mHealth Interventions in Low and Middle-Income Countries: A Systematic Review

Assessment of Use and Preferences Regarding Internet-Based Health Care Delivery: Cross-Sectional Questionnaire Study

Background

There has been an incremental increase in the use of technology in health care delivery. Feasibility, acceptability, and efficacy of interventions based on internet technologies are supported by a growing body of evidence.

Objective

The aim of this study was to investigate use and preferences in the general adult population in Germany for remote, internet-based interaction (eg, email, videoconferencing, electronic medical records, apps).

Methods

A nationwide cross-sectional questionnaire survey in adults that was representative in terms of age, sex and educational level was carried out.

Results

A total of 22.16% (538/2428) of survey participants reported not using the internet for work or private use. The nonuser phenotype can be described as being older, having lower educational and income status, and living in less populated areas. The majority of participants within the cohort of internet users reported that they would not consider using electronic medical records (973/1849, 52.62%), apps (988/1854, 53.29%), or emails to report symptoms (1040/1838, 56.58%); teleconference with one (1185/1852, 63.98%) or more experts (1239/1853, 66.86%); or participate in video psychotherapy (1476/1853, 79.65%) for the purpose of medical consultation or treatment. Older age and lower educational level were the most robust predictors of assumed future denial of use.

Conclusions

Our results point toward low use and preference rates among the general population for the use of telemedicine. It also seems that those who might benefit from telemedical interventions the most, are, in fact, those who are most hesitating. These low use and preference rates of eHealth should be considered prior to designing and providing future telemedical care, supporting the need for easy-to-use, data secure solutions.

Measuring mobility, disease connectivity and individual risk: a review of using mobile phone data and mHealth for travel medicine

RATIONALE FOR REVIEW

The increasing mobility of populations allows pathogens to move rapidly and far, making endemic or epidemic regions more connected to the rest of the world than at any time in history. However, the ability to measure and monitor human mobility, health risk and their changing patterns across spatial and temporal scales using traditional data sources has been limited. To facilitate a better understanding of the use of emerging mobile phone technology and data in travel medicine, we reviewed relevant work aiming at measuring human mobility, disease connectivity and health risk in travellers using mobile geopositioning data.

KEY FINDINGS

Despite some inherent biases of mobile phone data, analysing anonymized positions from mobile users could precisely quantify the dynamical processes associated with contemporary human movements and connectivity of infectious diseases at multiple temporal and spatial scales. Moreover, recent progress in mobile health (mHealth) technology and applications, integrating with mobile positioning data, shows great potential for innovation in travel medicine to monitor and assess real-time health risk for individuals during travel.

CONCLUSIONS

Mobile phones and mHealth have become a novel and tremendously powerful source of information on measuring human movements and origin-destination-specific risks of infectious and non-infectious health issues. The high penetration rate of mobile phones across the globe provides an unprecedented opportunity to quantify human mobility and accurately estimate the health risks in travellers. Continued efforts are needed to establish the most promising uses of these data and technologies for travel health.

Parent-targeted postnatal educational interventions in low and middle-income countries: A scoping review and critical analysis

OBJECTIVES

To identify and map existing postnatal educational interventions targeting parents in low and middle-income countries. A secondary objective is to conduct a critical analysis of the strengths and limitations of the educational strategies used for parent-targeted postnatal education. Design & data sources: Using scoping review methodology, MedLine, CINAHL, and SCOPUS were searched in October 2017.

REVIEW METHODS

All studies published after 2000 reporting on educational interventions that targeted parents from the period of birth to 6 weeks postnatally in low and middle-income countries were included. Studies were excluded if they targeted healthcare professionals or were community interventions that spanned antenatal to postnatal care. Title, abstract and full-text screening was conducted by two reviewers.

