Disparities in healthcare access and utilization and human papillomavirus (HPV) vaccine initiation in the United States

Currently in the United States, Human Papillomavirus (HPV) vaccination coverage among eligible individuals is lower compared to coverage goals of 80% set by the HealthyPeople 2030 initiative. In this study, we used the National Health and Nutrition Examination Survey (NHANES) 2015-2016 and 2017-2018 datasets to determine the association between HPV vaccine initiation among individuals of ages 9 to 26 years and their patterns of healthcare access and utilization. In particular, we examined the following healthcare characteristics: 1) having a routine place of healthcare, 2) having health insurance coverage, 3) frequency of healthcare visits per year, and 4) type of routine place of healthcare (outpatient primary care vs. ED, etc.). We fit independent multivariable logistic regression models for each NHANES dataset and controlled for sociodemographic characteristics and interactions with healthcare access and utilization characteristics. Our findings suggest that HPV vaccine initiation is positively associated with having a routine place of healthcare (2015-2016: aOR 1.92, 95% CI 1.25-2.95; 2017-2018: aOR 1.99, 95% CI 1.07-3.68). Relatedly, HPV vaccine initiation is negatively associated with never having received healthcare in the past year (2015-2016: aOR 0.61, 95% CI 0.41-0.90; 2017-2018: aOR 0.45, 95% CI 0.27-0.75). The results of this study suggest that interventions to promote HPV vaccination should include strategies that promote access to and utilization of routine health care services. Our findings are particularly salient in light of the drop in HPV vaccine initiation and healthcare access and utilization among adolescents during the COVID-19 pandemic.

Examining Associations between Knowledge and Vaccine Uptake Using the Human Papillomavirus Knowledge Questionnaire (HPV-KQ)

Objectives: Understanding the relationship between human papillomavirus (HPV) knowledge and vaccination behavior is important to inform public health interventions, yet few validated HPV knowledge scales exist. This study describes development of the Human Papillomavirus Knowledge Questionnaire (HPV-KQ) and its validation with parents residing in the southern United States (US). Methods: Drawing on previously published measures, we developed the 13-item HPV-KQ and administered the scale via Web-based survey to parents (N=1105) of adolescents ages 9 to 17 years. Dimensionality, internal consistency, model fit, and predictive validity were assessed. Results: The scale was bidimensional. One factor captured general HPV knowledge, and the second factor captured perceptions of gender differences in HPV infection and vaccine recommendations. The 13-item scale and 2-factor solution displayed strong internal consistency and good model fit. Parents of vaccinated adolescents scored higher on the 13-item HPV-KQ (Mean = 8.56) than parents of unvaccinated adolescents (Mean = 6.43) (p < .001). In regression models, controlling for key covariates, parents' performance on the HPV-KQ predicted adolescent HPV vaccination (p < .001). Conclusions: Evaluation indicates the HPV-KQ is a reliable and valid tool for measuring knowledge of HPV and the HPV vaccine among parents residing in the southern US. We recommend further efforts to validate the scale with other populations.

Knowledge, attitudes, and practices regarding cervical cancer screening among women in metropolitan Lima, Peru: a cross-sectional study

BACKGROUND

Cervical cancer is a leading cause of cancer deaths among women of reproductive age in Peru. Screening and early identification of pre-cancerous lesions are a cornerstone of the cervical cancer prevention strategy. Yet, there is limited literature on barriers to screening among Peruvian women. In this cross-sectional study, we aimed to examine Peruvian women's knowledge, attitudes, and practices regarding cervical cancer screening and identify possible reasons for the gap between knowledge and screening.

METHODS

The study was conducted in metropolitan Lima from June-August 2019. We purposefully recruited 12 women who had previously been screened, and 12 who had never been screened for cervical cancer. The women completed a 40-question knowledge and attitude survey and an in-depth interview about barriers to screening. Descriptive analysis was used to calculate a knowledge and attitude score and qualitative analysis was guided by the Health Belief Model constructs.

