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Mobile Phone Tools for Field-Based Health care Workers in Low-Income Countries
Abstract
In low-income regions, mobile phone-based tools can improve the scope and efficiency of field health workers. They can also address challenges in monitoring and supervising a large number of geographically distributed health workers. Several tools have been built and deployed in the field, but little comparison has been done to help understand their effectiveness. This is largely because no framework exists in which to analyze the different ways in which the tools help strengthen existing health systems. In this article we highlight 6 key functions that health systems currently perform where mobile tools can provide the most benefit. Using these 6 health system functions, we compare existing applications for community health workers, an important class of field health workers who use these technologies, and discuss common challenges and lessons learned about deploying mobile tools.
... Such an outcome was not consistent, with no clear differences in responses between Community Healthcare Workers (CHW) and nurses, despite differences in educational background and training [102], and in another case, poor adoption of mHealth occurred despite providing in-depth training to a well-educated user population prior to implementation and with technical support throughout [103]. Papers noted that training was considered positively and could be utilised as an incentive [104], that the demand for training was high [97], that training in local languages was needed [72,73,105,106], and that there was need for organisational readiness to train users [70]. One raised the issue of integration of training into the medical curriculum and accepted practice [84]. ...
... This has led to the recommendation for both online and offline capabilities for mHealth solutions [77]. Issues with a lack of reliable network coverage or power preventing the use or charging of mobile devices were the most common infrastructure issues noted [62,63,66,71,77,81,83,86,91,93,95,97,99,101,102,104,108,[110][111][112][113]115,118,[122][123][124][125][126], although this was not universal with one study reporting wider service coverage than expected [79] and another with coverage reaching even the most remote areas [72]. ...
... The ability, or inability, to easily charge mobile phones impacts mHealth adoption by healthcare workers. Access to electricity to charge phones was recognised as a challenge [83,104,119], with healthcare workers sometimes having to travel long distances to do so [120] or using car batteries [67]. For mHealth to be broadly adopted, battery charging must be resolved in innovative ways [93,120,121,125]. ...
Background:
mHealth applications provide health practitioners with platforms that enable disease management, facilitate drug adherence, facilitate drug adherence, speed up diagnosis, monitor outbreaks, take and transfer medical images, and provide advice. Many developing economies are investing more in mobile telecommunication infrastructure than in road transport and electric power generation. Despite this, mHealth has not seen widespread adoption by healthcare workers in the developing world. This study reports a scoping review of factors that impact the adoption of mHealth by healthcare workers in the developing world, and based on these findings, a framework is developed for enhancing mHealth adoption by healthcare workers in the developing world.
Methods:
A structured literature search was performed using PubMed and Scopus, supplemented by hand searching. The searches were restricted to articles in English during the period January 2009 to December 2019 and relevant to the developing world that addressed: mobile phone use by healthcare workers and identified factors impacting the adoption of mHealth implementations. All authors reviewed selected papers, with final inclusion by consensus. Data abstraction was performed by all authors. The results were used to develop the conceptual framework using inductive iterative content analysis.
Results and discussion:
Of 919 articles, 181 met the inclusion criteria and, following a review of full papers, 85 reported factors that impact (promote or impede) healthcare worker adoption of mHealth applications. These factors were categorised into 18 themes and, after continued iterative review and discussion were reduced to 7 primary categories (engagement/funding, infrastructure, training/technical support, healthcare workers' mobile-cost/ownership, system utility, motivation/staffing, patients' mobile-cost/ownership), with 17 sub-categories. These were used to design the proposed framework.
Conclusions:
Successful adoption of mHealth by healthcare workers in the developing world will depend on addressing the factors identified in the proposed framework. They must be assessed in each specific setting prior to mHealth implementation. Application of the proposed framework will help shape future policy and practice of mHealth implementation in the developing world and increase adoption by health workers.
... Another study focused on the technical flow of data being collected by mHealth systems, investigating issues related to, among other concepts, data storage and security (Prasad, 2015). Data collection can also be challenging due to non-technical factors like a lack of incentives for CHWs to collect data, a lack of training about data collection, and privacy concerns (Shovlin, Ghen, Simpson, & Mehta, 2013;DeRenzi et al., 2011). It is also important for data collection tools to fit into existing workflows. ...
... Data collection is an important organizational goal of Mashavu. Health data can be used to improve the healthcare systems in developing countries like Kenya (Macintyre, Lochigan, & Letipila, 2003 While many researchers have looked into and recommended the use of mobile phones as data collection devices (Braun, Catalani, Wimbush, & Israelski, 2013;Kahn, Yang, & Kahn, 2010;DeRenzi et al., 2011), this was determined to be a poor fit for the Mashavu CHWs due to their need to engage in conversation with customers, which is a type of relationships maintenance seen as important by both parties. Existing literature about relationship maintenance appears to be largely focused on banking (Fatima and Razzaque, 2013;Narteh and Kuada, 2014) and other types of service relationships (Aurier and N'Goala, 2010). ...
... As mobile technology develops further, and more techsavvy individuals become CHWs, this may change but at the current time the mobile phones proved to be more of an annoying distraction than helpful tools. Fear of theft, something mentioned as a challenge to mHealth data collection (DeRenzi et al., 2011) was also a concern of the Mashavu CHWs. ...
Community Health Workers (CHWs) have the potential to be a great resource in the further growth of the fledging healthcare systems that exist in many developing countries. Through their position as community members, CHWs can interact with other individuals in the areas where they live and work and serve as valuable health resources by providing basic health information and referrals up the healthcare chain. However, few studies have examined CHWs from a community-based perspective. This study analyzes the work and relationships of several CHWs working for the Mashavu mHealth venture in Nyeri, Kenya. Through the use of participant observation and interviews, the workflows of these CHWs were investigated with a specific eye towards interactions between CHWs and their communities and how these interactions affect potential health data collection opportunities. This community-based perspective reveals unique insights into the workflows of the CHWs and how technology might be designed to support them.
... Health promotion can be an effective tool for promoting healthy lifestyles and prevent unhealthy behavior (Hornik 2002;Clayman et al. 2010;Morris and Jenkins 2018). In a developing country such as Bangladesh, where public health care has progressed remarkably in the last decade despite a low-functioning economy, phones and media have been argued as assets for improving health care accessibility of mothers and new born children (Donner 2008;DeRenzi et al. 2011;Chowdhury et al. 2013;Ahmed et al. 2013;El Arifeen et al. 2013). This study assesses the application of health promotion in urban Bangladesh and how it might influence mothers' access to prenatal, delivery and postnatal care, as well as children's post-birth care. ...
... In recent years, various pilot projects were launched to evaluate the effectiveness of mobile phones in health care in developing countries, including Bangladesh (DeRenzi et al. 2011). For example, Islam et al. (2015) found that a Short Message Service (SMS) based intervention as an addition to standard care for type 2 diabetes was effective in improving glycemic control among adults in urban areas of Bangladesh. ...
... Moreover, in the patriarchal society of Bangladesh, women are not generally empowered to participate in family decisions, and having a mobile phone provides them a support tool to ask for help and reach out to the nearest health facility (Lund 2009;Lund et al. 2010). Receiving regular calls and text messages from health facilitators following delivery has been shown to reduce the risk of postnatal complications (DeRenzi et al. 2011;Cormick et al. 2012); however, whether follow-ups are properly conducted is a major concern in the societal context of Bangladesh. Also, more insight is needed regarding access to mobile phones by categorization between smart versus traditional phones, given smart phones can provide additional tools for health services (Chow et al. 2016). ...
Communications through mobile phones and mass media have shown to be useful for health promotion activities in developing nations. This study explored the potential association of mothers’ mobile phone ownership and mass media exposure on maternal health care services in a developing nation setting: urban Bangladesh. The Urban Health Survey 2013 was examined for antenatal care, delivery assistance, and postnatal care of both mothers and children through multiple regression models, adjusting for sociodemographic factors. Among 8987 ever-married female respondents, 64.1% owned mobile phones and 88% were exposed to mass media (TV, radio or newspaper) at least once a week. Mobile phone ownership was associated with a 48% greater likelihood of access to antenatal care, 34% greater delivery assistance and 31% greater postnatal care of the mother, but no differences were found for postnatal care of children. Similarly, frequent media exposure was associated with increased access to antenatal care (38%) and delivery assistance (46%), but not associated with postnatal care of mothers or children. The results suggested that mobile phones and mass media could be valid avenues for promoting access to maternal health services, and thus, support for mobile phone access and investment in awareness campaigns targeting relevant communities are worthwhile.
... The present study differed from the literature of similar projects bychoosing hospital-based population instead of the general population [21,22]. Tomlinson et al., (2009) utilized a similar study design to assess the use of mobile phones as a data collection tool among the general population [23]. ...
... The present study employed MARS to collect oral health data using the investigatoradministered method. The prime focus of our study was to gather responses of IR-team on usability and applicability of MARS in contrast to evaluating participant's response [8,21,22]. The relatively small sample size was selected considering the initial pilot-phase of testing MARS. ...
Background:
Smartphone compared to the traditional pen-paper method could enhance oral health data recording procedure by reducing the cost of data collection, risk of data loss, early detection of errors and reducing data entry time. The present research developed a mobile/tablet-based software application to capture oral health data and test its adaptability and operations in oral health surveys.
Methods:
A comparative cross-sectional study was conducted among the general population of Sanwer town, Indore district. The initial testing of the application was done on 120 individuals. A random sampling (lottery method) followed by a systematic sampling strategy was employed to select 120 households. A "one per household" design was implemented for the survey. The initial oral health data collection was done using mobile-assisted software application followed by a second examination scheduled after 15 days on the same participants using the conventional Pen-paper method to collect oral health data.
Results:
Six Investigator Recorder (IR) teams conducted the oral health data collection. Data collection through Smartphone-based application displayed less meantime (3.57 minutes) in comparison to pen-paper method (4.87 minutes) (p≤0.001). Survey team response showed the majority of investigators having strong agreement on user satisfaction and speed of data entry using software application.
Conclusion:
The initial testing of mobile-assisted recording system (MARS) efficiently captured oral health data among the general population with wide variations in oral disease level. The application facilitated minimal or no wastage of paper and had a high level of user-satisfaction, accuracy, speed of entry and low potential for any data loss.
... Derenzi et al. identify six essential health functions where mobile applications have been designed for CHWs: data collection, communication between health workers, job aids and decision support, health workers' supervision, health promotion, training, and access to reference material [23]. Some of the routine data collection activities that CHWs perform include household surveys, routine reporting, and supervisory reports [23]. ...
... Derenzi et al. identify six essential health functions where mobile applications have been designed for CHWs: data collection, communication between health workers, job aids and decision support, health workers' supervision, health promotion, training, and access to reference material [23]. Some of the routine data collection activities that CHWs perform include household surveys, routine reporting, and supervisory reports [23]. These are mostly done manually through the paper, which incurs inefciency and errors. ...
In India and other developing countries, Community Health Workers (CHWs) provide the frst line of care in delivering necessary
maternal and child health services. In this work, we assess the
training and skill-building needs of CHWs, through a mobile-based
training intervention deployed for six months to 500 CHWs for
conducting 144 training sessions in rural India. We qualitatively
probed 1178 questions, asked by CHWs, during training sessions,
and conducted a content analysis of the learning material provided
to CHWs. Further, we interviewed 48 CHWs to understand the
rationale of information seeking and perceptions of training needs.
We present our understanding of the knowledge gaps of CHWs and
how the current learning material and training methods are ineffective in addressing it. Our study presents design implications for
HCI4D researchers for mobile learning platforms targeted towards
CHWs. We also provide policy-level suggestions to improve the
training of CHWs in India or a similar context.
... In addition, the beneficiary verification mechanism, which captures the phone numbers of the beneficiaries, can be used by supervisors to verify agents' reported activities as earlier suggested by Aker (2011) and Aker et al. (2016). This finding validates the supposition that smartphone applications can provide platforms that enable remote supervision (DeRenzi et al., 2011). By enabling remote supervision, the e-diary eliminates the travel costs and time needed to physically supervise large numbers of field agents working in remote, widely dispersed geographic areas. ...
... In regards to real-time reporting and supervision, the e-diary enables the supervisors to get realtime reports from the field agents and subsequently immediate feedback from the beneficiaries. This finding corroborates the suggestion that mobile tools can enable the supervisors to monitor the activities of the field agents in near real-time and provide immediate feedback or immediate interventions were necessary (DeRenzi et al., 2011). According to Omisore (2014), daily reporting by subordinates enables the supervisors to monitor the productivity of the subordinates consistently. ...
The study aimed to assess the potential of smartphone applications for strengthening accountability in public agricultural extension services. Therefore, a smartphone application called 'e-diary' was developed and tested in Uganda. A Design Science Research approach was used for the development and assessment of the e-diary. Individual face-to-face interviews and focus group discussions were used for data collection. Data analysis was conducted using the content analysis method. The findings indicate that smartphone applications have the potential to strengthen accountability in the public agricultural extension services by enabling remote supervision in real-time, which reduces the costs and time of supervision. However, the study also indicates that the successful implementation of such tools requires incentives such as awards of recognition. These findings contribute to the understanding of the potential role of ICTs in strengthening the management of public services (such as agricultural extension) in developing economies.