RESULTS

We initially identified 9284 articles with 77 articles included after title, abstract and full-text screening. Most of the studies were quantitative (94%) with over half published after 2014. Most studies (61%) targeted a single newborn care education intervention, of which 75% targeted breastfeeding. Interventions used on average three different methods of implementation (e.g., verbal, written information, counselling). Interventions were provided in the hospital (76%), at home (23%), at a clinic/hospital (8%), and/or virtually through an eHealth intervention, including phone or text messages (12%). Maternal outcomes primarily included knowledge, self-efficacy, anxiety and stress while newborn outcomes primarily included exclusive breastfeeding, weight gain at follow-up, and morbidities. Positive changes were found to occur for reported maternal outcomes (89%) and newborn outcomes (56%).

CONCLUSIONS

Parent-targeted education varied in terms of educational topics covered, method and location of intervention, and outcomes examined. While the best strategies of implementing postnatal education interventions to parents in low and middle-income countries is yet to be determined, evidence suggests that current interventions had a positive impact on parents' outcomes using a combined approach. Further work is needed to evaluate the impact on newborn outcomes and to identify the most effective methods and timing of the interventions.

Impact of mobile health interventions during the perinatal period for mothers in low- and middle-income countries: a systematic review protocol

REVIEW QUESTION

The objective of this review is to determine the impact of mother-targeted mobile health (mHealth) education interventions available during the perinatal period in low- and middle-income countries on maternal and newborn outcomes. Thus, the review questions are: what is the impact of mother-targeted mHealth education interventions on.

Patient-Centered eHealth Interventions for Children, Adolescents, and Adults With Sickle Cell Disease: Systematic Review

Background

Sickle cell disease is an inherited blood disorder that affects over 100,000 Americans. Sickle cell disease–related complications lead to significant morbidity and early death. Evidence supporting the feasibility, acceptability, and efficacy of self-management electronic health (eHealth) interventions in chronic diseases is growing; however, the evidence is unclear in sickle cell disease.

Objective

We systematically evaluated the most recent evidence in the literature to (1) review the different types of technological tools used for self-management of sickle cell disease, (2) discover and describe what self-management activities these tools were used for, and (3) assess the efficacy of these technologies in self-management.

Methods

We reviewed literature published between 1995 and 2016 with no language limits. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and other sources. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers screened titles and abstracts, assessed full-text articles, and extracted data from articles that met inclusion criteria. Eligible studies were original research articles that included texting, mobile phone–based apps, or other eHealth interventions designed to improve self-management in pediatric and adult patients with sickle cell disease.

Results

Of 1680 citations, 16 articles met all predefined criteria with a total of 747 study participants. Interventions were text messaging (4/16, 25%), native mobile apps (3/16, 19%), Web-based apps (5/16, 31%), mobile directly observed therapy (2/16, 13%), internet-delivered cognitive behavioral therapy (2/16, 13%), electronic pill bottle (1/16, 6%), or interactive gamification (2/16, 13%). Interventions targeted monitoring or improvement of medication adherence (5/16, 31%); self-management, pain reporting, and symptom reporting (7/16, 44%); stress, coping, sleep, and daily activities reporting (4/16, 25%); cognitive training for memory (1/16, 6%); sickle cell disease and reproductive health knowledge (5/16, 31%); cognitive behavioral therapy (2/16, 13%); and guided relaxation interventions (1/16, 6%). Most studies (11/16, 69%) included older children or adolescents (mean or median age 10-17 years; 11/16, 69%) and 5 included young adults (≥18 years old) (5/16, 31%). Sample size ranged from 11 to 236, with a median of 21 per study: <20 in 6 (38%), ≥20 to <50 in 6 (38%), and >50 participants in 4 studies (25%). Most reported improvement in self-management–related outcomes (15/16, 94%), as well as high satisfaction and acceptability of different study interventions (10/16, 63%).

Conclusions

Our systematic review identified eHealth interventions measuring a variety of outcomes, which showed improvement in multiple components of self-management of sickle cell disease. Despite the promising feasibility and acceptability of eHealth interventions in improving self-management of sickle cell disease, the evidence overall is modest. Future eHealth intervention studies are needed to evaluate their efficacy, effectiveness, and cost effectiveness in promoting self-management in patients with sickle cell disease using rigorous methods and theoretical frameworks with clearly defined clinical outcomes.

