Malawi and South Africa. This paper provides insights into environment within which this platform is being co-designed and validated and discusses challenges and opportunities associated with co-designing a cross-border solution. While co-designing a solution optimized for subsequent adaptation with only limited need for scarce programming resources is demanding, the flexibility created can make a significant contribution to strengthening primary health delivery at scale in resource constrained environments.
... Paper-based registries are still the default data capture method in most primary healthcare facilities in resource constrained environments, particularly in Africa [2,3,6,7]. mHealth4Afrika has co-designed a modular, multilingual, state-of-the-art health information system, aimed at strengthening healthcare delivery in resource constrained environments [2, 4 -7]. It integrates Electronic Medical Record (EMR) with Electronic Health Record (EHR) functionality, medical sensors, data visualization and decision support tools to facilitate interpretation and holistic patient monitoring [2,6,7]. ...
... mHealth4Afrika has co-designed a modular, multilingual, state-of-the-art health information system, aimed at strengthening healthcare delivery in resource constrained environments [2, 4 -7]. It integrates Electronic Medical Record (EMR) with Electronic Health Record (EHR) functionality, medical sensors, data visualization and decision support tools to facilitate interpretation and holistic patient monitoring [2,6,7]. mHealth4Afrika incorporates an extensive set of programs (Medical History for adults and children, Obstetric History, Maternal Program, Family Planning, Cervical Cancer Screening, Child Under 5, Tuberculosis, Antiretroviral therapy, Diabetes, General and some specialist Outpatient Department) and functionality prioritised by participating key stakeholders. ...
... mHealth4Afrika incorporates an extensive set of programs (Medical History for adults and children, Obstetric History, Maternal Program, Family Planning, Cervical Cancer Screening, Child Under 5, Tuberculosis, Antiretroviral therapy, Diabetes, General and some specialist Outpatient Department) and functionality prioritised by participating key stakeholders. It supports realisation of SDG3 [1], by supporting effective technology adoption at the point of care and providing evidence of how adoption of appropriate technological innovation can support people-centered health services [2,6,7,20]. ...
Conference Paper
Full-text available
Supported by the European Commission under Horizon 2020, mHealth4Afrika is co-designing and validating a modular, multilingual, state-of-the-art primary healthcare platform for use in resource constrained environments. Based on active consultation and collaboration with Ministries of Health (MoH), district health officers, clinic managers and primary healthcare workers from urban, rural and deep rural health centres in Ethiopia, Kenya, Malawi and South Africa, mHealth4Afrika has co-designed a comprehensive range of health programs and associated functionality. This paper provides insights into how mHealth4Afrika is supporting a holistic, patient-centric, standards-based "cradle to grave" approach to replacing paper-based registries and program-specific (or siloed) electronic solutions installed in many cases by donors targeting specific diseases. mHealth4Afrika is a HL7 FHIR-based platform integrating Electronic Medical Record (EMR) and Electronic Health Record (EHR) functionality, leveraging medical sensors and decision support at the point of care, saving time associated with monthly aggregate data reporting and encouraging attendance through SMS communications with clients and community health workers.
... While electronic patient records are gradually being introduced into larger hospitals in Ethiopia, Kenya, Malawi and South Africa (current mHealth4Afrika beneficiary countries), paper-based registries [1,2,[5][6][7] remain the default data capture method in resource constrained urban, rural and deep rural health facilities. mHealth4Afrika supports the objectives of UN Sustainable Development Goal 3 (SDG3) by co-designing a comprehensive, patient-centric health platform that is adaptable and extensible, modular and multilingual [1 -6]. ...
... mHealth4Afrika has co-designed a comprehensive range of medical programs supporting easy and systematic data capture, storage and searching of patient centric data. Based on priorities of initial intervention countries (Ethiopia, Kenya, Malawi and South Africa) [1,2,5,6], medical programs currently implemented and validated include: medical history, maternal health, family planning, cervical cancer screening, child under 5, tuberculosis, antiretroviral therapy, diabetes, general and specialist outpatient department (OPD). mHealth4Afrika supports single registration of a patient at a health facility and subsequent enrolment in a range of different programs based on their health conditions over time [1,6]. ...
Article
Full-text available
Supported by the European Commission under Horizon 2020, mHealth4Afrika is co-designing and validating a modular, multilingual, state-of-the-art health information system addressing primary healthcare requirements in resource constrained environments. mHealth4Afrika has co-designed a comprehensive range of functionality and medical programs in partnership with Ministries of Health, district health officers, clinic managers and primary healthcare workers from urban, rural and deep rural health facilities in Ethiopia, Kenya, Malawi and South Africa. This paper provides insights into how mHealth4Afrika is leveraging HL7 FHIR to support standards-based data exchange and interoperability between Electronic Medical Records and DHIS2. This work is currently being validated in the field.