... Most digital health initiatives focus on helping community health workers to gather accurate data during home visits, enhance screening and information-seeking practices, visualization of tasks and facilitate communication with women [34,35,76,104,145]. While the digital transformation in maternal health is opening up opportunities for HCI research for development (HCI4D) in South Africa [28,50,100,133], Kenya [113,114], Pakistan [12,99,127], India [35,64,72,73], Bangladesh [138], Lebanon [140,141], Uganda and Tanzania [68], there is limited research looking at women's experiences during pregnancy complications [12] and among indigenous communities [8,57] and Latin America as a region remains unexplored for HCI4D research in healthcare [19,135]. ...
... For example, the complex medical terminology was difficult to understand in textual and verbal form in Spanish with little translation available in Kichwa due to its writing limitations. Furthermore mobile technology can offer opportunities to enhance doctor's home visits [34,35,121] and the medication informational order [31,32] (e.g., what, when, how and why to take a medication) at home, and can facilitate the self-management of gestational diabetes to control weight gain [53]. Introducing self-monitoring devices both at the rural subcenters and at home can facilitate the early detection and management of hypertensive disorders during pregnancy [102,103]. ...
Previous research has explored the potential use of digital health to support maternal health in the Global South highlighting the importance of understanding the socio-cultural context to inform system design. However, the experiences of indigenous women managing pregnancy complications in Latin America remain underexplored in HCI. We present a qualitative study with 25 indigenous pregnant women in an Ecuadorian
rural community looking at their experiences during complications, their antenatal care visits and their access and use of technologies. Our findings highlight key barriers that hinder the use of antenatal care services and influence women’s experiences managing complications. Based on the findings, we present opportunities for digital health centered on indigenous women to enhance antenatal care in rural Ecuador.
... SMS alone has been shown to help bridge the communication gap in the health sector between health workers and patients, different managerial levels, and between Ministry of Health and facilities in the peripheral areas (Tamrat & Kachnowski, 2012). This technology can enable faster data collection which can then be uploaded directly to a centralized server (DeRenzi et al., 2011). Also, mobile applications for data collection ensure that only valid data values are accepted which reduces the risk of transcription error (DeRenzi et al., 2011, p. 407). ...
... Furthermore, insufficient staff, both in quality and quantity to support supervision demands, have been reported as a key challenge for the Rwanda CHW programme, with the consequence that some CHWs go many months without being supervised (Ministry of Health, 2013). It is argued that incorporating technologies into CHW programmes has the potential to improve supervision as they can address several of the challenges of supervision, including communication difficulties between supervisors and CHWs (DeRenzi, 2011). For mHealth projects that entail data collection by CHWs, (such as RapidSMS) managers or supervisors should be positioned to provide real-time supervision and monitor work rate, attendance and working hours of the staff involved (Barrington, Wereko-Brobby, Ward, Mwafongo, & Kungulwe, 2010). ...
This article explores the determinants of using mobile phone technologies for public health (mHealth) through a quantitative study with community health workers (CHWs) in rural Rwanda. A total of 72 CHWs from two districts in Rwanda who were using the mHealth tool, RapidSMS, were surveyed in June 2014. Using a socio- technical approach, user, programme and technical char-acteristics were tested and deemed influential in determining use. Technical characteristics (reminders and alerts) were by far the strongest predicting factors of use. The user characteristic, age, had no influence on utilization, while supports though training and supervision (programme characteristics) revealed mixed findings. These findings illustrate the uniqueness of each context and reiterate the need to consider social and technical factors when implementing mHealth projects.
... Contrary to the clinical focus of AIM applications in high-resource countries, it appears that AIM in low-and middle-income countries is often related to automation technology, such as the mobile phone framework, concerned with the delivery of health information and health communication that could improve public health outcomes [16,[55][56][57][58]. For example, in Tanzania, the electronic version of the Integrated Management of Childhood Illness (IMCI) protocol, dubbed e-IMCI, has allowed local clinicians to use personal digital assistants (PDAs) to classify and treat child illnesses, thereby in the long run, contributing to better pediatric healthcare [59]. ...
... This expert system, which integrates the second generation protocol specification format GuideLine Interchange Format (GLIF), is particularly suited to low-income settings given that computer systems training for IMCI were 23-29% less expensive and as effective as standard training methods [59]. Not only would PDA and mobile phone-based tools improve the scope and efficiency of field health workers in low-income regions, they would also be of tremendous help in monitoring and containing chronic diseases and communicable diseases thanks to their wide availability [57,58]. Under these programs, also known as 'e-health', governments in several low-and middle-income countries have successfully implemented community information systems for disease surveillance [56]. ...
This review paper presents a framework to evaluate the artificial intelligence (AI) readiness for the healthcare sector in developing countries: a combination of adequate technical or technological expertise, financial sustainability, and socio-political commitment embedded in a healthy psycho-cultural context could bring about the smooth transitioning toward an AI-powered healthcare sector. Taking the Vietnamese healthcare sector as a case study, this paper attempts to clarify the negative and positive influencers. With only about 1500 publications about AI from 1998 to 2017 according to the latest Elsevier AI report, Vietnamese physicians are still capable of applying the state-of-the-art AI techniques in their research. However, a deeper look at the funding sources suggests a lack of socio-political commitment, hence the financial sustainability, to advance the field. The AI readiness in Vietnam’s healthcare also suffers from the unprepared information infrastructure—using text mining for the official annual reports from 2012 to 2016 of the Ministry of Health, the paper found that the frequency of the word “database” actually decreases from 2012 to 2016, and the word has a high probability to accompany words such as “lacking”, “standardizing”, “inefficient”, and “inaccurate.” Finally, manifestations of psycho-cultural elements such as the public’s mistaken views on AI or the non-transparent, inflexible and redundant of Vietnamese organizational structures can impede the transition to an AI-powered healthcare sector.
... Additionally, due to the hierarchical, top-down and supply-driven nature of public systems, monitoring by the beneficiaries is also a challenge (Anderson and Feder 2004;Feder et al. 2010). This is further aggravated by the lack of resources and robust accountability mechanisms to enable both the supervisors and beneficiaries to adequately monitor the activities of the field agents and hold them accountable (DeRenzi et al. 2011;Nakasone and Torero 2016). Moreover, typically, there is also a lack of incentives for the field agents, leading to a lack of motivation and low morale (Bitzer 2016). ...
Purpose: To assess the potential of a paper diary for strengthening accountability in public agricultural extension services. Therefore a paper diary called ‘Diary for Agricultural Extension Officers’ was developed and tested in Uganda.
Design/methodology/approach: A qualitative case study research approach was applied for the development and assessment of the diary. Data were collected using focus group discussions and individual face-to-face interviews. Data analysis was conducted using the content analysis method.
Findings: Paper diaries can strengthen accountability in public agricultural extension services by enabling alignment of the extension activities of the field agents to the goals of the extension service and to the needs of the beneficiaries, in addition to mitigating information asymmetry about the extension activities. However, the implementation of paper diaries requires sensitization of the beneficiaries on the need for verification and feedback.
Practical Implications: This study is centred around addressing a practical problem of field agents’ accountability and results have the potential to improve management of public services such as agricultural extension. Moreover, the findings could also be relevant for all types of organizations and service delivery methods.
Theoretical implications: This study expanded the boundaries of the principal-agent theory by applying it to the accountability of agricultural extension services using paper diaries, which have hitherto not been widely applied.
Originality/value: This study advances the debates of accountability and coordination of agricultural extension services by assessing the potential of a paper diary as the literature has to date assessed the potential of electronic diaries.
... Investigations into how technologies can assist traditional reporting systems for data collection have shown they support programs, policies, and top-down interventions attempting to identify the needs of citizens for global development. Examples include: data collection through numeric paper forms for NGOs [106]; replacing paper-based data collection with digital tools, such as CAM [84]; and collecting survey responses through sensor events such as MyExperience [41] and Commcare [32]. ...
... The use of MHealth for patient populations is popular especially at the treatment stage of the health delivery process (Bobrow et al., 2016) and during the palliative care (Alcaraz et al., 2017;DeRenzi et al., 2011). The MHealth plays a very important role in medication adherence and provides great support and prevention against repeated hospital visitations (Leon et al., 2015). ...
ABSTRACT
The introduction of consumer MHealth technology is highly extolled for its potential to facilitate access to health, alleviate the shortage of health care resources, reduce hospitalization of patients, and mitigate health cost. The overwhelming endorsement shows the use of MHealth to complement existing healthcare infrastructure by targeting heterogeneous audience for specific health need. However, consumer MHealth innovation is traditionally considered for measures of coverage, efficacy, and cost-effectiveness with little discussion of the unintended consequences of escalating inequalities for underserved consumers of low socioeconomic populations. Furthermore, MHealth studies show that inequalities are fundamentally addressed as derivative of socioeconomic phenomenon without further explanation of how social and technology factors reinforce and aggravate its patterns. Therefore, the proliferation of consumer MHealth innovation and its concomitant health inequalities have important consequences. Researchers, managers, and other health information systems’ stakeholders increasingly face the dilemma of reconciling the perplexing, and often contradictory rise in health inequalities in their commitment to implement MHealth innovation.
Existing studies reveal the paucity of empirical research and methodological limitation, including the lack of relevant theories to describe, explain or predict how sociotechnical mechanisms reinforce and aggravate inequalities in MHealth. Thus, the study of inequalities in consumer MHealth presents fundamental challenges relating to its substantive nature, its origin, and scope; as well as the methodological concern of how to address the anomalies.
It is therefore the objective of this research to address these gaps by exploring the antecedents of inequalities in consumer MHealth, and to resolve the following challenges: (1) the lack of consensus on the theoretical concepts of the relevant factors, (2) the elaboration of the relationship between the antecedent factors, and (3) to develop IS framework which can be used to mitigate inequalities in consumer MHealth innovation for PAB.
To achieve the above objective, the researcher adopted the interpretivist paradigm and qualitative approach as a reflective method to capture the emergent complexity of human sense making in a natural sociotechnical interaction between information technology, the people, and the context. Multiple case study and purposive sampling were also adopted to enable comparative selection of cases, and to intensify comprehensive data gathering that captures the richness of the cases. Accordingly, the prerequisite technology artefact was operationalised with MHealth for physical activity and fitness (PAF). Essentially, the aim was to document in
xiv
detail the conduct of everyday events in the implementation and use of MHealth for PAF and to identify the meaning assigned to these experiences by participants.
The research study was conducted in the Republic of Ireland (ROI); and the data collection occurred in the period between July 2019 and March 2020. Twenty-four individuals from twelve households of ethnic minority people of African background (PAB) participated individually in the data collection which involved demographic survey, observational data with think-aloud protocol (TAP), and role-play demonstration (RPD), as well as in-depth interviews. The lack of pre-existing notion of the MHealth phenomenon and the originality of this study necessitated the use of TAP and RPD, which were devised as templates to apprehend the true nature of the emerging phenomenon. The TAP and RPD are direct observational tools designed to illuminate human interactions which are situated in practice, to grasp knowledge that are mainly observed but absent from other documentation. The researcher reasoned that unless research participants are extremely insightful, they might not know or remember all the rationale for their behaviour. Thus, the researcher prepared and collected quantitative and qualitative data from each participant for eight weeks. Thereafter, the researcher organised all data with NVivo QDAS and concurrently conducted grounded theoretical analysis. The qualitative analysis resulted to categories and core categories which have explanatory and predictive powers and provide understanding of the inequalities in consumer MHealth.
Thus, this research study has immense contribution to IS theory and practice, especially for its novel methodology which uncovers the nine antecedents for examining inequalities in MHealth. Similarly, the discovery of the formative factors of inequalities in MHealth provides useful taxonomy, and clearly reveals that socioeconomic factor is one part of the nine antecedents that impact MHealth. Furthermore, the researcher developed the MHES model, and a framework to mitigate inequalities in consumer MHealth innovation. Consequently, the IS stakeholders, the PAB and underserved populations can leverage the MHESF at individual, social or organisational level to mitigate inequalities in consumer MHealth innovation.
However, the transdisciplinary nature of sociotechnical research such as this requires complementary representation from relevant IS reference disciplines, as well as greater involvement of MHealth stakeholders for richer insight. Furthermore, qualitative studies of this type are subjective, idiographic, and emic, with emphasis on relevance. Notwithstanding, this study paves way for mixed method research that combines relevance and theory verification.
... This study contributes to expanding the evidence base on how DHTs can be applied to improve access to NCD care in LMICs. 11,[16][17][18] Overall, the programs that applied DHTs were similar to programs that did not use DHTs in terms of country of implementation and targeted disease areas. However, industry-led access programs targeting type 2 diabetes in LMICs were significantly more likely to apply DHTs than not. ...
Background:
There is limited research on how digital health technologies (DHTs) are used to promote access to care for patients with noncommunicable diseases (NCDs), particularly in low- and middle-income countries (LMICs). We describe the use of DHTs in pharmaceutical industry-led access programs aimed at improving access to NCD care in LMICs.