Feasibility of using smartphones by village health workers for pregnancy registration and effectiveness of mobile phone text messages on reduction of homebirths in rural Uganda

Introduction

Homebirths are common in low and middle income countries and are associated with poor child survival. We assessed the feasibility of using smartphones by village health workers for pregnancy registration and the effectiveness of health text messages (SMS) sent to pregnant women through village health workers in reducing homebirths in rural Uganda.

Methods

A non-randomised intervention study was undertaken in 26 villages. In the intervention arm, village health workers registered pregnant women (n = 262) in 13 villages using a smartphone app (doForm) and paper forms and gestation age-timed SMS were sent through village health workers to the pregnant women. In 13 control villages, (n = 263) pregnant women were registered on paper forms only and no SMS was sent. The main outcome was place of birth measured through a self-report. Logistic regression with generalised estimating equations was used to explore the effect of the intervention.

Results

Comparing 795 corresponding data fields on phone and paper revealed that numeric variable fields were 86%-95% similar while text fields were 38%-48% similar. Of the 525 pregnant women followed, 83 (15.8%) delivered at home. In the adjusted analysis, the intervention was associated with lower odds of homebirths [AOR = 0.38, 95%CI (0.15–0.97)]. Muslim religion [AOR = 4.0, 95%CI (1.72–9.34)], primary or no maternal education [AOR = 2.51, 95%CI (1.00–6.35)] and health facility distance ≥ 2 km [AOR = 2.26, 95%CI (0.95–5.40)] were independently associated with homebirths.

Conclusion

Village health workers can register pregnant women at home using phones and relay gestation age specific SMS to them to effectively reduce homebirths.

Feasibility of Electronic Health Information and Surveillance System (eHISS) for disease symptom monitoring: A case of rural Ghana

Introduction

The current surge of mobile phone use in many African countries creates the opportunity to provide caregivers with limited access to the health care system with vital health recommendations. At the same time such communication system can be utilised to collect tempero-spatial data on disease symptoms.

Objective

We assessed the feasibility of an mHealth system among caregivers with children under-five years, designed as a health information and surveillance tool in a rural district of Ghana.

Methods

A mobile phone-based electronic health information and surveillance system was piloted from February to December 2015. Toll-free numbers were provided to 1446 caregivers, which they could call to receive health advice in case their children showed disease symptoms. The system was setup to evaluate the illness of a sick child. Symptoms reported via the system were evaluated and compared to clinician’s report after follow-up. Cogency of the reported symptoms was assessed using Cohen’s kappa coefficient.

Results

A total of 169 children with disease symptoms were identified based on phone calls from caregivers. The predominant reported symptoms were fever (64%; n = 108), cough (55%; n = 93) and diarrhoea (33%; n = 55). Temporal pattern of symptomatic cases revealed a peak saturation in the month of September, with fever registering the highest number of symptoms observed. Reported symptoms and clinician’s report revealed a very good agreement for fever (95%, kappa = 0.89); good for diarrhoea (87%, kappa = 0.73) and moderate for cough (76%, kappa = 0.49).

Conclusion

This pilot concept, has demonstrated the practicality of using mobile phones for assessing childhood disease symptoms and encouraging caregivers to seek early treatment for their children if needed. The strategy to use mobile phones in disease surveillance and treatment support is a promising strategy especially for areas with limited access to the health care system.

A mobile phone based tool to identify symptoms of common childhood diseases in Ghana: development and evaluation of the integrated clinical algorithm in a cross-sectional study

Background

The aim of this study was the development and evaluation of an algorithm-based diagnosis-tool, applicable on mobile phones, to support guardians in providing appropriate care to sick children.

Methods

The algorithm was developed on the basis of the Integrated Management of Childhood Illness (IMCI) guidelines and evaluated at a hospital in Ghana. Two hundred and thirty-seven guardians applied the tool to assess their child’s symptoms. Data recorded by the tool and health records completed by a physician were compared in terms of symptom detection, disease assessment and treatment recommendation. To compare both assessments, Kappa statistics and predictive values were calculated.