RESULTS

Previously screened participants had greater knowledge of cervical cancer symptoms, risk factors, and prevention (mean score = 28.08, S.D. = 4.18) compared to participants who had never been screened (mean score = 21.25, S.D. = 6.35). Both groups described lack of priority and embarrassment as barriers to cervical cancer screening. For participants who had never been screened before, major barriers included the fear of a cancer diagnosis and lack of information about screening services. Pregnancy, unusual gynecological symptoms and encouragement from friends and family were cues to action for participants seeking screening. Most participants in both groups recognized the benefits of getting screened for cervical cancer. Being previously screened increased participants' self-efficacy for engaging in screening behaviors again. Misconceptions regarding screening procedures and cervical cancer were also noted as barriers for participants accessing screening services.

CONCLUSIONS

Improving knowledge and awareness about cervical cancer and screening programs may improve screening behaviors among women. Targeting women who have never been screened before and addressing their fears and concerns around embarrassment may be other areas for intervention. Misconceptions that deter women from screening services are an important issue that should be addressed in order to increase the number of women who get timely screenings.

Birth and death notification via mobile devices: a mixed methods systematic review

BACKGROUND

Ministries of health, donors, and other decision-makers are exploring how they can use mobile technologies to acquire accurate and timely statistics on births and deaths. These stakeholders have called for evidence-based guidance on this topic. This review was carried out to support World Health Organization (WHO) recommendations on digital interventions for health system strengthening.

OBJECTIVES

Primary objective: To assess the effects of birth notification and death notification via a mobile device, compared to standard practice. Secondary objectives: To describe the range of strategies used to implement birth and death notification via mobile devices and identify factors influencing the implementation of birth and death notification via mobile devices.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, the Global Health Library, and POPLINE (August 2, 2019). We searched two trial registries (August 2, 2019). We also searched Epistemonikos for related systematic reviews and potentially eligible primary studies (August 27, 2019). We conducted a grey literature search using mHealthevidence.org (August 15, 2017) and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies in Web of Science and Google Scholar (May 15, 2020). We searched for studies published after 2000 in any language.  SELECTION CRITERIA: For the primary objective, we included individual and cluster-randomised trials; cross-over and stepped-wedge study designs; controlled before-after studies, provided they have at least two intervention sites and two control sites; and interrupted time series studies. For the secondary objectives, we included any study design, either quantitative, qualitative, or descriptive, that aimed to describe current strategies for birth and death notification via mobile devices; or to explore factors that influence the implementation of these strategies, including studies of acceptability or feasibility. For the primary objective, we included studies that compared birth and death notification via mobile devices with standard practice. For the secondary objectives, we included studies of birth and death notification via mobile device as long as we could extract data relevant to our secondary objectives. We included studies of all cadres of healthcare providers, including lay health workers; administrative, managerial, and supervisory staff; focal individuals at the village or community level; children whose births were being notified and their parents/caregivers; and individuals whose deaths were being notified and their relatives/caregivers.

DATA COLLECTION AND ANALYSIS

For the primary objective, two authors independently screened all records, extracted data from the included studies and assessed risk of bias. For the analyses of the primary objective, we reported means and proportions, where appropriate. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence and we prepared a 'Summary of Findings' table. For the secondary objectives, two authors screened all records, one author extracted data from the included studies and assessed methodological limitations using the WEIRD tool and a second author checked the data and assessments. We carried out a framework analysis using the Supporting the Use of Research Evidence (SURE) framework to identify themes in the data. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in the evidence and we prepared a 'Summary of Qualitative Findings' table.

MAIN RESULTS

For the primary objective, we included one study, which used a controlled before-after study design. The study was conducted in Lao People's Democratic Republic and assessed the effect of using mobile devices for birth notification on outcomes related to coverage and timeliness of Hepatitis B vaccination. However, we are uncertain of the effect of this approach on these outcomes because the certainty of this evidence was assessed as very low. The included study did not assess resource use or unintended consequences. For the primary objective, we did not identify any studies using mobile devices for death notification. For the secondary objective, we included 21 studies. All studies were conducted in low- or middle-income settings. They focussed on identification of births and deaths in rural, remote, or marginalised populations who are typically under-represented in civil registration processes or traditionally seen as having poor access to health services. The review identified several factors that could influence the implementation of birth-death notification via mobile device. These factors were tied to the health system, the person responsible for notifying, the community and families; and include: - Geographic barriers that could prevent people's access to birth-death notification and post-notification services - Access to health workers and other notifiers with enough training, supervision, support, and incentives - Monitoring systems that ensure the quality and timeliness of the birth and death data - Legal frameworks that allow births and deaths to be notified by mobile device and by different types of notifiers - Community awareness of the need to register births and deaths - Socio-cultural norms around birth and death - Government commitment - Cost to the system, to health workers and to families - Access to electricity and network connectivity, and compatibility with existing systems - Systems that protect data confidentiality We have low to moderate confidence in these findings. This was mainly because of concerns about methodological limitations and data adequacy.