Methods:
The Access Observatory is the largest publicly available repository containing detailed information about pharmaceutical industry-led access programs targeting NCDs. The repository includes 101 access program reports submitted by 19 pharmaceutical companies. From each report, we extracted data relating to geographic location, disease area, beneficiary population, use of DHTs, partnerships, strategies, and activities. Data were analyzed descriptively using SAS Statistical Software and categorized according to the World Health Organization Digital Health Classification Framework.
Results:
A total of 43 access programs (42.6%) included DHTs. The majority of programs using DHTs were clustered across sub-Saharan Africa (72.1%) and targeted cancer (60.5%) followed by metabolic disorders (39.5%). The applied DHTs mostly related to program strategies on health service strengthening (74.4%) and community awareness (41.9%) and were largely directed toward health providers, followed by data services and clients. Only a few DHTs were used for health system management. To promote access, most DHTs focused on improving data collection, management, and use (51.1%); building health provider capacity through training (37.2%); and providing targeted patient information (34.8%).
Conclusion:
The range of DHTs applied by the pharmaceutical industry offers opportunities for more effective access to NCD care. Transparent reporting on DHT use and its contributions to access programs' achievements may reduce duplicative and redundant efforts and provide learnings for private and public stakeholders that may contribute to greater access to NCD care in LMICs.
... Capacity-building requires the allocation of protected time for pre-service and in-service training to explore policy-relevant research questions, and to build the relationships with other stakeholders that are needed for effective and embedded research processes (Bautista, 2019).Educational fees for trainees vary widely around the world, but can be prohibitively high in many countries. This makes it essential to ensure that the costs of education do not prevent key stakeholder groups from becoming effective contributors to learning teams and organizations(Frenk et al., 2010).Apart from initial commitments towards learning goals, fiscal flexibility and stability are key to developing and sustaining infrastructure for learning(Friedman et al., 2017;Morain et al., 2017; Akhnif et al., 2018).Many applications of information technology offer economicaland feasible learning solutions at scale(Kahn et al., 2010;Derenzi et al., 2011). Technology is useful not only to facilitate the flow of information, but also to accelerate deliberative and experiential forms of learning through simple and low-cost applications such as online learning platforms -which are used increasingly in low-resource settings(Scott & Gilson, 2017).However, some technologies can also require significant fixed and running costs in the long term, and these costs should beweighed judiciously against the benefits (Vuong et al., 2019). ...
Learning – at individual, team, organization and cross-organization levels – is fundamental to health systems strengthening and the achievement of health goals. Yet, many health systems, especially in LMICs, still do not have adequate capacity to generate and use the knowledge that they need to be effective. Investments in learning activities tend to be a remarkably small proportion of overall investments in health programmes and systems, and learning-focused activities have historically not found place or favour in budgets when compared with other health system priorities. This report advances a comprehensive understanding of what is meant by – and how to create – learning health systems. It outlines the benefits of learning health systems and the actions needed to build such systems.
... The study mainly relies on electronic questionnaires for data collection, which is based on a popular social app in China called WeChat. Compared with traditional paper-based questionnaires, electronic questionnaires are more efficient in data management and can avoid more logical errors [42][43][44]. Under special conditions, paper-based questionnaires are allowed, and the data need to enter into the cloud system later. ...
Background
As reported, 27-93 % of pregnant women take at least one drug during pregnancy. However, drug exposure during pregnancy still lacks sufficient foetal safety evidence of human origin. It is urgent to fill the knowledge gap about medication safety during pregnancy for optimization of maternal disease treatment and pregnancy drug consultation.
Methods and analysis
The China Teratology Birth Cohort (CTBC) was established in 2019 and is a hospital-based open-ended prospective cohort study with the aim of assessing drug safety during pregnancy. Pregnant women who set up the pregnancy health records in the first trimester or who seek drug consultation regardless of gestational age in the member hospitals are recruited. Enrolled pregnant women need to be investigated four times, namely, 6–14 and 24–28 weeks of gestational age, before discharge after hospital delivery, and 28–42 days after birth.
Maternal medication exposure during pregnancy is the focus of the CTBC. For drugs, information on the type, name, and route of medication; start and end time of medication; single dose; frequency of medication; dosage form; manufacturer; and reason for medication is collected. The adverse pregnancy outcomes collected in the study include birth defects, stillbirth, spontaneous abortion, preterm birth, post-term birth, low birth weight, macrosomia, small for gestational age, large for gestational age and low Apgar score. CTBC uses an electronic questionnaire for data collection and a cloud system for data management. Biological samples are collected if informed consents are obtained. Multi-level logistic regression, mixed-effect negative binomial distribution regression and spline function regression are used to explore the effect of drugs on the occurrence of birth defects.
Discussion
The findings of the study will assist in further understanding the risk of birth defects and other adverse pregnancy outcomes associated with maternal drug exposure and developing the optimal treatment plans and drug counselling for pregnant women.
Trial registration
This study was approved by the Research Ethics Committee of the West China Second Hospital of Sichuan University and registered at the Chinese Clinical Trial Registry ( http://www.chictr.org.cn/index.aspx , registration number ChiCTR1900022569 ).
... Medrano et al. presented their expertise during Covid 19 pandemic at Nicaragua, using telemedicine to medical advice through mobile phone with successful result to vulnerable people [15]. ...
SARS-CoV-2 its infectious diseases was named coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) a really pandemic. The first report on prevalence of SARS-Cov2 at Nicaragua, showed the first cases March 2020 and during the months of June and July began exponential growth period. The telemedicine can provide rapid access, efficient and immediately available person. This approach has been explored most fully in the context of Covid 19 stroke. The estimates of intervention costs are really challenge, particularly for low- and middle-income countries. Create a health strategy during a health emergency with the lowest cost investment but great population health impact are the primary objective. The gold of this study is decide the economic impact, through of the cost benefit of medical advice through mobile phone during the COVID-19 pandemia , as health strategy at Nicaragua
... The COVID19 symptoms reported as Richarson et al. The Information was proceed using Excel office 2010, the univariable review was realized with frequency and percentages [10][11][12]. ...
In December 2019 an outbreak of pneumonia of unknown etiology emerged in Wuhan, China. World Health Organization named coronavirus disease 2019 (COVID-19) several health platforms have used the mobil phone as tool in different aspects and situations, the pandemia one of these. The golds this study is collection of epidemiological data and to ease medical advice using mobil phone during the pandemic by COVID-19 at Nicaragua. Method: Descriptive study, cohort. We reviewed the file of 5,712 phone call, during two months, using Interactive Voice Response (IVR) service to provide medical advice. Physicians trained with knowledge about COVID 19 according to WHO- PHO and John Hopkins University’s courses. Data collection realized with a format: call number, call duration, demographic data, symptoms, question about COVID 19, medical advice. The Information proceed using Excel office 2010, the univariable review realized with frequency and percentages. Results: During two months (June and July 2020) we received 5712 mobil phone call. The distribution for departments: 4264 (75%) correspondent to Managua, fallow of Masaya 336 (6%) Chinandega 220 (4%), Granada and León (3%) each one, the others minor to 1%. The female represented 3311(58%) and men 2401(42%) according who made the phone call. The distribution according age : 4035(70.6%) major of 30 years and 1677(29.4%) minor to 30 years Each day the ranges of mobil phone call were 110-120 , average 115 for day. Duration call 5-10 minutes, average was 8 minutes. The symptoms reported were: loss of smell and taste 53-52% respectively fallow of myalgia and fever. The medical advice relationship with the most frequent question about: Symptoms, medical treatment, frequent complications, family protection and mask use. Conclusion: Ours results as the international reports show the greatest utility to epidemiological data collection during a health emergency principally in vulnerable peoples and know a part of the behavior of disease in our country. Also have permitted to ease medical advice by health workers trained on the subject.
... There is growing interest in the use of mobile information and communication technologies (commonly referred to as mHealth) to revolutionize the work of CHWs in low-resource settings by providing them with efficient communication and data collection systems (Akter & Ray, 2010;Buehler, Ruggiero, & Mehta, 2013;Hurt et al., 2016;Tomlinson et al., 2009). Partly as a result, there is a wide body of literature across many developing countries that reports on mHealth interventions with CHWs as the primary users of the mHealth technologies (Buehler et al., 2013;DeRenzi et al., 2011;Kumar et al., 2015;Ramachandran, Canny, Das, & Cutrell, 2010). Possible mHealth applications span different types of tasks performed by CHWs including data collection and reporting, information and decision support applications, and communication with healthcare professionals and patients . ...
This book offers a detailed account of a range of mHealth initiatives across South, Southeast and East Asia. It provides readers with deep insights into the challenges such initiatives face on the ground, and a view of the diverse cultural contexts shaping strategies for overcoming these challenges. The book brings together various discussions on the broader mHealth literature, and demonstrates how a research focus on diverse Asian contexts influences the success and/or failure of current mHealth initiatives. It also highlights the important roles social scientists can play in advancing theoretical approaches, as well as planning, implementing and evaluating mHealth initiatives. The book is a valuable resource for project planners, policy developers in NGOs and government institutions, as well as academics, researchers and students in the fields of public health, communications and development studies.
This book is open access under a CC BY license
... There are interesting sets of work evolving around, the needs of developing and under-developed countries using the novel mobile-based applications presented by Dell, Francis, Sheppard, Simbi, & Borriello (2014) One major application of the mobile phone-based applications in-developing country context is healthcare and many researchers have taken the advantage to explore that aspect with novel ideas supported by Dell et al. (2014), DeRenzi et al. (2011), and Hartung et al. (2010 have explored innovative ways of using the mobile phone to support the information system-based application. The research work conducted by Yasir, Nibir, & Ahmed (2014) uses the mobile phone to improve the healthcare situation in Bangladesh which shows the importance of the mobile phone-based application in the context of this country. ...
Touchscreen-based phones can be challenging for people with visual impairment. These phones require special features to cater to their needs when it comes to a developing country’s perspective like Bangladesh. The interface needs to remain simple as well as it must support the required functionalities. It is often observed that touchscreen phones are not desirable for the user community in Bangladesh as it offers a complex set of functions. We have considered visually impaired personnel in terms of physical limitations and the community who falls in the older age limit as our target community. Our user study has confirmed that the visually impaired user community here asks for a simple and functional interface. We have designed, developed, and deployed a simple system ifreePhony that captures the minimalistic features. We have considered both the elderly and the visually impaired community in our user studies. It shows around 36% reduction in search time and around 57% increase in text typing compared to a traditional phone.
... This question is key, in that fairer elections are more likely to keep leaders accountable to the electorate (Besley and Burgess, 2002;Downs, 1957;Fujiwara, 2015;Przeworski et al., 1999). 1 The rapid adoption of ICT by citizens in developing countries represents a dramatic change in their capacity to communicate and mobilize for action (Alozie, Akpan-Obong and Foster, 2011;Bratton, 2013;Shirazi, 2008). The literature on democratic engagement has shown the promise of ICT to improve electoral integrity (Bailard and Livingston, 2014;Callen et al., 2016); crowd-source information on violence, corruption, and government performance (Cecchini and Scott, 2003;DeRenzi et al., 2011;Findley et al., 2012;Pierskalla and Hollenbach, 2013;Shapiro and Weidmann, 2015;Van der Windt and Humphreys, 2014;Weidmann and Callen, 2013); and strengthen accountability between citizens and politicians (Grossman, Humphreys and Sacramone-Lutz, 2014). The broad reach of the technology has also illustrated the ability to increase the political engagement of marginalized populations such as the poor, those in peripheral regions, and women (Findley et al., 2012;Grossman, Humphreys and Sacramone-Lutz, 2014). ...
We introduce a new mobile money interface that permits Sri Lankans to deposit mobile airtime balances directly into a formal bank account. Randomizing access and prices, we find a small increase in savings deposits with the partner institution and formal banks more generally, but no change in overall savings. When the deposit transaction costs are completely removed, only 26 percent use the mobile deposit service, and only 7 percent use it frequently. Our results imply that deposit transaction costs are not a significant barrier to increasing savings, limiting the potential gains of mobile-linked savings products for financial inclusion.
... In the case of integrated management of childhood illnesses, provider compliance with the digital protocol increased by up to 30% compared to the use of a paper-based protocol [5]. In addition to the impact on protocol-driven treatment, digital health applications have been applied in low-resource settings to facilitate task shifting, improve work planning and coordination between providers, as well as enhance the performance of health workers [12][13][14][15]. These data support the use of digital health applications to improve compliance with protocol-driven treatment [16][17][18]. ...
Background:
In high-income countries (HICs), increased rates of survival among pediatric cancer patients are achieved through the use of protocol-driven treatment. Compared to HICs, differences in infrastructure, supportive care, and human resources, make compliance with protocol-driven treatment challenging in low- and middle-income countries (LMICs). For successful implementation of protocol-driven treatment, treatment protocols must be resource-adapted for the LMIC context, and additional supportive tools must be developed to promote protocol compliance. In Tanzania, an LMIC where resource-adapted treatment protocols are available, digital health applications could promote protocol compliance through incorporation of systematic decision support algorithms, reminders and alerts related to patient visits, and up-to-date data for care coordination. However, evidence on the use of digital health applications in improving compliance with protocol-driven treatment for pediatric cancer is limited. This study protocol describes the development and evaluation of a digital health application, called mNavigator, to facilitate compliance with protocol-driven treatment for pediatric cancer in Tanzania.
