Assessing the Effect of mHealth Interventions in Improving Maternal and Neonatal Care in Low- and Middle-Income Countries: A Systematic Review

How and why front-line health workers (did not) use a multifaceted mHealth intervention to support maternal and neonatal healthcare decision-making in Ghana

Introduction

Despite increasing use of mHealth interventions, there remains limited documentation of 'how and why' they are used and therefore the explanatory mechanisms behind observed effects on beneficiary health outcomes. We explored 'how and why' an mHealth intervention to support clinical decision-making by front-line providers of maternal and neonatal healthcare services in a low-resource setting was used. The intervention consisted of phone calls (voice calls), text messaging (short messaging service (SMS)), internet access (data) and access to emergency obstetric and neonatal protocols via an Unstructured Supplementary Service Data (USSD). It was delivered through individual-use and shared facility mobile phones with unique Subscriber Identification Module (SIM) cards networked in a Closed User Group.

Methods

A single case study with multiple embedded subunits of analysis within the context of a cluster randomised controlled trial of the impact of the intervention on neonatal health outcomes in the Eastern Region of Ghana was performed. We quantitatively analysed SIM card activity data for patterns of voice calls, SMS, data and USSD. We conducted key informant interviews and focus group discussions with intervention users and manually analysed the data for themes.

Results

Overall, the phones were predominantly used for voice calls (64%), followed by data (28%), SMS (5%) and USSD (2%), respectively. Over time, use of all intervention components declined. Qualitative analysis showed that individual health worker factors (demographics, personal and work-related needs, perceived timeliness of intervention, tacit knowledge), organisational factors (resource availability, information flow, availability, phone ownership), technological factors (attrition of phones, network quality) and client perception of health worker intervention usage explain the pattern of intervention use observed.

Conclusion

How and why the mHealth intervention was used (or not) went beyond the technology itself and was influenced by individual and context-specific factors. These must be taken into account in designing similar interventions to optimise effectiveness.

mHealth interventions targeting pregnancy intakes in low and lower-middle income countries: Systematic review

Dietary intake during pregnancy plays a vital role in determining the health of both mother and baby. Maternal undernutrition affects a large proportion of women in low and lower middle income countries (LLMIC) likely influencing high maternal, infant, and child mortality in these countries. Mobile health (mHealth) interventions have been proposed as effective solutions to improve maternal and neonatal health. This paper reviews the literature to evaluate the effectiveness of mHealth interventions on improving dietary/nutrients intake of pregnant women in LLMIC. Eight electronic databases were searched from inception up to April 2018, including the MEDLINE, EMBASE, CINAHL, Cochrane, Web of Science, Scopus, Global Index Medicus, and Maternity and Infant Care. Using Covidence, two reviewers assessed articles for inclusion, assessed study quality and extracted data. Only studies published in English language were included. Data were summarised narratively. In total, 6,778 were identified of which four were included, with three randomised controlled trials and one prepost experimental study. Studies were conducted in India (n = 2), Indonesia (n = 1), and Kenya (n = 1). All articles evaluated the use of nutrient supplements; iron supplements (n = 1), vitamin supplements (composition not mentioned; n = 1), or calcium supplements (n = 1). This review suggests that mHealth interventions can be used to improve intake of micronutrient supplementation and nutritional status of pregnant women in LLMIC. Further studies are needed to address the limited evidence base related to mHealth nutrition interventions targeting dietary intakes of pregnant women in LLMIC.

Effect of an interactive voice response system on self-management in kidney transplant recipients: Protocol for a randomized controlled trial

INTRODUCTION

Adherence to a complex and ongoing set of therapeutic recommendations significantly determines short and long-term outcomes after kidney transplantation (KT). Interactive voice response system (IVRS) is a novel phone-based platform which is potentially useful to deliver health behavior interventions.

OBJECTIVE

The aims of the study is to describe the development of a theory-driven and educational IVRS investigate the effect of an IVRS on the self-management outcomes in KT recipients as compared with the control group.

METHODS

This study has been designed as a randomized, 2 parallel groups controlled trial. The KT recipients' older than18 years of age with access to a cellphone will be included. A total of 120 patients will be randomly assigned to the control and intervention groups. The participants in the intervention group will receive completely automatic calls in 3 categories: educational, medication adherence, and reminders by the IVRS, whereas those in the control group will receive usual care. The follow up will be performed within 6 months. The primary outcome will be the medication adherence while patients' transplant knowledge, health-related quality of life, and rehospitalization rates will be considered as secondary outcomes.

RESULTS

Thus far, recruitment of participants has not been completed and results will be published in 2019.

DISCUSSION

The IVRS is potentially useful to help KT recipients improve the self-management outcomes. The hypothesis is using an IVRS intervention makes a significant difference between basel assessment of adherence to immunosuppressive medications scale, 12-item short form survey, second version, kidney transplant understanding tool baseline scores, and those obtained at the end of study.

TRIAL REGISTRATION NUMBER

This trial is registered with the Iran Trial Registrar under registration number IRCT20180124038492N1 and registration date 30 January 2018. https://irct.ir/trial/29215.