... Despite the progress being made in introducing electronic patient records in larger hospitals in urban areas, paper-based registries are the default data capture method in resource constrained urban, rural and deep rural health centres in Ethiopia, Kenya, Malawi and South Africa (current mHealth4Afrika beneficiary countries). None of the participating health centres have access to a complete electronic patient record system [4,6,7]. Prior to engaging with mHealth4Afrika, intervention clinics in Ethiopia, Kenya and Malawi were not using electronic medical devices or an electronic system to record patient data at the point of care [5]. ...
... mHealth4Afrika aims to provide both direct and indirect contributions to primary healthcare delivery at health centre level by supporting improvements in: (a) the quality and impact of primary healthcare delivery through timely capture of information, systematic storage of important data points in the patient electronic record, and improved follow up; (b) data quality (by reducing human error); (c) frequency of contact with a focus on prevention through adoption of state-of-the-art technologies at the point of care; (d) accuracy and quality of monthly aggregate program indicators; and (e) access to educational materials for clinic staff and patients to strengthen digital literacy and health skills [5,7]. mHealth4Afrika has introduced the use of medical sensors at the point of care [5][6][7]. The intervention clinics currently have access to an oximeter (SpO2, pulse), glucometer (sugar levels), blood pressure, contactless thermometer, weighing scales and the HemoCue Hb 201 (haemoglobin). ...
Article
Full-text available
Background: mHealth4Afrika is a collaborative research and innovation project, co-funded under Horizon 2020. It is focused on supporting Sustainable Development Goal 3 and Horizon 2020 Societal challenges by researching and evaluating the potential impact of co-designing and developing an open source, multilingual enabled mHealth platform to support quality community-based primary maternal healthcare delivery at semi-urban, rural and deep rural clinics, based on end-user requirements in Southern Africa (Malawi, South Africa), East Africa (Kenya) & Horn of Africa (Ethiopia). Methods: A mixed methods strategy is applied. For technical development of the platform, design science research techniques are applied. The various platform iterations are implemented using an agile development process. Qualitative data collection and ethnographic observation was used during the needs requirements and base line study and validation of system iterations. These methods support regular interaction with policy makers, district and clinic managers and healthcare workers as part of the co-design process. Results: This paper aims to share insights into the co-design process to develop a platform that integrates Electronic Medical Records, Electronic Health Records, medical sensors and visualisation tools, and automatically generates monthly program indicators. Conclusions: mHealth4Afrika has developed a custom application to strengthen primary healthcare delivery in resource-constrained environments. It supports a range of interdependent programs defined in consultation with key stakeholders. This is achieved by interacting with a data model set up in DHIS2 via a WebAPI to facilitate holistic monitoring of a patient's wellbeing.
... While there is a massive advancement in the use of mHealth for providing healthcare in developing countries [8] [9] [10], with several mHealth initiatives such as mHealth4Afrika which focuses on designing mHealth solutions with local stakeholders in Ethiopia, Kenya, Malawi and South Africa [11] [12] [13], there is a limited application of mHealth for maternal healthcare within the Namibian context. Recent reports suggest that maternal and infant mortality is high in Namibia with approximately 200 deaths per 100 000 live births [14]. ...
Conference Paper
Full-text available
The purpose of this paper was to define mobile health (mHealth) for maternal healthcare in the context of developing countries. This paper also aimed to identify and classify different mHealth apps and services used for maternal healthcare in developing countries by means of a Literature Survey. This paper is part of a larger study which aims to develop guidelines and strategies for implementing mHealth apps and services to support maternal healthcare in public hospitals in Namibia. Studies have revealed that mHealth apps and services have been useful tools in facilitating patient engagement in the healthcare process. This paper contributes to the understanding of existing apps and services which have been adopted for maternal healthcare in developing countries and provides useful insights on the research gaps to support the development of guidelines and strategies for implementing mHealth apps and services for maternal healthcare in public hospitals in Namibia. Twenty papers on mHealth apps and services met the inclusion and exclusion criteria. The findings suggest that short message service and mobile apps have been popular for supporting pregnant and postpartum women in developing countries. Research gaps were identified and recommendations were provided for the Namibian public health sector. The findings of this paper could inform researchers as well as health policymakers within the Namibian public health sector on services which could improve maternal healthcare services in Namibia.
Conference Paper
Full-text available
mHealth4Afrika is a collaborative research and innovation project, co-funded under Horizon 2020. It is focused on supporting Sustainable Development Goal 3 and Horizon 2020 Societal challenges by developing, researching and evaluating the potential impact of co-designing an open source, multilingual enabled mHealth platform to support quality community-based primary maternal healthcare delivery at semi-urban, rural and deep rural clinics, based on end-user requirements in Southern Africa (Malawi, South Africa), East Africa (Kenya) & Horn of Africa (Ethiopia). This paper aims to share the co-design process applied to develop and validate the alpha prototype, and the implications this had on the design of the beta platform. The validation of the alpha prototype was undertaken with 49 participants from 14 healthcare clinics across Northern Ethiopia, Western Kenya, Southern Malawi and Eastern Cape, South Africa during November - December 2016, using a mix of observation and semi-structured interviews. These findings have informed the co-design of the mHealth4Afrika beta platform, which will be installed in participating clinics on a phased basis during Q3 2017. The expected outcome is a multi-region proof of concept that can make a significant contribution in accelerating exploitation of mHealth across Africa.