Methods:
mNavigator is a digital case management system that incorporates nationally-approved and resource-adapted treatment protocols for two pediatric cancers in Tanzania, Burkitt lymphoma and retinoblastoma. mNavigator is developed from an open-source digital health platform, called CommCare, and guided by the Consolidated Framework for Implementation Research. From July 2019-July 2020 at Bugando Medical Centre in Mwanza, Tanzania, all new pediatric cancer patients will be registered and managed using mNavigator as the new standard of care for patient intake and outcome assessment. Pediatric cancer patients with a clinical diagnosis of Burkitt lymphoma or retinoblastoma will be approached for participation in the study evaluating mNavigator. mNavigator users will document pre-treatment and treatment details for study participants using digital forms and checklists that facilitate compliance with protocol-driven treatment. Compliance with treatment protocols using mNavigator will be compared to historical compliance rates as the primary outcome. Throughout the implementation period, we will document factors that facilitate or inhibit mNavigator implementation.
Discussion:
Study findings will inform implementation and scale up of mNavigator in tertiary pediatric cancer facilities in Tanzania, with the goal of facilitating protocol-driven treatment.
Trial registration:
The study protocol was registered in ClinicalTrials.gov (NCT03677128) on September 19, 2018.
... By partnering with a well-established non-pro t mHealth organization, Medic Mobile (http://medicmobile.org/), and integrating with their existing software platform, open-source community and current efforts to integrate with existing health information systems (HIS) throughout sub-Saharan Africa, our team and proposed intervention are well positioned to scale up and sustain any promising results. Since 2008, Medic Mobile has been a leader in the global mHealth community (47)(48)(49), equipping more than 13,500 health workers serving over 8 million people across 23 countries. The Mobile Medic Toolkit is an Androidbased application that supports texting in any language and works with or without internet connectivity on basic phones, smartphones, tablets, and computers (50). ...
Background: Surgical male circumcision (MC) safely reduces risk of female-to-male HIV-1 transmission by up to 60%. The average rate of global moderate and severe adverse events (AEs) is 0.8%: 99% of men heal from MC without incident. To reach the 2016 global MC target of 20 million, productivity must double in countries plagued by severe healthcare worker shortages like Zimbabwe. The ZAZIC consortium partners with the Zimbabwe Ministry of Health and Child Care and performed over 120,000 MCs. MC care in Zimbabwe requires in-person, follow-up visits at post-operative days 2,7, and 42. ZAZIC program adverse event rate is 0.4%; therefore, overstretched clinic staff conducted more than 200,000 unnecessary reviews for MC clients without complications. Methods: Through an un-blinded, prospective, randomized, control trial in two high-volume MC facilities, we will compare two groups of adult MC clients with cell phones randomized 1:1 into two groups: 1) routine care (control group N=361) and 2) clients who receive and respond to a daily text with in-person follow-up only if desired or if a complication is suspected (intervention N=361). If an intervention client responds affirmatively to any automated daily text with a suspected AE, an MC nurse will exchange manual, modifiable, scripted texts with the client to determine symptoms and severity, requesting an in-person visit if desired or warranted. Both arms will complete a study-specific, Day 14, in-person, follow-up review for verification of self-reports (intervention) and comparison (control). Data collection includes extraction of routine client MC records, study-specific database reports, and participant usability surveys. Intent-to-treat (ITT) analysis will explore differences between groups to determine if two-way texting (2wT) can safely reduce MC follow-up visits; estimate the cost savings associated with 2wT over routine MC follow-up; and assess the acceptability and feasibility of 2wT for scale-up. Discussion: It is expected that this mobile health intervention will be as safe as routine care while providing distinct advantages in efficiency, costs, and reduced healthcare worker burden. The success of this intervention could lead to adaptation and adoption of this intervention at the national level, increasing efficiency of MC scale up, reducing burdens on providers and patients. Clinical Trial Registration Number NCT03119337
... By partnering with a well-established non-pro t mHealth organization, Medic Mobile (http://medicmobile.org/), and integrating with their existing software platform, open-source community and current efforts to integrate with existing health information systems (HIS) throughout sub-Saharan Africa, our team and proposed intervention are well positioned to scale up and sustain any promising results. Since 2008, Medic Mobile has been a leader in the global mHealth community (47)(48)(49), equipping more than 13,500 health workers serving over 8 million people across 23 countries. The Mobile Medic Toolkit is an Androidbased application that supports texting in any language and works with or without internet connectivity on basic phones, smartphones, tablets, and computers (50). ...
Background: Surgical male circumcision (MC) safely reduces risk of female-to-male HIV-1 transmission by up to 60%. The average rate of global moderate and severe adverse events is 0.8%: 99% of men heal from MC without incident. To reach the 2016 global MC target of 20 million, productivity must double in countries plagued by severe healthcare worker shortages like Zimbabwe. The ZAZIC consortium partners with the Zimbabwe Ministry of Health and Child Care and performed over 120,000 MCs. MC care in Zimbabwe requires in-person, follow-up visits at post-operative days 2,7, and 42. ZAZIC program adverse event rate is 0.4%; therefore, overstretched clinic staff conducted more than 200,000 unnecessary reviews for MC clients without complications.
Methods: Through an un-blinded, prospective, randomized, control trial in two high-volume MC facilities, we will compare two groups of adult MC clients with cell phones randomized 1:1 into two groups: 1) routine care (control group N=361) and 2) clients who receive and respond to a daily text with in-person follow-up only if desired or if a complication is suspected (intervention N=361). If an intervention client responds affirmatively to any automated daily text with a suspected AE, an MC nurse will exchange manual, modifiable, scripted texts with the client to determine symptoms and severity, requesting an in-person visit if desired or warranted. Both arms will complete a study-specific, Day 14, in-person, follow-up review for verification of self-reports (intervention) and comparison (control). Data collection includes extraction of routine client MC records, 2WT study-specific database reports, and participant usability surveys. Intent-to-treat (ITT) analysis will explore differences between groups to determine if two-way texting (2wT) can safely reduce MC follow-up visits; estimate the cost savings associated with 2wT over routine MC follow-up; and assess the acceptability and feasibility of 2wT for scale-up.
Discussion: It is expected that this mobile health intervention will be as safe as routine care while providing distinct advantages in efficiency, costs, and reduced healthcare worker burden. The success of this intervention could lead to adaptation and adoption of this intervention at the national level, increasing efficiency of MC scale up, reducing burdens on providers and patients.
ClinicalTrials.gov Registration Number: NCT03119337. Registered April 18, 2017, https://clinicaltrials.gov/ct2/show/NCT03119337
Keywords: Voluntary medical male circumcision, Zimbabwe, mobile health, healthcare delivery innovations
... These are Short Message Service (SMS) and telephone call or voice call. These interventions shown to be more effective reduce patients missed medication and at increasing attendance rates [13]. SMS text message is more effective to be used as reminder technology particularly in the developing nations where mobile network connections are not stable. ...
... With two thirds of the world's population having access to mobile phones, mobile health (mHealth) strategies are being used worldwide. [8][9][10][11] This expansion of technology has fostered the creation and implementation of health-focused educational videos spanning a wide range of diseases and diagnoses, including reproductive health, glaucoma, foot care, schistosomiasis, human immunodeficiency virus (HIV), and the hepatitis C virus. [12][13][14][15][16][17] Most of the existing literature focuses on the effectiveness of health education videos for urban populations in high-resource settings; documented implementation and evaluation of videos in low-resource settings are limited. ...
SETTING: Access to information about tuberculosis (TB) is vital to ensure timely diagnosis, treatment, and control among vulnerable communities. Improved approaches for distributing health education materials to remote populations are needed. OBJECTIVE: To evaluate the impact of two comprehensive video training curricula in improving patient, community member, and community health worker knowledge of TB in a remote area of Madagascar. DESIGN: A pre-test/post-test design was used to measure knowledge acquisition. Educational videos were short, culturally appropriate films presented at critical moments in the TB cascade of care. RESULTS: Of the total 146 participants, 86 (58.9%) improved their score on the post-test, 50 (34.2%) obtained the same score, and 10 (6.8%) received a worse score. A statistically significant difference was observed between the pre- and post-test scores, wherein scores increased by a median of 10.0% (interquartile range 0.0–20.0) after viewing the videos ( P < 0.001). There was a significant difference between the number of correct answers on the pre-test and the number of correct answers on the post-test ( P < 0.001). CONCLUSION: Educational videos were found to significantly improve TB knowledge among a low-literacy, remote population in Madagascar. Our findings suggest educational videos could be a powerful, low-cost, and sustainable tool to improve access to TB education materials globally.
... However, very little research has been done to understand its effectiveness. For example, community health care workers commonly use mobile technology to collect field-based health data, receive alerts and reminders, and facilitate health education, often requiring them to participate in the design and evaluation process [7]. Commonly, mHealth programs emerge from a strongly clinical perspective, focusing on engaging community healthcare workers and asking them to adhere to evidence-based protocols, policies, and procedures. ...
This paper explores the challenges of HCI work within multidisciplinary research projects across health sciences, social sciences, and engineering, through discussion of a specific case study research project focused on supporting under-resourced pregnant women. Capturing the perspectives of community-based health care workers (N=14) using wearable technology for servicing pregnant women provided insight into considerations for technology for this specific population. Methods of inquiry included design and development of a prototype wearable and mobile system as well as self-report via a survey detailing their experience with the system and how it can possibly benefit their duties of monitoring their pregnant patients. The process outcomes of this work, however, provide broader insight into the challenges of conducting this kind of interdisciplinary work that remain despite decades of effort and financial investment to support interdisciplinary research, particularly in health informatics and interactive technologies for health.
... Anthropometric measurements were taken using standardized procedures. Data collection was carried out electronically in ODK (Open Data Kit), an Android-based open-source mobile platform software (24) . ...
... Collected information was recorded electronically in an android based mobile app, ODK (Open Data Kit), with an efficient user-friendly interface, which is particularly effective in low resource settings. ODK can be performed in both online and offline and can be administered by people with minimal educational attainment [25]. ...
Background:
Despite progress, suboptimal feeding practices and undernutrition particularly in the form of stunting still remains a major issue among children aged less than 5 years in Bangladesh. Since mothers are the primary caregivers of young children, maternal nutrition counselling can be effective in improving knowledge and practices on child feeding. The Building Resources Across Communities (BRAC) initiated a nutrition counselling intervention using its essential health care (EHC) skeleton in 114 sub-districts of Bangladesh in 2012. This study assessed the role of this intervention on the prevalence of stunting and feeding practices among children aged less than 5 years.
Methods:
The data was collected as part of a nationwide cross-sectional survey, which followed a two-stage cluster random sampling procedure and was conducted between October 2015 and January 2016. The present study analyzed the information of 3009 mother-children dyads from two selected survey areas: i) areas where the EHC package was delivered (comparison; n = 1452), ii) areas with EHC plus nutrition counselling package (intervention; n = 1557) was delivered. The Chi-square test was done to compare the child feeding practices and stunting prevalence between intervention and comparison. The degree of strength of the association of stunting and the intervention was estimated using a mixed-effect logistic regression model.
Results:
The study revealed that the prevalence of stunting was significantly lower in areas where the intervention was delivered compared to the comparison areas (29% vs. 37%, P < 0.001). Furthermore, after adjusting for administrative zone, household wealth quintile, child's age, gender, maternal age, education, occupation, cluster disparity, and variation between study groups, it was seen that the risk of stunting was 25% lower in the intervention areas compared to the comparison areas (aOR: 0.75, 95% CI: 0.60-0.94; P = 0.012). Optimal child feeding practices were also more common among mothers from intervention areas than those of the comparison areas (exclusive breastfeeding: 72.7 vs. 59.4%, P = 0.008; feeding 4+ food groups: 42.9 vs. 34.1%, P < 0.001; having minimum acceptable diet: 31.2 vs. 25.3%, P = 0.017; feeding multiple micro-nutrient powder: 16.2 vs. 7.4%, P < 0.001).
Conclusions:
The study highlighted that nutrition counselling of mothers may be effective in reducing childhood stunting with concomitant improvement in optimal feeding practices in children under 5 years of age. The frontline community health workers can be trained to counsel mothers on optimal child feeding practices and this could help reduce the prevalence of stunting.
... By partnering with a well-established non-profit mHealth organization, Medic Mobile (http://medicmobile.org/), and integrating with their existing software platform, open-source community and current efforts to integrate with existing health information systems (HIS) throughout sub-Saharan Africa, our team and proposed intervention are well-positioned to scale up and sustain any promising results. Since 2008, Medic Mobile has been a leader in the global mHealth community [46][47][48], equipping more than 13,500 health workers serving over 8 million people across 23 countries. The Mobile Medic Toolkit is an Android-based application that supports texting in any language and works with or without Internet connectivity on basic phones, smartphones, tablets, and computers [49]. ...