AUTHORS' CONCLUSIONS

We need more, well-designed studies of the effect of birth and death notification via mobile devices and on factors that may influence its implementation.

Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research

BACKGROUND

Nearly 90% of deaths due to cervical cancer occur in low- and middle-income countries (LMICs). In recent years, many digital health strategies have been implemented in LMICs to ameliorate patient-, provider-, and health system-level challenges in cervical cancer control. However, there are limited efforts to systematically review the effectiveness and current landscape of digital health strategies for cervical cancer control in LMICs.

OBJECTIVE

We aim to conduct a systematic review of digital health strategies for cervical cancer control in LMICs to assess their effectiveness, describe the range of strategies used, and summarize challenges in their implementation.

METHODS

A systematic search was conducted to identify publications describing digital health strategies for cervical cancer control in LMICs from 5 academic databases and Google Scholar. The review excluded digital strategies associated with improving vaccination coverage against human papillomavirus. Titles and abstracts were screened, and full texts were reviewed for eligibility. A structured data extraction template was used to summarize the information from the included studies. The risk of bias and data reporting guidelines for mobile health were assessed for each study. A meta-analysis of effectiveness was planned along with a narrative review of digital health strategies, implementation challenges, and opportunities for future research.

RESULTS

In the 27 included studies, interventions for cervical cancer control focused on secondary prevention (ie, screening and treatment of precancerous lesions) and digital health strategies to facilitate patient education, digital cervicography, health worker training, and data quality. Most of the included studies were conducted in sub-Saharan Africa, with fewer studies in other LMIC settings in Asia or South America. A low risk of bias was found in 2 studies, and a moderate risk of bias was found in 4 studies, while the remaining 21 studies had a high risk of bias. A meta-analysis of effectiveness was not conducted because of insufficient studies with robust study designs and matched outcomes or interventions.

CONCLUSIONS

Current evidence on the effectiveness of digital health strategies for cervical cancer control is limited and, in most cases, is associated with a high risk of bias. Further studies are recommended to expand the investigation of digital health strategies for cervical cancer using robust study designs, explore other LMIC settings with a high burden of cervical cancer (eg, South America), and test a greater diversity of digital strategies.

Prevalence and correlates of maternal early stimulation behaviors during pregnancy in northern Ghana: a cross-sectional survey

BACKGROUND

Per UNICEF's Nurturing Care Framework, early childhood development (ECD) begins during pregnancy and many lower-resource settings need data to inform their programs for optimal child development. The maternal-fetal relationship can be partly examined via a series of bonding activities called early stimulation behaviors (ESB). This study describes early stimulation behaviors and the associated correlates among pregnant women in Ghana.

METHODS

This cross-sectional study used data from a cluster-randomized trial in two districts of Northern Ghana. A total of 374 pregnant women were enrolled at baseline and administered a pre-intervention survey. Communication-related early stimulation behaviors was the primary outcome which was evaluated using three maternal-fetal bonding activities; did the woman self-report touching and/or talking, singing, and/or talking about family to her belly. A generalized estimating equation modified Poisson model was used for the bivariate and multivariable analysis.

RESULTS

About half of the participants reported performing communication-related ESB during pregnancy frequently or sometimes. Bivariate analysis revealed that negative life experiences including higher rates of emotional, physical and sexual intimate partner violence (IPV) and having moderate to severe depressive symptoms were associated with women performing early stimulation behaviors more often. In the multivariable model, physical intimate partner violence remained significantly associated with early stimulation behaviors.

CONCLUSION

Research on early stimulation behaviors is still in a nascent phase. It is unclear why our results revealed an association between intimate partner violence and early stimulation behaviors; this could reflect a coping mechanism for the expectant mother. Further research is needed to better understand this association and explore potential long-term impacts of early stimulation behaviors during pregnancy on child development.

TRIAL REGISTRATION

Clinical Trials # NCT03665246 , August 29, 2018.

Barriers to the uptake of cervical cancer services and attitudes towards adopting new interventions in Peru

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Cervical cancer is the leading cause of mortality in women of reproductive age in Peru.