Results

The tool detected the symptoms of cough, fever, diarrhoea and vomiting with good agreement to the physicians’ findings (kappa = 0.64; 0.59; 0.57 and 0.42 respectively). The disease assessment barely coincided with the physicians’ findings. The tool’s treatment recommendation correlated with the physicians’ assessments in 93 out of 237 cases (39.2% agreement, kappa = 0.11), but underestimated a child’s condition in only seven cases (3.0%).

Conclusions

The algorithm-based tool achieved reliable symptom detection and treatment recommendations were administered conformably to the physicians’ assessment. Testing in domestic environment is envisaged.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0600-3) contains supplementary material, which is available to authorized users.

m-Health Policy Readiness and Enabling Factors: Comparisons of Sub-Saharan Africa and Organization for Economic Cooperation and Development Countries

Background:As an innovative solution to poor access to care in low- and middle-income countries (LMICs), m-health has gained wide attention in the past decade.

Introduction:Despite enthusiasm from the global health community, LMICs have not demonstrated high uptake of m-health promoting policies or public investment.

Materials and Methods:To benchmark the current status, this study compared m-health policy readiness scores between sub-Saharan Africa and high-income Organization for Economic Cooperation and Development (OECD) countries using an independent two-sample t test. In addition, the enabling factors associated with m-health policy readiness were investigated using an ordinal logistic regression model. The study was based on the m-health policy readiness scores of 112 countries obtained from the World Health Organization Third Global Survey on e-Health.

Results:The mean m-health policy readiness score for sub-Saharan Africa was statistically significantly lower than that for OECD countries (p = 0.02). The enabling factors significantly associated with m-health policy readiness included information and communication technology development index (odds ratio [OR] 1.57; 95% confidence interval [CI] 1.12–2.2), e-health education for health professionals (OR 4.43; 95% CI 1.60–12.27), and the location in sub-Saharan Africa (OR 3.47; 95% CI 1.06–11.34).

Discussion:The findings of our study suggest dual policy goals for m-health in sub-Saharan Africa. First, enhance technological and educational support for m-health. Second, pursue global collaboration for building m-health capacity led by sub-Saharan African countries with hands-on experience and knowledge.

Conclusion:Globally, countries should take a systematic and collaborative approach in pursuing m-health policy with the focus on technological and educational support.

Tanzania Health Information Technology (T-HIT) System: Pilot Test of a Tablet-Based System to Improve Prevention of Mother-to-Child Transmission of HIV

Background

The prevention of mother-to-child transmission (PMTCT) of HIV requires innovative solutions. Although routine monitoring is effective in some areas, standardized and easy-to-scale solutions to identify and monitor pregnant women, test them for HIV, and treat them and their children is still lacking. Mobile health (mHealth) offers opportunities for surveillance and reporting in rural areas of low- and middle-income countries.

Objective

The aim of this study was to document the preliminary impacts of the Tanzania Health Information Technology (T-HIT) system mHealth intervention aimed at health workers for PMTCT care delivery and capacity building in a rural area of Tanzania.

Methods

We developed T-HIT as a tablet-based system for an electronic data collection system designed to capture and report PMTCT data during antenatal, delivery, and postnatal visits in Misungwi, Tanzania. T-HIT was tested by health workers in a pilot randomized trial comparing seven sites using T-HIT assigned at random to seven control sites; all sites maintained standard paper record-keeping during the pilot intervention period. We compared numbers of antenatal visits, number of HIV tests administered, and women testing positive across all sites.

Results

Health workers recorded data from antenatal visits for 1530 women; of these, 695 (45.42%) were tested for HIV and 3.59% (55/1530) tested positive. Health workers were unable to conduct an HIV test for 103 women (6.73%, 103/1530) because of lack of reagent, which is not captured on paper logs. There was no difference in the activity level for testing when comparing sites T-HIT to non-T-HIT sites. We observed a significant postintervention increase in the numbers of women testing positive for HIV compared with the preintervention period (P=.04), but this was likely not attributable to the T-HIT system.

Conclusions

T-HIT had a high degree of acceptability and feasibility and is perceived as useful by health workers, who documented more antenatal visits during the pilot intervention compared with a traditional system of paper logs, suggesting potential for improvements in antenatal care for women at risk for HIV.