Background:
Surgical male circumcision (MC) safely reduces risk of female-to-male HIV-1 transmission by up to 60%. The average rate of global moderate and severe adverse events (AEs) is 0.8%: 99% of men heal from MC without incident. To reach the 2016 global MC target of 20 million, productivity must double in countries plagued by severe healthcare worker shortages like Zimbabwe. The ZAZIC consortium partners with the Zimbabwe Ministry of Health and Child Care and has performed over 120,000 MCs. MC care in Zimbabwe requires in-person, follow-up visits at post-operative days 2,7, and 42. The ZAZIC program AE rate is 0.4%; therefore, overstretched clinic have staff conducted more than 200,000 unnecessary reviews of MC clients without complications.
Methods:
Through an un-blinded, prospective, randomized, controlled trial in two high-volume MC facilities, we will compare two groups of adult MC clients with cell phones, randomized 1:1 into two groups: (1) routine care (control group, N = 361) and (2) clients who receive and respond to a daily text with in-person follow up only if desired or if a complication is suspected (intervention group, N = 361). If an intervention client responds affirmatively to any automated daily text with a suspected AE, an MC nurse will exchange manual, modifiable, scripted texts with the client to determine symptoms and severity, requesting an in-person visit if desired or warranted. Both arms will complete a study-specific, day 14, in-person, follow-up review for verification of self-reports (intervention) and comparison (control). Data collection includes extraction of routine client MC records, study-specific database reports, and participant usability surveys. Intent-to-treat (ITT) analysis will be used to explore differences between groups to determine if two-way texting (2wT) can safely reduce MC follow-up visits, estimate the cost savings associated with 2wT over routine MC follow up, and assess the acceptability and feasibility of 2wT for scale up.
Discussion:
It is expected that this mobile health intervention will be as safe as routine care while providing distinct advantages in efficiency, costs, and reduced healthcare worker burden. The success of this intervention could lead to adaptation and adoption of this intervention at the national level, increasing the efficiency of MC scale up, and reducing burdens on providers and patients.
Trial registration:
ClinicalTrials.gov, NCT03119337 . Registered on 18 April 2017.
... The mHealth prototype was develop by Medic Mobile, a non-profit technology organization that designs, builds and implements open-source software for community health workers, including a parallel low-cost SIM card application operating on thin SIM cards [20]. The prototype was based on "human-centered design" [21]; this approach prioritises the needs of the users of the prototype, and takes into account the context and setting in which it will be used. ...
Background:
Rates of cervical and oral cancer in India are unacceptably high. Survival from these cancers is poor, largely due to late presentation and a lack of early diagnosis and screening programmes. Mobile Health ('mHealth') shows promise as a means of supporting screening activity, particularly in rural and remote communities where the required information infrastructure is lacking.
Methods:
We developed a mHealth prototype and ran training sessions in its use. We then implemented our mHealth-supported screening intervention in 3 sites serving poor, low-health-literacy communities: RUHSA (where cervical screening programmes were already established), Mungeli (Chhattisgarh) and Padhar (Madhya Pradesh). Screening was delivered by community health workers (CHWs - 10 from RUHSA, 8 from Mungeli and 7 from Padhar), supported by nurses (2 in Mungeli and Padhar, 5 in RUHSA): cervical screening was by VIA; oral cancer screening was by mouth inspection with illumination. Our evaluation comprised an analysis of uptake in response to screening and follow-up invitations, complemented by qualitative data from 8 key informant interviews and 2 focus groups.
Results:
8686 people were screened through the mHealth intervention - the majority (98%) for oral cancer. Positivity rates were 28% for cervical screening (of whom 37% attended for follow-up) and 5% for oral cancer screening (of whom 31% attended for follow-up). The mHealth prototype was very acceptable to CHWs, who felt it made the task of screening more reliable. A number of barriers to screening and follow-up in test-positive individuals were identified. Use of the mHealth prototype has had a positive effect on the social standing of the CHWs delivering the interventions.
Conclusions:
mHealth approaches can support cancer screening in poor rural communities with low levels of health literacy. However, they are not sufficient to overcome the range of social, cultural and financial barriers to screening and follow-up. Approaches which combine mHealth with extensive community education, tailored to levels of health literacy in the target population, and well-defined diagnostic and treatment pathways are the most likely to achieve a good response in these communities.
Background
Differentiated service delivery (DSD) increases antiretroviral therapy (ART) access in sub-Saharan Africa by moving clients out of congested ART clinics to communities for care. However, DSD settings challenge provider adherence to complex, chronic care treatment guidelines and have burdensome systems for client monitoring and evaluation (M&E), reducing data for decision-making. Electronic medical record systems (EMRS) improve client outcomes and reduce M&E workload. Traditional EMRS cannot operate in most DSD settings with unreliable power and poor connectivity.
Objective
This study aims to detail the human-centered design (HCD) process of developing a mobile EMRS for community-based DSD services in Lilongwe, Malawi.
Methods
Lighthouse Trust (LT) operates 2 Ministry of Health (MoH) clinics in Lilongwe, Malawi, with a combined total of >35,000 ART clients. LT’s real-time, point-of-care EMRS collects complex client M&E data and provides decision-making support, ensuring adherence to integrated HIV and tuberculosis guidelines that optimize client and program outcomes. LT’s EMRS scaled to all large MoH ART clinics. LT also implements a nurse-led community-based ART program (NCAP), a DSD model to provide ART and rapid assessment for 2400 stable LT clients in the community. LT, alongside collaborators, from the University of Washington’s International Training and Education Center for Health and technology partner, Medic, used the open-source Community Health Toolkit (CHT) and HCD to develop an open-source, offline-first, mobile EMRS-like app, “community-based ART retention and suppression” (CARES). CARES aims to bring EMRS-like provider benefits to NCAP’s DSD clients.
Results
CARES design took approximately 12 months and used an iterative process of highly participatory feedback sessions with provider, data manager, and M&E team inputs to ensure CARES optimization for the NCAP and LT settings. The CARES mobile EMRS prototype supports NCAP providers with embedded prompts and alerts to ensure adherence to integrated MoH ART guidelines, aiming to improve the quality of client care. CARES facilitates improved data quality and flow for NCAP M&E, aiming to reduce data gaps between community and clinic settings. The CARES pilot demonstrates the potential of a mobile, point-of-care EMRS-like app that could benefit NCAP clients, providers, and program teams with integrated client care and complete M&E data for decision-making. CARES challenges include app speed, search features to align longitudinal records, and CARES to EMRS integration that supports timely care alerts.
Conclusions
Leveraging the CHT and HCD processes facilitated the design of a locally specified and optimized mobile app with the promise to bring EMRS-like benefits to DSD settings. Moving from the CARES prototype to routine NCAP implementation should result in improved client care and strengthened M&E while reducing workload. Our transparent and descriptive process shares the progress and pitfalls of the CARES design and development, helping others in this digital innovation area to learn from our experiences at this stage.
Behavior change and improving health literacy based on normative ideals of motherhood is a dominant paradigm to address maternal health challenges. However, these ideals often remove women’s control over their bodies overlooking how the bodily experiences of pregnancy are socially and culturally constructed. We report on 27 interviews with pregnant women and nursing mothers in rural and semi-urban areas of South India, and six focus groups with 23 frontline health workers as secondary data. We explore how the embodied pregnancy experiences are infuenced and negotiated by the socio-cultural context and existing care infrastructures. Our fndings highlight how the ways of seeing, knowing, and caring for a body of a pregnant woman through often conficting norms, beliefs and practices of medicine, nourishment and care actively shape the experiences of pregnancy. We open up a space for novel opportunities for digital health technologies to enhance women’s embodied experiences and pregnancy care infrastructures in the Global South.
A well-managed and accountable agricultural extension service can play an essential role in realizing food security and improving rural livelihoods. However, for the majority of the developing countries, establishing an accountable agricultural extension system remains a challenge. Public agricultural extension services, in particular, have been highly criticized for weak accountability of field agents to both their supervisors and their clients. Public agricultural extension systems often deploy large numbers of field agents in geographically dispersed, remote areas, which makes supervision difficult. Typically, there is also a lack of resources and of robust mechanisms to enable both the supervisors and beneficiaries to adequately follow up the activities of the field agents and provide feedback, which contributes to problems of absenteeism of field staff. Due to resource constraints, central managers also face challenges to supervise the agricultural extension managers, who are the supervisors of the field agents. Taking Uganda as a case study, this thesis explores the use of new mechanisms for addressing these long-standing challenges of creating accountability in public agricultural extension services. The thesis had three objectives: (1) To design a diary for agricultural field agents, which should facilitate planning and supervision of agricultural extension service provision; (2) to assess the potential of different versions of this diary for strengthening accountability in public extension services; and (3) to analyze the performance of agricultural extension managers. To meet the first two objectives, three versions of a diary for agricultural field agents were designed. The first version was a diary in a paper format, which was specifically designed to match the system of planning and reporting applied in Ugandas public extension service. This version was then transformed into an electronic version of the diary (e-diary), which resembled an electronic questionnaire. Based on the assessment of these two diary versions, an improved e-diary was developed, which comprises a smartphone application to be used by the field agents, and a web-based system that allows extension supervisors to review the data entered by the field agents and provide them with feedback. Moreover, the system was designed in such a way that it is possible for extension supervisors to collect information from the beneficiaries for verification. For the assessment of the three different versions of the diary, a qualitative participatory research approach was applied. Data on the experience with using the diary was collected through a combination of focus group discussions and individual face-to-face interviews. The content analysis method was applied to analyse the data. The results suggest that a diary for agricultural field agents has a unique potential to strengthen accountability in public agricultural extension services. This is achieved through improving planning, reporting, monitoring and evaluation of extension activities and through reducing absenteeism as well as enabling of beneficiary feedback. The findings further indicate that, for the following reasons, an electronic version of the diary is more effective in strengthening accountability than a paper version: An e-diary can make use of the Global Positioning System (GPS), which allows extension supervisors to verify whether field agents actually conducted the activities that they indicate in the diary. Thus, an e-diary enables remote supervision, which reduces the time and costs of supervision. An e-diary also facilitates real-time reporting, which enables near real-time supervision, thereby increasing the frequency of supervision. However, the first e-diary version that resembled an electronic questionnaire had drawbacks, since it focused on data collection and had limited opportunities for feedback and interaction between the extension agents and their supervisors. However, the final e-diary version, which combines a smartphone app with a web-based system, made it possible to address this limitation. Expectedly, the assessment also revealed some limitations regarding the e-diary. Some of the users were initially apprehensive about the e-diary due to their limited experience with the use of smartphones. Consequently, the implementation of the e-diary necessitates intensive training of the users, which should not be underestimated. The results also showed that the use of the e-diary was affected by inaccessibility to electricity. Therefore, promoting the use of solar chargers or power banks in areas with poor electrification is recommended. Moreover, limited network coverage implies that the e-diary needs to be programmed in such a way that data can be entered off-line. Furthermore, the findings suggest the need to combine the implementation of the e-diary with incentives, such as awards of recognition. In view of the essential role that extension managers, as the supervisors of the field agents, play for accountability, an analysis of their performance was included as the third objective of the thesis. To meet this research objective, a quantitative research approach was applied. The main data source was the extension management system that was set up by the Ugandan Ministry of Agriculture, Animal Industries and Fisheries (MAAIF). This system provides data on the timeliness of the submission of work plans and reports by the extension managers, which makes it possible to calculate measurable indicators of managers performance based on their expected roles and responsibilities. In addition to preparing descriptive statistics of such performance indicators, econometric models were estimated, using additional data from secondary sources on variables, which were hypothesized to influence the managers performance. The descriptive statistics of the performance indicators showed that the majority of the extension managers were not able to meet the performance requirements of MAAIF. The econometric analysis made it possible to identify factors that were associated with performance. The amount of the extension grant provided to the district and the ratio of extension workers to households were found to be key factors. The findings led to the recommendation to improve the performance of the extension managers through capacity building, especially in management, and through setting-up a strict performance monitoring system, to which the use of the e-diary could contribute. It was also recommended to increase funding to the districts and improve the ratio of extension workers to households so as to provide better working conditions and incentives to extension staff and their managers. Overall, the thesis indicates that diaries, especially electronic ones, in combination with monitoring systems for extension managers, offer a unique and largely underutilized potential to address entrenched problems of ensuring accountability in public agricultural extension services. It was also pointed out that additional accountability mechanisms will be useful to further strengthen accountability, in particular mechanisms that allow the beneficiaries of the extension service to provide direct feedback on the quality of service provision. The thesis also highlights the potential of using digital tools for strengthening both upward and downward accountability in public extension services. The findings of the thesis are likely to be relevant not only for agricultural extension services but also for other public services, such as rural health care and education, which face similar problems of managing large numbers of field agents in geographically dispersed, remote areas, where effective supervision is an inherent challenge.
The introduction of digital technology has sparked new debates about the value of community health workers in low- and middle-income countries. This debate offers important insights into the conventions that are relevant in global public health. Community health workers, a workforce that was already celebrated during the 1970s Primary Health Care movement, are having a remarkable revival in recent years, and myriad actors seek to boost their impact through mobile devices. Our content analysis of the public health literature evaluating this impact reveals the centrality of attempts at reconciling equity and cost effectiveness concerns, and thus considerable normative tensions. Additionally, we find that discussions about “domestic” values such as privacy and gender roles come with a paternalistic undertone, calling for feminist and postcolonial engagement with the digitalization of community health work.