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Increasing knowledge and awareness may promote cervical cancer screening uptake.

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Mitigating financial barriers may increase treatment rates among diagnosed women.

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Participants reported high willingness to adopt new cervical cancer interventions.

Cervical cancer mortality is high among Peruvian women of reproductive age. Understanding barriers and facilitators of cervical cancer screening and treatment could facilitate development of contextually-relevant interventions to reduce cervical cancer incidence and mortality. From April to October 2019, we conducted a cross-sectional survey with 22 medical personnel and administrative staff from Liga Contra el Cancer, in Lima, Peru. The survey included structured and open-ended questions about participants’ roles in cervical cancer prevention and treatment, perceptions of women’s barriers and facilitators for getting screened and/or treated for cervical cancer, as well as attitudes towards adopting new cervical cancer interventions. For structured questions, the frequency of responses for each question was calculated. For responses to open-ended questions, content analysis was used to summarize common themes. Our data suggest that the relative importance and nature of barriers that Peruvian women face are different for cervical cancer screening compared to treatment. In particular, participants mentioned financial concerns as the primary barrier to treatment and a lack of knowledge or awareness of human papillomavirus and/or cervical cancer as the primary barrier to screening uptake among women. Participants reported high willingness to adopt new interventions or strategies related to cervical cancer. Building greater awareness about benefits of cervical cancer screening among women, and reducing financial and geographic barriers to treatment may help improve screening rates, decrease late-stage diagnosis and reduce mortality in women who have a pre-cancer diagnosis, respectively. Further studies are needed to generalize study findings to settings other than Lima, Peru.

Parental concerns and uptake of childhood vaccines in rural Tanzania - a mixed methods study

BACKGROUND

Vaccine hesitancy has been recognized as an important barrier to timely vaccinations around the world, including in sub-Saharan Africa. In Tanzania, 1 in 4 children is not fully vaccinated. The objective of this mixed methods study was to describe and contextualize parental concerns towards vaccines in Tanzania.

METHODS

Between 2016 and 2017, we conducted a cross-sectional survey (n = 134) and four focus group discussions (FGDs, n = 38) with mothers of children under 2 years of age residing in Mtwara region in Southern Tanzania. The survey and FGDs assessed vaccination knowledge and concerns and barriers to timely vaccinations. Vaccination information was obtained from government-issued vaccination cards.

RESULTS

In the cross-sectional survey, 72% of mothers reported missed or delayed receipt of vaccines for their child. Although vaccine coverage was high, timeliness of vaccinations was lower and varied by vaccine. Rural mothers reported more vaccine-related concerns compared to urban mothers; literacy and access to information were identified as key drivers of the difference. Mothers participating in FGDs indicated high perceived risk of vaccine-preventable illnesses, but expressed concerns related to poor geographic accessibility, unreliability of services, and missed opportunities for vaccinations resulting from provider efforts to minimize vaccine wastage.

CONCLUSIONS

Findings from our cross-sectional survey indicate the presence of vaccination delays and maternal concerns related to childhood vaccines in Tanzania. In FGDs, mothers raised issues related to convenience more often than issues related to vaccine confidence or complacency. Further research is necessary to understand how these issues may contribute to the emergence and persistence of vaccine hesitancy and to identify effective mitigation strategies.

Lessons learned through piloting a community-based SMS referral system for common mental health disorders used by female community health volunteers in rural Nepal

Objective

The Community Informant Detection Tool (CIDT) is a paper-based proactive case detection strategy with evidence for improving help-seeking behavior for mental healthcare. Key implementation barriers for the paper-based CIDT include delayed reporting of cases and lack of active follow up. We used mobile phones and structured text messages to improve timeliness of case reporting, encouraging follow up, and case record keeping. 36 female community health volunteers piloted this mobile phone CIDT (mCIDT) for three months in 2017 in rural Nepal.

Results

Only 8 cases were identified by health volunteers using mCIDT, and only two of these cases engaged with health services post-referral. Accuracy with the mCIDT was considerably lower than paper-based CIDT, especially among older health volunteers, those with lower education, and those having difficulties sending text messages. Qualitative findings revealed implementation challenges including cases not following through on referrals due to perceived lack of staff at health facilities, assumptions among health volunteers that all earthquake-related mental health needs had been met, and lack of financial incentives for use of mCIDT. Based on study findings, we provide 5 recommendations—in particular attitudinal and system preparedness changes—to effectively introduce new mental healthcare technology in low resource health systems.