Conference Paper
Full-text available
mHealth4Afrika is a collaborative research and innovation project, co-funded under Horizon 2020, that is evaluating the potential impact of co-designing an open source, multilingual mHealth platform on the quality of maternal and newborn healthcare delivery in rural and deep rural clinics. This paper presents results from a comprehensive baseline study carried out with 40 informants from the leadership of 19 healthcare clinics in Northern Ethiopia, Western Kenya, Southern Malawi and Eastern Cape, South Africa during November-December 2015, using focus groups and semi-structured interviews. These findings identified human resource capacity, environmental, practical and technical challenges, and equipment and infrastructure deficits. Training requirements of healthcare workers were also identified. Constraints identified include the need for: intuitive, easy-to-use user interfaces to reduce the need for extensive training; use of flexible data protocols to facilitate cost effective bandwidth and effective data exchange; cost effective; low power consumption technologies to reduce cost of replication and scaling; solar charging units to increase availability; support for sensors and telemedicine due to a deficit of healthcare professionals in rural and deep rural clinics; and the need for easy configuration and adaptation to facilitate wider adoption. This insight will be used to inform co-design of the mHealth4Afrika platform during 2016-2018, based on user-centered design principles, leveraging current state-of-the-art in terms of electronic patient record systems and medical sensors. It will also inform the minimum ICT infrastructure required in each clinic. The expected outcome is a multi-region proof of concept that can make a significant contribution in accelerating exploitation of mHealth across Africa.
Article
To review e-health interventions for maternal and child health (MCH) and to explore their influence on MCH practices in sub-Sahara Africa (SSA). Keyword searches were used to retrieve articles from four databases and the websites of organisations involved in e-health projects for MCH in SSA. A total of 18relevant articles were retrieved using inclusion and exclusion criteria. The researchers reveal the prevalence of the application of mobile phones for MCH care and the influence of the use of information and communication technology (ICT) for delivering MCH information and services to target populations. There is a need to move the application of ICT for MCH care from pilot initiatives to interventions involving all stakeholders on a sub-regional scale. These interventions should also adopt an integrated approach that takes care of the information needs at every stage along the continuum of care. It is anticipated that the study would be useful in the evolution and implementation of future ICT-based programmes for MCH in the region.
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A sequential design utilizing identical samples was used to classify mixed methods studies via a two-dimensional model, wherein sampling designs were grouped according to the time orientation of each study's components and the relationship of the qualitative and quantitative samples. A quantitative analysis of 121 studies representing nine fields in the social or health sciences revealed that more studies utilized a sampling design that was concurrent (66.1%) than sequential (33.9%). Also, identical sampling designs were the most prevalent, followed by nested sampling, multilevel sampling, and parallel sampling, respectively. Qualitative analysis suggested that across a number of studies the researchers made statistical generalizations that were not sufficiently warranted—culminating in interpretive inconsistency and contributing to crises of representation, legitimation, integration, and politics.
Article
The continuum of care has become a rallying call to reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths, and 6 million child deaths. The continuum for maternal, newborn, and child health usually refers to continuity of individual care. Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). We define a population-level or public-health framework based on integrated service delivery throughout the lifecycle, and propose eight packages to promote health for mothers, babies, and children. These packages can be used to deliver more than 190 separate interventions, which would be difficult to scale up one by one. The packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle. Mothers and babies are at high risk in the first days after birth, and the lack of a defined postnatal care package is an important gap, which also contributes to discontinuity between maternal and child health programmes. Similarly, because the family and community package tends not to be regarded as part of the health system, few countries have made systematic efforts to scale it up or integrate it with other levels of care. Building the continuum of care for maternal, newborn, and child health with these packages will need effectiveness trials in various settings; policy support for integration; investment to strengthen health systems; and results-based operational management, especially at district level.
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Implications of Baseline Study Findings from Rural and Deep Rural Clinics in Ethiopia, Kenya, Malawi and South Africa for the co-design of mHealth4Afrika
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Green Paper on mobile Health
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Denscombe, M. (2010) The Good Research Guide. Open University Press European Commission (2014) Green Paper on mobile Health ("mHealth") COM(2014) 219
A Design Science Primer
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Johannesson, P., Perjons, E. (2012) A Design Science Primer, 1st edition, ISBN: 978-1477593943