This study, conducted in Karea village (Daskalgram-Karea II) under Bolpur subdivision of Birbhum district, aimed to assess how mobile telephony is impacting delivery and availability of healthcare services. Given that the village has previously had issues with healthcare support system, it emerged as ideal ground for this study. Employing survey, focus group discussion and interviews of varied stakeholders, this study found high mobile phone ownership in the village. Smartphone use is also not uncommon. People are using mobiles for healthcare purposes, but a large number is not doing so. They are using their phones for other purposes, but not really for healthcare. This underlines opportunity for healthcare workers and officials to encourage more villagers to use mobile phones for calling health support. Notwithstanding this, phones are being used by villagers to call for ambulances and doctors and get patients admitted into hospitals. Workers and officials are also using phones to spread awareness about health issues and health-related programmes. More awareness-building initiatives about use of mobiles for availing healthcare services, need to be undertaken which can make beneficial impact on ground.
Mobile survey tools (MSTs) are helpful for the collection and management of massive field information for the surveying and planning of township land resources. Willingness and consciousness information, which are derived from residents, are critical for land resources business at the rural scale. However, existing MSTs focus on surrounding environmental information collection (locations, environmental photos, and geography features records), while subjective information that reflects residents' consciousness and willingness is rarely considered. To overcome this deficiency, this study developed ‘Townplan-APP’ to collect multiple types of information for township land resource surveying. Three functions were realized to ensure that objective and subjective information could be collected and managed in real time. First, collection of surrounding environment information is determined as the basic function, which is designed in accordance with existing APPs. This function supports the recording of latitude and longitude, as well as photos and texts that represent environmental features. Second, the interview and questionnaire information collection function, which is the most important novel component in this APP, was designed to record specific residents' consciousness and willingness according to online questionnaires filling. This function was operated in accordance with universal processes, such as ‘template presetting - questionnaire updating-questionnaire filling-questionnaire delivering’. Hence, default templates are provided and can be applied directly to the following surveys, which are oriented to similar businesses, rather than redesigning questionnaires. In addition, updating and revising templates are also supported. Third, back-end management, especially the surveying data representation function, which ensures that multiple types of surveying information can be transmitted and represented from front-end (Mobile APP) to back-end (web-based platform) in real time, not only improves the efficiency of data transmission but also enhances the visualization effect. In general, Townplan-APP is an effective tool for township land resources surveying and planning that can be applied and promoted in international areas.
This chapter reveals the overview of mobile health systems; the adoption of mobile health systems; mobile health systems and patient monitoring; the overview of mobile health technology; the advanced issues of Electronic Health Record (EHR); and the challenges of EHR in global health care. Mobile health helps deliver the health care services with quality care, improved workflow, and increased patient interaction while minimizing complexity and cost to achieve the desired goals in health care settings. EHR systems are the real-time and patient-centered records that make information available instantly and securely to authorized users. The chapter argues that applying mobile health systems and EHR has the potential to improve health care efficiency and gain sustainable competitive advantage in global health care.
Background and Purpose: Inadequate uptake of testing for HIV remains a primary bottleneck towards universal access to treatment and care as well as an obstacle to realizing the potential of new
interventions for preventing HIV infection, including treatment for prevention and pre-exposure prophylaxis (PrEP). Kenya recently launched HIV Self testing (HIVST) approach as a strategy to increase the proportion of people living with HIV who know their HIV status. Living Goods Kenya, the implementer, in collaboration with Medic Mobile, the technology partner has conducted a HIV Self testing study to assess the effectiveness of Community health Volunteers (CHVs) in
administering HIV Self Testing Kits in the communities that they serve. This approach is aimed at reaching and empowering the hard to reach populations such as partners of Antenatal Care (ANC) attending mothers, adolescents and key population groups.
Methods: Quasi- Experimental design with a comparison between a treatment and control group intervention design with baseline surveys of households and CHVs was used.
Results: An analysis carried out showed that 78% of community members prefer assisted testing compared to unassisted testing.
Conclusions: Study results revealed that CHVs have been able to successfully carry out community distribution of HIV Self -Test kits, provide health education, counselling, testing, referral and followup of reactive clients.
Inadequate uptake of testing for HIV remains a primary bottleneck towards universal access to treatment and care as well as an obstacle to realizing the potential of new
interventions for preventing HIV infection, including treatment for prevention and pre-exposure prophylaxis (PrEP). Kenya recently launched HIV Self testing (HIVST) approach as a strategy to increase the proportion of people living with HIV who know their HIV status. Living Goods Kenya, the implementer, in collaboration with Medic Mobile, the technology partner has conducted a HIV Self testing study to assess the effectiveness of Community health Volunteers (CHVs) in administering HIV Self Testing Kits in the communities that they serve. This approach is aimed at reaching and empowering the hard to reach populations such as partners of Antenatal Care (ANC) attending mothers, adolescents and key population groups.
Access to primary healthcare in Kenya is still a challenge to many people, especially among resource-poor communities. This is mainly due to inadequate health coverage,
limited health insurance, alongside constraining socio-cultural and institutional factors. Allocative inefficacies in health spending and poor uptake of health information systems has further aggravated the already dire healthcare situation. Leveraging on well supported Community Health Workers and focusing their efforts towards the most at need members of their communities, has proven to be an effective way of providing primary health care. The purpose of this study is to test a predictive algorithm embedded in a community health workflow application that runs on android based smartphones. The algorithm utilizes historic and routine data to identify individuals with elevated risk for future negative health outcomes. By creating data driven risk profiles, the intervention enables
CHWs to optimize their time and effort towards serving the most at need members of their communities.
Community health workers (CHWs) have been effectively utilised in resource-limited settings to combat a growing demand for health access that cannot be met by the current workforce. The purpose of this study was to evaluate a CHW training programme in Malawi that integrated technology into rehabilitation care delivery. This was a retrospective cross-sectional study of a training programme conducted in December 2018. The participants were a convenience sample of all active home-based palliative care CHWs at St. Gabriel's Hospital (n = 60). The data collected included the following: a written pre- and post-knowledge test, skills competency checklist and a post-training programme survey. Descriptive frequencies described skill competency and quantitative responses from the post-training programme survey. Paired t test (α = 0.05) analysis determined the significance of knowledge acquisition. Themes in the narrative responses in the post-training survey were identified. Both training programme groups showed significantly greater knowledge on the post-test (M = 9.50, SD = 0.861; M = 9.43, SD = 0.971) compared to the pre-test (M = 7.97, SD = 1.351; M = 7.90, SD = 1.900); t(29) = 6.565, p < .001; t(29) = 4.104, p < .001 for Group 1 and Group 2, respectively. All participants demonstrated skill competency in 100% of the skills. All participants responded that the training programme helped them review skills and understand how to use technology 'A lot' on a Likert scale (no, a little, some, a lot). Facilitators of their work included training programmes, phones, communication with the hospital and collaboration amongst CHWs. Barriers included transportation needs, lack of patient care supplies and lack of caregiver compliance. Overall, utilisation of their knowledge and skills from the training programmes helped their patients make improvements in mobility and function that are meaningful to their quality of life in the village. This study highlights the importance of assessing programmes in low-resource settings with a focus on feasibility and developing local capacity.
Early detection of developmental and growth deviations enables early intervention so that children and parents suffer minimal irreversible physical and financial damage. In India however, pediatricians operate within acute time constraints that keep them from performing comprehensive developmental assessments for their patients. Parents' lack of awareness regarding growth and development milestones further hinders early detection. Our paper contributes the design and evaluation of a probe that seeks to understand the needs of variously resource-constrained middle-class parents in India for monitoring their children's growth, development, and immunization milestones. Our findings highlight the potential of mobile information-based applications to engage, assist, and empower Indian parents. In addition, we describe the affordances of a design process that originated amidst a richly resourced hackerspace organized to address the needs of under-resourced settings, and discuss the consequences of this process on our design.
The role of ICTs in providing improved healthcare to poor populations in the developing world has been the subject of considerable interest to the development community. However, despite a substantial literature, little published research has modelled both the value-added aspects of ICTs for social and economic development and those simultaneous challenges that often deter the effective utilisation of ICTs. This study investigates the benefits of, and barriers to, the effective use of ICTs within the healthcare system, specifically in Aceh Besar, Indonesia. We advance and evaluate a theoretical model which extends the so-called value-of-ICTs-to-education framework of Banuri, Zaidi, and Spanger-Siegfried (United Nations Development Programme, 200551.
United Nations Development Programme . 2005 . Promoting ICT for human development in Asia: Realizing the millennium development goals . India : Elsevier . View all references). The effect of ICTs on maternal and infant healthcare is examined in the context of the Aceh Besar Midwives Mobile-Phone Project. Focus group discussions and in-depth interviews (N=86) were conducted over three phases. Analysis of transcripts showed ICT-utilisation benefits, including the facilitation of communication, greater time efficiency, and better access to medical information. As suggested by the enhanced model, infrastructural, economic, technological, and socio-cultural factors were also observed. The implications of these findings for research and policy-making are discussed.
In this paper, we present a phone-based application called CommCare which supports community health workers (CHWs) as they provide home-based care and social support to HIV+ and other chronic patients. We report on our experience developing and testing the application with five CHWs in Dar es salaam, Tanzania. We have developed a simple and easily useable system by rapidly prototyping CommCare with the community health workers, in quick iterations based on their feedback. The system guides the user through about 15 questions during each household visit. The CHWs answer the questions using the phone's number pad, and the results are submitted over the cellular network to our server when the session is over. We report on lessons learned from training and our initial deployment. We discuss the few hardware and software problems that arose during our initial piloting, most of which have been addressed. This use of CommCare has little effect on the time or efficiency of home visits, but results in much easier, much faster, and potentially more accurate reporting. In particular, it saves the CHWs approximately four hours per month spent on compiling reports in the paper system.
Throughout the developing world, delivery of women’s health care, specifically cervical cancer screening, is limited by cost and access to trained personnel. Visual inspection with application of 4% acetic acid (VIA) is a practical, inexpensive alternative to cytology-based screening in areas where resources are limited. Mobile telemedicine using a cellular phone to photograph the cervix after VIA allows clinicians in “see and treat” cervical cancer screening clinics to capture high-quality images of the cervix, which can then be transmitted through the cellular network to a gynecology specialist located remotely. We present results of a prospective case-control study evaluating the accuracy of offsite (remote) expert diagnosis using mobile telemedicine photographic images of the cervix with VIA (PIA) in HIV-positive women in Gaborone, Botswana.
Health information access by low-literate community health workers is a pressing need of community health programs across the developing world. We present results from a needs assessment we conducted to understand the health information access practices and needs of various types of health workers in Pakistan. We also present a prototype for speech-based health information access, as well as discuss our experiences from a pilot study involving its use by community health workers in a rural health center.
Information access by low literate users is a difficult task. Critical information, such as in the field of healthcare, can often mean the difference between life and death. We have developed spoken language interface prototypes aimed at low literate users, and tested them with community health workers in Pakistan. We present results showing that 1) in contrast to previous reports in the literature, well-designed speech interfaces significantly outperform touch-tone equivalents for both low-literate and literate users, and that 2) literacy significantly impacts task success for both modalities.
Researchers have long been interested in the potential of ICTs to enable positive change in developing regions com- munities. In these environments,ICT interventionsoften fail because political, social and cultural forces work against the changes ICTs entail. We argue that familiar uses of ICTs for information services in these contexts are less potent than their use for persuasion and motivation in order to facilitate change. We focus on India's rural maternal health system where health workers are employed in villages to persuade pregnant women to utilize health services. Health workers face challengesduetoresistance tochangein thevillage, and because of their limited education,training andstatus. These factors appear to reduce the motivation of health workers and impair their performance. For two months, we deployed short videos on mobile phones designed to persuade village women and motivate health workers. We also asked health workers to record their own videos. While our results are preliminary, they show evidence that the creation and use of videos did help (1) engage village women in dialogue, (2) show positive effects toward health worker motivation and learning, and (3) motivate key community influencers to participate in promoting the health workers. Author Keywords
Every year almost 10 million children die before reaching the age of five despite the fact that two-thirds of these deaths could be prevented by effective low-cost interventions. To combat this, the World Health Organization (WHO) and UNICEF developed the Integrated Management of Childhood Illness (IMCI) treatment algorithms. In Tanzania, IMCI is the national policy for the treatment of childhood illness. This paper describes e-IMCI, a system for administering the IMCI protocol using a PDA. Our preliminary investigation in rural Tanzania suggests that e- IMCI is almost as fast as the common practice and potentially improves care by increasing adherence to the IMCI protocols. Additionally, we found clinicians could quickly be trained to use e-IMCI and were very enthusiastic about using it in the future.