Development of mNavigator: Digital Health Application to Facilitate Compliance With Standardized Pediatric Cancer Treatment Protocols in Tanzania

PURPOSE

Use of standardized treatment protocols has been demonstrated to improve outcomes for pediatric patients with cancer. Yet it is challenging to implement standardized treatment protocols in low- and middle-income countries as a result of infrastructure and resource constraints, as well as poor health provider compliance with treatment protocols. At Bugando Medical Centre (BMC) in Tanzania, health provider compliance with standardized paper-based treatment protocols is low at 22%. One-year overall survival rates among pediatric patients with cancer at BMC are 40% and almost one third of patients abandon treatment. We posit that improving protocol compliance in this setting may decrease treatment abandonment and improve survival rates. Use of digital case management systems has been shown to improve compliance with treatment protocols because of the ability to incorporate such features as decision-support algorithms, prompts and alerts, and checklists. The digital health application mNavigator was designed to facilitate health provider compliance with standardized pediatric cancer treatment protocols in Tanzania.

METHODS

mNavigator was developed by adapting an open-source digital case management platform called CommCare. The three stages of mNavigator development were as follows: workflow mapping and form development; form programming in CommCare; and quality assurance using mock and deidentified patient records to identify errors in information flow or outputs, assess preliminary usability, and determine areas for improvement. Standardized treatment protocols for Burkitt lymphoma and retinoblastoma were initially incorporated into mNavigator. The mNavigator prototype underwent usability testing at BMC before implementation in routine clinical practice.

RESULTS

Preliminary system usability, acceptance, and satisfaction evaluation demonstrated high usability response scores (> 80%). Perceived benefits of the mNavigator system included a user-friendly interface, improved record keeping, and assistance with patient tracking using standardized treatment protocols. Suggestions for improvement centered on the incorporation of other standardized treatment protocols (eg, Wilms tumor), improving interoperability with existing electronic recordkeeping systems, and making similar systems available for other clinical departments.

CONCLUSION

To our knowledge, mNavigator is the first digital health case management system specifically developed to improve health provider compliance with pediatric cancer treatment protocols in a low-resource setting. With high usability and acceptability, mNavigator has been implemented in routine clinical practice. Implementation and patient outcomes evaluations are ongoing and will inform the scale-up for use in other low- and middle-income countries.

Correction: Evaluating the Feasibility and Acceptability of a Mobile Health–Based Female Community Health Volunteer Program for Hypertension Control in Rural Nepal: Cross-Sectional Study

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Patterns of Mobile Phone Ownership and Use Among Pregnant Women in Southern Tanzania: Cross-Sectional Survey

Background

There is a paucity of subnational data on patterns of mobile phone ownership and use in Tanzania to inform the development of digital health interventions.

Objective

The aim of this study is to assess patterns of mobile phone ownership and use in pregnant women to inform the feasibility and design of digital health interventions for promoting timely uptake of childhood vaccines in southern Tanzania.

Methods

Between August and November 2017, pregnant women in their third trimester were enrolled at health facilities and from surrounding communities, and asked about their patterns of mobile phone ownership and use in an interviewer administered survey.

Results

Of 406 women, only 3 had never used a phone. Most women (>98%) could make and receive phone calls. Compared to urban women, rural women reported higher mobile phone use rates but were less likely to be sole owners of phones, and less likely to send or receive SMS, transact money, browse the internet, or use social media via mobile phones.

Conclusions

The findings suggest high feasibility for digital health interventions delivered via mobile phones to pregnant women in southern Tanzania. The feasibility of smartphone-based interventions or strategies relying on the use of social media or the internet is limited.

Using digital health to facilitate compliance with standardized pediatric cancer treatment guidelines in Tanzania: protocol for an early-stage effectiveness-implementation hybrid study

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.