The introduction of information and communication technologies (ICT) such as mobile phones to basic health service providers in rural areas can help bridge lacunae in their work environment, resulting from under-capacitated resources, constrained access to information and delayed interventions. The midwife mobile phone project was implemented in 15 health centres in Aceh Besar, Indonesia involving 223 midwives. The study group (121 participants) used project cell phones to transmit health statistics to a central database, contact coordinators and peers for health advice and information, and communicate with doctors and patients. The ICT for healthcare development model (Author, Lwin, Ang, Lin, & Santoso, 2008) was used a heuristic to determine project effectiveness. Findings from the project indicate that the mobile phone has proven to be an effective and efficient device for facilitating smoother communication, and allowing speedier emergency response. The system also aids in gathering and disseminating health-related information to midwives, who in turn convey this knowledge to the patient community. The Technology-Community-Management model (Author & Zhao, 2009; Lee & Author, 2008) was used as a conceptual framework for probing the design of ICT for development projects. In particular, infrastructural, economic, technological, and socio-cultural barriers were examined to highlight the tension between a top-down hierarchical model of technology diffusion versus a more participatory bottom-up approach.
This article seeks to highlight some distinctive issues involved in the use of mobile information and communication technologies (MICTs) in the healthcare context. A three-layered framework for analysing cases of MICT-in-use is developed from the literature and employed to analyse evidence from a number of healthcare MICT pilot studies. These indicate that MICTs create new implementation challenges, and that developers and implementers appear to pay little attention to the particular workflow modalities of mobility and their relationship with the type of MICT. In terms of effects on clinical work practices, MICTs seemed to make access to information easier but not necessarily faster. Better integration of MICTs with other hospital systems and use of wireless networks were seen as necessary to achieve greater uptake. Areas for further research that might support the implementation of MICTs in healthcare are identified.
Background:
Clinical trials can serve as an opportunity gateway for enhanced health benefits to the target population, above and beyond the specific intervention being tested.
Objective:
The Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT), a randomized, controlled clinical trial in Lombok, Indonesia, found that supplementation during pregnancy with multiple micronutrients reduced 90-day infant mortality by nearly 20% as compared with iron-folic acid. This trial was designed as both a program and research trial and used community facilitators to serve as liaisons between the study and the pregnant women. This analysis documents the programmatic impacts of SUMMIT on health-seeking and early infant mortality resulting from community facilitators' field activities.
Methods:
Data on compliance, human resource practices, health-seeking, and health outcomes from the 31,290 SUMMIT enrollees were analyzed.
Results:
Overall compliance with either iron-folic acid or multiple micronutrients was high in the program, at 85.0%. Early prenatal care visits increased significantly. Sixty-three percent of primiparous women used a skilled birth attendant (SBA); among multiparous women, the rate of use of a SBA rose from 35% for the last birth to 53%. Use of a SBA resulted in a 30% reduction in early infant mortality (RR, 0.70; 95% CI, 0.59 to 0.83; p < .0001), independently of any reductions due to multiple micronutrients. The community facilitators played a central role in improving health-seeking; however, the quality of the community facilitators' performance was associated with the impact of the micronutrient supplement on infant health. In a subsample of community facilitators, better-performing facilitators were found to markedly improve the overall impact of the multiple micronutrients on early infant mortality (RR, 0.67; 95% CI, 0.49 to 0.92; p = .0117). In contrast, infants of women with poorly performing community facilitators were found to derive no additional benefit from the multiple micronutrients (RR, 1.04; 95% CI, 0.64 to 1.72; p = .8568).
Conclusions:
Systematic enhancements to the quality of implementation of SUMMIT led to significant increases in use of SBAs at delivery, resulting in a 30% reduction in early infant mortality independent of the impact of micronutrient supplementation. Therefore, if women were to consume multiple micronutrients on a regular basis and were to use a SBA at delivery, the risk of early infant mortality could be reduced by nearly 50%. The impacts of community facilitators in effecting changes in women's health behaviors are notable and are applicable to other health programs. Enhancements to program implementation should be driven by evidence, be accountable to the communities the program serves, and be evaluated on the basis of measurable gains in health for women and children.
Health care workers in developing countries continue to lack access to basic, practical information to enable them to deliver safe, effective care. This paper provides the first phase of a broader literature review of the information and learning needs of health care providers in developing countries.
A Medline search revealed 1762 papers, of which 149 were identified as potentially relevant to the review. Thirty-five of these were found to be highly relevant. Eight of the 35 studies looked at information needs as perceived by health workers, patients and family/community members; 14 studies assessed the knowledge of health workers; and 8 looked at health care practice.
The studies suggest a gross lack of knowledge about the basics on how to diagnose and manage common diseases, going right across the health workforce and often associated with suboptimal, ineffective and dangerous health care practices. If this level of knowledge and practice is representative, as it appears to be, it indicates that modern medicine, even at a basic level, has largely failed the majority of the world's population. The information and learning needs of family caregivers and primary and district health workers have been ignored for too long. Improving the availability and use of relevant, reliable health care information has enormous potential to radically improve health care worldwide.
Introduction of artemisinin combination therapy (ACT) has boosted interest in parasite-based malaria diagnosis, leading to increased use of rapid diagnostic tests (RDTs), particularly in rural settings where microscopy is limited. With donor support, national malaria control programmes are now procuring large quantities of RDTs. The scarcity of health facilities and trained personnel in many sub-Saharan African countries means that limiting RDT use to such facilities would exclude a significant proportion of febrile cases. RDT use by volunteer community health workers (CHWs) is one alternative, but most sub-Saharan African countries prohibit CHWs from handling blood, and little is known about CHW ability to use RDTs safely and effectively. This Zambia-based study was designed to determine: (i) whether Zambian CHWs could prepare and interpret RDTs accurately and safely using manufacturer's instructions alone; (ii) whether simple, mostly pictorial instructions (a "job aid") could raise performance to adequate levels; and (iii) whether a brief training programme would produce further improvement.
The job aid and training programme were based on formative research with 32 CHWs in Luangwa District. The study team then recruited three groups of CHWs in Chongwe and Chibombo districts. All had experience treating malaria based on clinical diagnosis, but only six had prior RDT experience. Trained observers used structured observation checklists to score each participant's preparation of three RDTs. Each also read 10 photographs showing different test results. The first group (n = 32) was guided only by manufacturer's instructions. The second (n = 21) used only the job aid. The last (n = 26) used the job aid after receiving a three-hour training.
Mean scores, adjusted for education, age, gender and experience, were 57% of 16 RDT steps correctly completed for group 1, 80% for group 2, and 92% for group 3. Mean percentage of test results interpreted correctly were 54% (group 1), 80% (group 2), and 93% (group 3). All differences were statistically significant (p < 0.05).
Manufacturer's instructions like those provided with the RDTs used in this study are insufficient to ensure safe and accurate use by CHWs. However, well-designed instructions plus training can ensure high performance. More study is underway to determine how well this performance holds up over time.
To characterize community health worker (CHW) performance using an algorithm for managing common childhood illnesses in Siaya District, Kenya, we conducted CHW evaluations in 1998, 1999, and 2001.
Randomly selected CHWs were observed managing sick outpatient and inpatient children at a hospital, and their management was compared with that of an expert clinician who used the algorithm.
One hundred, 108, and 114 CHWs participated in the evaluations in 1998, 1999, and 2001, respectively. The proportions of children treated "adequately" (with an antibiotic, antimalarial, oral rehydration solution, or referral, depending on the child's disease classifications) were 57.8%, 35.5%, and 38.9%, respectively, for children with a severe classification and 27.7%, 77.3%, and 74.3%, respectively, for children with a moderate (but not severe) classification. CHWs adequately treated 90.5% of malaria cases (the most commonly encountered classification). CHWs often made mistakes assessing symptoms, classifying illnesses, and prescribing correct doses of medications.
Deficiencies were found in the management of sick children by CHWs, although care was not consistently poor. Key reasons for the deficiencies appear to be guideline complexity and inadequate clinical supervision; other possible causes are discussed.
Clinical research can be facilitated by the use of informatics tools. We used an existing electronic medical record (EMR) system and personal data assistants (PDAs) to assess the characteristics and outcomes of patients with acute respiratory illnesses (ARIs) visiting a Kenyan rural health center.
We modified the existing EMR to include details on patients with ARIs. The EMR database was then used to identify patients with ARIs who were prospectively followed up by a research assistant who rode a bicycle to patients' homes and entered data into a PDA.
A total of 2986 clinic visits for 2009 adult patients with respiratory infections were registered in the database between August 2002 and January 2005; 433 patients were selected for outcome assessments. These patients were followed up in the villages and assessed at 7 and 30 days later. Complete follow-up data were obtained on 381 patients (88%) and merged with data from the enrollment visit's electronic medical records and subsequent health center visits to assess duration of illness and complications. Symptoms improved at 7 and 30 days, but a substantial minority of patients had persistent symptoms. Eleven percent of patients sought additional care for their respiratory infection.
EMRs and PDA are useful tools for performing prospective clinical research in resource constrained developing countries.
GuideView is a system designed for structured, multi-modal delivery of clinical guidelines. Clinical instructions are presented simultaneously in voice, text, pictures or video or animations. Users navigate using mouse-clicks and voice commands. An evaluation study performed at a medical simulation laboratory found that voice and video instructions were rated highly.
Personal digital assistants (PDAs) are extending how we use software normally associated with desktop and laptop computers. As interface design improves and specialized software becomes available, health professionals are choosing to usePDAs. A logical next step to use PDAs is in remote areas where electronic data collection is needed and electricity is limited. A test of PDAs', equipped with global positioning system, ability to improve household surveys in rural Mozambique was completed in February 2006.
Survey data are traditionally collected using pen-and-paper, with double data entry, comparison of entries and reconciliation of discrepancies before data cleaning can commence. We used Personal Digital Assistants (PDAs) for data entry at the point of collection, to save time and enhance the quality of data in a survey of over 21,000 scattered rural households in southern Tanzania.
Pendragon Forms 4.0 software was used to develop a modular questionnaire designed to record information on household residents, birth histories, child health and health-seeking behaviour. The questionnaire was loaded onto Palm m130 PDAs with 8 Mb RAM. One hundred and twenty interviewers, the vast majority with no more than four years of secondary education and very few with any prior computer experience, were trained to interview using the PDAs. The 13 survey teams, each with a supervisor, laptop and a four-wheel drive vehicle, were supported by two back-up vehicles during the two months of field activities. PDAs and laptop computers were charged using solar and in-car chargers. Logical checks were performed and skip patterns taken care of at the time of data entry. Data records could not be edited after leaving each household, to ensure the integrity of the data from each interview. Data were downloaded to the laptop computers and daily summary reports produced to evaluate the completeness of data collection. Data were backed up at three levels: (i) at the end of every module, data were backed up onto storage cards in the PDA; (ii) at the end of every day, data were downloaded to laptop computers; and (iii) a compact disc (CD) was made of each team's data each day.A small group of interviewees from the community, as well as supervisors and interviewers, were asked about their attitudes to the use of PDAs.
Following two weeks of training and piloting, data were collected from 21,600 households (83,346 individuals) over a seven-week period in July-August 2004. No PDA-related problems or data loss were encountered. Fieldwork ended on 26 August 2004, the full dataset was available on a CD within 24 hours and the results of initial analyses were presented to district authorities on 28 August. Data completeness was over 99%. The PDAs were well accepted by both interviewees and interviewers.
The use of PDAs eliminated the usual time-consuming and error-prone process of data entry and validation. PDAs are a promising tool for field research in Africa.
To review individual case histories of children who had died of pneumonia in rural Uganda and to investigate why these children did not survive.
This case-series study was done in the Iganga/Mayuge demographic surveillance site, Uganda, where 67 000 people were visited once every 3 months for population-based data and vital events. Children aged 1-59 months from November 2005 to August 2007 were included. Verbal and social autopsies were done to determine likely cause of death and care-seeking actions.
Cause of death was assigned for 164 children, 27% with pneumonia. Of the pneumonia deaths, half occurred in hospital and one-third at home. Median duration of pneumonia illness was 7 days, and median time taken to seek care outside the home was 2 days. Most first received drugs at home: 52% antimalarials and 27% antibiotics. Most were taken for care outside the home, 36% of whom first went to public hospitals. One-third of those reaching the district hospital were referred to the regional hospital, and 19% reportedly improved after hospital treatment. The median treatment cost for a child with fatal pneumonia was US$ 5.8.
There was mistreatment with antimalarials, delays in seeking care and likely low quality of care for children with fatal pneumonia. To improve access to and quality of care, the feasibility and effect on mortality of training community health workers and drug vendors in pneumonia and malaria management with prepacked drugs should be tested.
The expansion of mobile phone networks and services to developing countries presents a strategic opportunity for the health sector to maximize the contribution of the technology to meeting health objectives. Mobile phones were first introduced to Egypt in 1997, in the past few years the number of subscribers has climbed to 14 million, representing 20 percent of the country's population. Along with increased access to fixed-line telephone services and emergency wireless systems, mobile phones are changing how health services are accessed by Egyptians as well as how they are coordinated. This paper explores the natural progression of mobile phone use for health in rural and urban communities in Minia Governorate, Egypt with the objective of informing projects and policies aimed at the formal integration within the health sector.
We describe the Ca:sh project and our experiences in scaling it up from a research project to the foundation of a global operation. The Ca:sh project is a handheld-based electronic medical record (EMR) in operation in Ballabhgarh, India. The system is designed for paramedical health workers serving remote areas, giving them access to large medical databases in the field. The system addresses two important problems in developing countries: prenatal care and child health. It is open source software based on the free Linux operating system. Currently the system has been operational for 8 months and is used by 10 health workers to track over 70,000 patients. This paper first describes the technical challenges and innovation needed in the design, development, adaptation and implementation of the handheld EMR in a rural setting in India. The paper further describes the adaptations needed to scale up this pilot project to larger , diverse settings and our path from research to developmental entrepreneurship.
Claim Mobile is a platform designed to support a project that subsidizes healthcare by reimbursing health service providers in Uganda for treatment of patients with sexually transmitted infections. As with many development projects, the Uganda Output-Based Aid (OBA) project involves a number of stakeholders: the service providers, the project implementers, the financiers, and the Ugandan government. Design of an appropriate solution requires meeting the various and conflicting requirements of all of these stakeholders. In this paper we detail the rapid design and testing of a pilot implementation of a mobile and web-based system for processing claims forms, based on two prior field visits to Uganda. Based on a comparative device study, semi-structured interviews, health clinic surveys, and a brief deployment, we affirm the selection of the mobile phone as a platform from the health clinic perspective, and further suggest that effective design for development requires more than addressing requirements of the the ¿users¿ of the mobile phones but also all the other stakeholders involved, who may have conflicting requirements.
Persuasive technologies for healthcare have great potential to beneficially impact the well-being of individuals with chronic disease, support self-care, and encourage adherence to correct treatment guidelines by non-physician care providers such as medics and community health workers. However healthcare poses special challenges with respect to design and development of persuasive applications. We describe GuideView, a system now undergoing beta testing, that enables interactive, structured, multi-modal delivery of clinical advice and the authoring of such content. Information and advice is presented simultaneously using voice, pictures, video, and animation. GuideView is multi-platform, executing on desktops, over the web, on Pocket PCs, and on Windows Mobile cell-phones.
Visual inspection of the cervix with application of 4% acetic acid (VIA) is an inexpensive alternative to cytology-based screening in areas where resources are limited, such as in many developing countries. We have examined the diagnostic agreement between off-site (remote) expert diagnosis using photographs of the cervix (photographic inspection with acetic acid, PIA) and in-person VIA. The images for remote evaluation were taken with a mobile phone and transmitted by MMS. The study population consisted of 95 HIV-positive women in Gaborone, Botswana. An expert gynaecologist made a definitive positive or negative reading on the PIA results of 64 out of the 95 women whose PIA images were also read by the nurse midwives. The remaining 31 PIA images were deemed insufficient in quality for a reading by the expert gynaecologist. The positive nurse PIA readings were concordant with the positive expert PIA readings in 82% of cases, and the negative PIA readings between the two groups were fully concordant in 89% of cases. These results suggest that mobile telemedicine may be useful to improve access of women in remote areas to cervical cancer screening utilizing the VIA 'see-and-treat' method.
Mobile (cell) phone communication has been suggested as a method to improve delivery of health services. However, data on the effects of mobile health technology on patient outcomes in resource-limited settings are limited. We aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load.
WelTel Kenya1 was a multisite randomised clinical trial of HIV-infected adults initiating antiretroviral therapy (ART) in three clinics in Kenya. Patients were randomised (1:1) by simple randomisation with a random number generating program to a mobile phone short message service (SMS) intervention or standard care. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 h. Randomisation, laboratory assays, and analyses were done by investigators masked to treatment allocation; however, study participants and clinic staff were not masked to treatment. Primary outcomes were self-reported ART adherence (>95% of prescribed doses in the past 30 days at both 6 and 12 month follow-up visits) and plasma HIV-1 viral RNA load suppression (<400 copies per mL) at 12 months. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00830622.
Between May, 2007, and October, 2008, we randomly assigned 538 participants to the SMS intervention (n=273) or to standard care (n=265). Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group (relative risk [RR] for non-adherence 0·81, 95% CI 0·69-0·94; p=0·006). Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group, (RR for virologic failure 0·84, 95% CI 0·71-0·99; p=0·04). The number needed to treat (NNT) to achieve greater than 95% adherence was nine (95% CI 5·0-29·5) and the NNT to achieve viral load suppression was 11 (5·8-227·3).
Patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcome in resource-limited settings.
US President's Emergency Plan for AIDS Relief.
Low physician density, undercapacitated laboratory infrastructures, and limited resources are major limitations to the development and implementation of widely accessible cervical cancer prevention programs in sub-Saharan Africa.
We developed a system operated by nonphysician health providers that used widely available and affordable communication technology to create locally adaptable and sustainable public sector cervical cancer prevention program in Zambia, one of the world's poorest countries.
Nurses were trained to perform visual inspection with acetic acid aided by digital cervicography using predefined criteria. Electronic digital images (cervigrams) were reviewed with patients, and distance consultation was sought as necessary. Same-visit cryotherapy or referral for further evaluation by a gynecologist was offered. The Zambian system of "electronic cervical cancer control" bypasses many of the historic barriers to the delivery of preventive health care to women in low-resource environments while facilitating monitoring, evaluation, and continued education of primary health care providers, patient education, and medical records documentation.
The electronic cervical cancer control system uses appropriate technology to bridge the gap between screening and diagnosis, thereby facilitating the conduct of "screen-and-treat" programs. The inherent flexibility of the system lends itself to the integration with future infrastructures using rapid molecular human papillomavirus-based screening approaches and wireless telemedicine communications.
We present a model for the development of sustainable primary health care in village communities in Honduras through the training and support of community health workers. The model follows a "bottom-up" approach using community-centered data generation, problem-specific curriculum development, and ongoing knowledge maintenance and support for community-based care givers. Health worker training, evaluation, and support are provided by US-based primary care professionals.
The intervention is designed in five stages: (1) background needs assessment based on patient chart reviews to identify prevalent health problems, (2) selection of target communities, (3) obtaining community involvement and prospective health worker commitment, (4) development and implementation of a needs-specific curriculum for health worker training and community health education, and (5) maintenance, evaluation, and expansion of training and support for community health workers.
Chart review of 725 children identified respiratory tract disease, gastrointestinal infections, and skin infections as predominant health problems. A curriculum for health workers was designed to address these and was implemented in a 1-week training program in two target communities. After 15 months of practice, health workers had attended 2,347 patients. Three monthly review and refresher sessions improved case management accuracy significantly.
The establishment of sustainable primary health care in remote, underserved communities using community health workers is possible and feasible, even in countries that do not have a national health worker network. Primary care professionals can play an instrumental role in project design, management, and supervision.
The aim of this new statement is to provide a comprehensive and evidence-based review of the scientific data evaluating the use of telemedicine for stroke care delivery and to provide consensus recommendations based on the available evidence. The evidence is organized and presented within the context of the American Heart Association's Stroke Systems of Care framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class of evidence. Evidence-based recommendations are included for the use of telemedicine in general neurological assessment and primary prevention of stroke; notification and response of emergency medical services; acute stroke treatment, including the hyperacute and emergency department phases; hospital-based subacute stroke treatment and secondary prevention; and rehabilitation.
The low-cost Microscopic Observation Drug Susceptibility (MODS) assay is a non-proprietary test that delivers rapid and accurate diagnosis of tuberculosis (TB) and multidrug-resistant TB. Although methodologically straightforward, implementation is challenging in isolated settings where personnel trained in plate reading are lacking. One affordable strategy to address this shortfall is the use of mobile phones, first to transmit images captured by an inverted microscope to a remote site where pattern recognition is performed by trained personnel, and second to receive the resulting output of this analysis. Such a system could be used for training of laboratory personnel through distance learning, resolution of equivocal appearances and quality assurance.
This article is based on a collaborative research study of policy and practice in national community health worker (CHW) programs in developing countries. The study involved a review of the relevant literature, case studies in Botswana, Colombia and Sri Lanka, and an international workshop where the future of such programs was discussed. The findings of this research are discussed under four headings: unrealistic expectations, poor initial planning, problems of sustainability, and the difficulties of maintaining quality. It is clear that existing national community health worker programs have suffered from conceptual and implementation problems. However, given the interest and political will, governments can address these problems by adopting more flexible approaches within their CHW programs, by planning for them within the context of all health sector activities rather than as a separate activity, and by immediately addressing weaknesses in task allocation, training and supervision. CHWs represent an important health resource, whose potential in extending coverage and providing a reasonable level of care to otherwise underserved populations must be fully tapped.
Integrated Management of Childhood Illness (IMCI) has been adopted by over 80 countries as a strategy for reducing child mortality and improving child health and development. It includes complementary interventions designed to address the major causes of child mortality at community, health facility, and health system levels. The Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (IMCI-MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. The MCE is coordinated by the Department of Child and Adolescent Health and Development of the World Health Organization. MCE studies are under way in Bangladesh, Brazil, Peru, Tanzania and Uganda. In Tanzania, the IMCI-MCE study uses a non-randomized observational design comparing four neighbouring districts, two of which have been implementing IMCI in conjunction with evidence-based planning and expenditure mapping at district level since 1997, and two of which began IMCI implementation in 2002. In these four districts, child health and child survival are documented at household level through cross-sectional, before-and-after surveys and through longitudinal demographic surveillance respectively. Here we present results of a survey conducted in August 2000 in stratified random samples of government health facilities to compare the quality of case-management and health systems support in IMCI and comparison districts. The results indicate that children in IMCI districts received better care than children in comparison districts: their health problems were more thoroughly assessed, they were more likely to be diagnosed and treated correctly as determined through a gold-standard re-examination, and the caretakers of the children were more likely to receive appropriate counselling and reported higher levels of knowledge about how to care for their sick children. There were few differences between IMCI and comparison districts in the level of health system support for child health services at facility level. This study suggests that IMCI, in the presence of a decentralized health system with practical health system planning tools, is feasible for implementation in resource-poor countries and can lead to rapid gains in the quality of case-management. IMCI is therefore likely to lead to rapid gains in child survival, health and development if adequate coverage levels can be achieved and maintained.
To assess the feasibility of remote management of extremity wound by using a mobile camera phone to transfer clinical images and online communication, teleconsultations were carried out on 60 patients between January and August 2003 for 82 extremity wounds presented to the emergency room between residents and consultant plastic surgeons. A questionnaire about wound descriptors (gangrene, necrosis, erythema, and cellulitis/infection), as well as clinical opinions regarding treatment with antibiotics or debridement, was filled out. In this study, 3 surgeons were able to make 80%, 76%, 66%, and 74% agreement, respectively, in the remote diagnosis regarding presence of gangrene, necrosis, erythema, and cellulitis/infection. Recognition of gangrene had the highest agreement percent (80%), sensitivity (85%), and specificity (93%). There were 68% to 90% of image sets that could be made with equivalent diagnoses of wound descriptors and 83% of wounds managed as per the remote treatment recommendation regarding whether to use antibiotics or to perform debridement. The preliminary results showed that the camera phone is valuable and bears potential for remote management of the extremity wound.
In low and middle income countries, health workers are essential for the delivery of health interventions. However, inadequate health-worker performance is a very widespread problem. We present an overview of issues and evidence about the determinants of performance and strategies for improving it. Health-worker practices are complex behaviours that have many potential influences. Reviews of intervention studies in low and middle income countries suggest that the simple dissemination of written guidelines is often ineffective, that supervision and audit with feedback is generally effective, and that multifaceted interventions might be more effective than single interventions. Few interventions have been evaluated with rigorous cost-effectiveness trials, and such studies are urgently needed to guide policy. We propose an international collaborative research agenda to generate knowledge about the true determinants of performance and about the effectiveness of strategies to improve performance. Furthermore, we recommend that ministries of health and international organisations should actively help translate research findings into action to improve health-worker performance, and thereby improve health.
Medical residents from Yaounde I University in Cameroon are required to spend periods of time in rural or remote locations to complete their training. To determine if e-health might lessen their isolation and enhance patient care, a needs assessment of the residents was performed using a brief questionnaire (five items) about the situation in which residents found themselves outside their medical school environment. We gave the questionnaires to 45 residents. Seventeen questionnaires had been returned at the time of the site visit, a response rate of 38%. Most residents indicated that the ability to contact a mentor would have either made them feel more confident (16, or 94%) or altered their handling of recent cases (15, or 88%). All residents had access to a mobile phone, and many (11, or 65%) had used it to contact a medical colleague for guidance. A low-cost and technologically simple telemedicine solution that maximized use of mobile phone capability, provided access to medical and health-care information, and permitted exchange of images would be an appropriate response to the identified needs.
To investigate community health workers' (CHW) adherence over time to guidelines for treating ill children and to assess the effect of refresher training on adherence.
Analysis of 7151 ill-child consultations performed by 114 CHWs in their communities from March 1997-May 2002. Adherence was assessed with a score (percentage of recommended treatments that were prescribed), calculated for each consultation. Recommended treatments were those that were indicated based on CHW assessments. We used piecewise regression models to evaluate adherence before and after training.
The average adherence score was 79.4%. Multivariable analyses indicate that immediately after the first refresher training, the mean adherence level improved for patients with a severe illness, but worsened for patients without severe illness. Adherence scores declined rapidly during the 6 months after the second refresher training.
The first refresher was partially effective, the second refresher had an effect contrary to that intended, and patient characteristics had a strong influence on adherence patterns. Longitudinal studies are useful for monitoring the dynamics of CHW performance and evaluating effects of quality improvement interventions.
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