Evaluating the Feasibility and Acceptability of a Mobile Health-Based Female Community Health Volunteer Program for Hypertension Control in Rural Nepal: Cross-Sectional Study

BACKGROUND

Hypertension is a major modifiable risk factor for cardiovascular disease, the world's leading cause of death. The prevalence of hypertension is disproportionately higher in South Asian countries than in other regions of the world. Screening for hypertension in primary care settings remains a challenge in many South Asian countries, including Nepal. Nepal is located in the Himalayan Mountains region, posing significant geographical challenges for its rural citizens to access primary health care and service delivery. This barrier increases the costs and inconvenience for rural Nepalis to access hypertension screening and treatment. As a result, the prevalence of hypertension in Nepal tripled in the last 25 years to 22.4%-38.6%. Nepal's Ministry of Health and Population relies on female community health volunteers to link health centers and communities to provide basic health services. Over 50,000 of these volunteers in Nepal have received basic health care training and are assigned to take care of maternal and child health. Due to limited health care resources, adopting new methods to control hypertension is an urgent need in Nepal. Several recent studies in Nepal have recommended extending the role of female community health volunteers to include hypertension management through blood pressure monitoring and home-based education.

OBJECTIVE

The goal of this study was to assess if a mobile health-based female community health volunteer approach of combining the traditional community health volunteer program with digital technologies would be feasible and acceptable in rural Nepal.

METHODS

In this study, we recruited 17 female community health volunteers and extended their role from maternal and child health to hypertension management through screening blood pressures.

RESULTS

All 17 female community health volunteers successfully measured 1113 rural Nepalis' blood pressures, identified 169 hypertensive patients, and collected health behaviors data of the 169 hypertensive patients. Among the 169 patients, 70% of them had a mobile phone, and 92% were interested in receiving health-related information via a mobile phone. Among those who were interested in receiving information via a mobile phone, 84% preferred voice calls, and 7% and 1% preferred texting and apps, respectively.

CONCLUSIONS

Results from this study indicate that a digital health intervention that leverages feature-phones combined with female community health volunteers may be an acceptable and pragmatic way to implement an evidence-based program to reduce hypertension in rural Nepal.

Do mobile phone-based reminders and conditional financial transfers improve the timeliness of childhood vaccinations in Tanzania? Study protocol for a quasi-randomized controlled trial

Background

Vaccination is a cost-effective strategy for reducing morbidity and mortality among children under 5 years old. To be fully protected from diseases such as tuberculosis, diphtheria, pertussis, and polio, children must receive all recommended vaccinations in a timely manner. In many countries, including Tanzania, high overall vaccination rates mask substantial regional variation in vaccination coverage and low rates of vaccination timeliness. This study evaluates the efficacy of mobile phone-based (mHealth) reminders and incentives for improving vaccination timeliness in the first year of life.

Methods

The study, conducted in Mtwara Region in Tanzania, includes 400 late-stage pregnant women enrolled from rural and urban health facilities and surrounding communities. The primary outcome is timeliness of vaccinations among their children at 6, 10, and 14 weeks after birth. Timeliness is defined as vaccination receipt within 28 days after the vaccination due date. The quasi-randomized controlled trial includes three arms: (1) standard of care (no reminders or incentives), (2) mobile phone-based reminders, and (3) mobile phone-based reminders and incentives in the form of conditional financial transfers. Assignment into study arms is based on scheduled vaccination dates. Reminder messages are sent to arms 2 and 3 participants via mobile phones 1 week and 1 day prior to each scheduled vaccination. For arm 3 participants, reminder messages offer an incentive that is provided in the form of a mobile phone airtime recharge voucher code for each timely vaccination. Vaccination dates are recorded via participant contact with an mHealth system, phone calls with mothers, and a review of government-issued vaccination cards during an end-line survey. Random effects logistic regression models will be used to estimate the effects of reminders and incentives on the timeliness of vaccinations.

Discussion

The results will inform implementation science research on the effectiveness of reminders and incentives as a means of improving vaccination timeliness.

Trial registration

ClinicalTrials.gov, NCT03252288. Registered on 17 August 2017 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3430-4) contains supplementary material, which is available to authorized users.

Establishing Standards to Evaluate the Impact of Integrating Digital Health into Health Systems

The key milestones in the rise of digital health illustrate efforts to bridge gaps in the evidence base, a shifting focus to scale-up and sustainability, growing attention to the precise costing of these strategies, and an emergent implementation science agenda that better characterizes the ecosystem—the social, political, economic, legal, and ethical context that supports digital health implementation—necessary to take digital health approaches to scale.

Digital Health and Health Systems of the Future

Digital strategies have been formally recognized as a critical health systems strengthening strategy to help meet the Sustainable Development Goals and universal health coverage targets. This landscaping collection reviews multiple possible approaches across health system pillars, from digital referrals to decision support systems, identifying key knowledge gaps across these domains and recognizing the growth needed in the field to realize its full potential.

Strengthening Delivery of Health Services Using Digital Devices

BACKGROUND

Delivery of high-quality efficient health services is a cornerstone of the global agenda to achieve universal health coverage. According to the World Health Organization, health service delivery is considered good when equitable access to a comprehensive range of high-quality health services is ensured within an integrated and person-centered continuum of care. However, good health service delivery can be challenging in low-resource settings. In this review, we summarize and discuss key advances in health service delivery, particularly in the context of using digital health strategies for mitigating human resource constraints.

METHODS

The review updates the foundational systematic review conducted by Agarwal et al. in 2015. We used PubMed, EMBASE, and CINAHL to find relevant English-language peer-reviewed articles published 2018. Our search strategy for MEDLINE was based on MeSH (medical subject headings) terms and text words of key articles that we identified a priori. Our search identified 92 articles. After screening, we selected 24 articles for abstract review, of which only 6 met the eligibility criteria and were ultimately included in this review.

RESULTS

Despite encouraging advances in the evidence base on digital strategies for health service delivery, the current body of evidence is still quite limited in 3 main areas: the effectiveness of interventions on health outcomes, improvement in health system efficiencies for service delivery, and the human capacity required to implement and support digital health strategies at scale. Two particular areas, digital health-enhanced referral coordination and mobile clinical decision support systems, demonstrate considerable potential to improve the quality and comprehensiveness of care received by patients, but they require a greater level of standardization and an expanded scope of health worker engagement across the health system in order to scale them up effectively.

CONCLUSIONS

Additional research is urgently needed to inform the effectiveness of interventions on health outcomes, improvement in health system efficiencies, and cost-effectiveness of service delivery. In particular, more documentation and research on ways to standardize and engage health workers in digital referral and clinical decision support systems can provide the foundation needed to scale these promising approaches in low- and middle-income settings.

A survey of healthcare-seeking practices and related stigma among community- and street-based children in Cambodia

Background

Globally, street children comprise a growing population of vulnerable children. Understanding how they interact with healthcare systems is fundamental to efforts to improve their health and well-being.

Methods

We surveyed 75 street- and community-based children in Battambang, Cambodia regarding their healthcare-seeking practices and related stigma.

Results

For demographically similar street and community children, hospitals and pharmacies were preferred healthcare institutions, with this choice being motivated by the caretaker's decision or cost. Street children reported increased fear of being refused treatment.

Conclusions

Street children and demographically similar community children have similar healthcare-seeking practices and preferences, although street children face increased stigmatization.

Feasibility of Using a Digital Case Management Application to Expand the Patient Navigator System at Bugando Medical Centre

Abstract 36

Purpose

Each year, more than 200,000 children globally are diagnosed with cancer, more than 80% of which occurs in low- to middle-income countries. Pediatric cancer survival rates in low- to middle-income countries are 5% to 25% compared with 80% in high-income countries, with treatment abandonment accounting for one third of the survival gap. A mobile case management system can improve patient communication and reduce treatment abandonment. The current proposal evaluated the feasibility and acceptability of a mobile phone–based case management system at Bugando Medical Centre (BMC) in Mwanza, Tanzania.

Methods

We surveyed 40 families of children with cancer who attended BMC and 10 pediatric oncology providers at BMC to assess mobile phone ownership, use patterns, communication preferences (eg, voice v text messaging), and the advantages and disadvantages of a mobile case management system.

Results

In all, 85% of families owned a mobile phone and 100% of providers owned smart phones. Of families, 98% wanted to communicate with a health care provider regarding treatment support using a mobile phone, 92% wanted to receive laboratory results via mobile phone, 95% wanted to receive reminders of upcoming appointments, and 88% wanted to receive educational information on cancer via mobile phone. Of providers, 100% thought that it would be useful to use a mobile phone to communicate with patients, share laboratory results, and view standardized pediatric treatment protocols and checklists.

Conclusion

Most families of pediatric patients with cancer at BMC use mobile phones, with high interest in using mobile technology to communicate with providers. This increases the likelihood of success for a mobile case management platform that is aimed at reducing the abandonment of care among pediatric patients with cancer.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the authors.