Human-Centered Design of Video-Based Health Education: An Iterative, Collaborative, Community-Based Approach

Drawing on 5 years of experience designing, producing, and disseminating video health education programs globally, we outline the process of creating accessible, engaging, and relevant video health education content using a community-based, human-centered design approach. We show that this approach can yield a new generation of interventions, which are better aligned with the needs and contexts of target communities. The participation of target communities and local stakeholders in the content production and design process fosters ownership of the content and increases the likelihood that the resulting intervention will resonate within its intended primary audience and be disseminated broadly. Ease of future adaptation for additional global audiences and modification of the content for multiple dissemination pathways are important early considerations to ensure scalability and long-term impact of the intervention. Recent advances in mobile technology can facilitate the dissemination of accessible, engaging health education at scale, thereby enhancing the potential impact of video-based educational tools.

Accessible and engaging health education is a cornerstone of health behavior change. Especially in low- and middle-income countries, increasing access to effective health education can contribute to improved health outcomes. Prior research has identified several characteristics of effective health education interventions. These include the integration of pictures, narratives, and entertainment-education, in which the health messages that make up the educational content are embedded. However, the effectiveness and long-term impact of health messages ultimately depend on how well the end users can identify with the content that is presented. This identification, in turn, is a function of how well the messages correspond to user needs and wants and how this correspondence is communicated through the design characteristics of the health education intervention.

Using participatory methods to build an mHealth intervention for female entertainment workers in Cambodia: the development of the Mobile Link project

BACKGROUND

The HIV epidemic in Cambodia is strongly and disproportionately concentrated among key populations. One important hard-to-reach key population is the expanding community of female entertainment workers (FEWs). HIV as well as other sexual and reproductive health (SRH) outcomes including sexually transmitted infections (STIs), contraception, and gynecologic health are also substandard among FEWs. To address these concerns, a mobile health intervention (mHealth) using short message service (SMS) and voice message (VM) services-the Mobile Link project-was constructed. This paper aims to describe the development of this mHealth intervention that used participatory methodologies and to illustrate how these findings can be useful in future mHealth projects.

METHODS

This intervention development process used an iterative, participatory approach. Twenty-seven focus group discussions (FGDs) covering SRH topics were designed and conducted and implemented across four provinces in Cambodia. Additionally, six in-depth interviews (IDIs) were conducted with FEWs living with HIV in Siem Reap and Phnom Penh. Data from the FGDs and IDIs were analyzed using content and matrix analysis methods to identify prioritized themes for messages. Two data validation workshops were organized to present the prioritized themes to FEWs and outreach workers (outreach workers) for validation. The workshops included activities stimulating participation such as listening to sample messages in order to determine health priorities as well as message tone and style.

RESULTS

The findings from the qualitative research provided guidance on how to tailor the intervention to the FEW community in terms of the tone, timing, content and delivery mode of the messages. Participants preferred a friendly, professional female voice for VM. Participants revealed that health priorities such as gynecologic issues (vaginal infections/irritation) and cervical and breast cancer, were emphasized more than HIV and family planning. Participants also reported a number of misconceptions about contraception, particularly around oral contraceptives and intrauterine devices, and STI transmission. Participants expressed the need to build trust in outreach workers and linkages, affirming the emphasis on the link within the Mobile Link project. Lastly, from the IDIs, FEWs living with HIV highlighted wanting supportive/messages to address depressive feelings that may stem from their perceived stigma.

CONCLUSIONS

Utilizing participatory methodologies was demonstrated to be useful in intervention content creation and program implementation. As a result of this intervention development process, the research team gleaned lessons that may be applicable to future mHealth projects including the idea of adding some layers of choice to mHealth interventions for further tailoring at the individual level and the importance of human contact and trusting relationship.

mLearning in the Democratic Republic of the Congo: A Mixed-Methods Feasibility and Pilot Cluster Randomized Trial Using the Safe Delivery App

Health worker knowledge and self-confidence in basic emergency obstetric and newborn care (BEmONC) increased significantly 3 months after introduction of the Safe Delivery App in intervention facilities compared with controls.

Background:

Substandard delivery care has been widely documented as a major cause of maternal mortality in health facilities globally. Health worker learning via mobile devices is increasing rapidly; however, there is little evidence of mLearning effectiveness. This study sought to determine the feasibility, acceptability, and potential effect of the Safe Delivery App (SDA) on health workers' practices in basic emergency obstetric and newborn care (BEmONC) in the Democratic Republic of the Congo (DRC). The Theoretical Domains Framework was used to guide this research.

Methods:

Eight BEmONC facilities in central DRC were randomized to either an mLearning intervention or to standard practice (control). Maternal and newborn health workers in intervention facilities (n=64) were trained on the use of smartphones and the French version of the SDA. The SDA is an evidence-based BEmONC training resource with visual guidance using animated videos and clinical management instructions developed by the Maternity Foundation and the Universities of Copenhagen and Southern Denmark. Knowledge on postpartum hemorrhage (PPH) and neonatal resuscitation (NR) and self-confidence in performing 12 BEmONC procedures were assessed at baseline and at 3 months post-intervention. Eighteen qualitative interviews were conducted with app users and key stakeholders to assess feasibility and acceptability of mLearning and the use of the SDA. Maternal mortality was compared in intervention and control facilities using a smartphone-based Open Data Kit (ODK) data application. One smartphone with SDA and ODK was entrusted to intervention facilities for the study period, whereas control facilities received smartphones with ODK only.

Results:

The analysis included 62 heath workers. Knowledge scores on postpartum hemorrhage and neonatal resuscitation increased significantly from baseline among intervention participants compared with controls at 3 months post-intervention (mean difference for PPH knowledge, 17.4 out of 100; 95% confidence interval [CI]=10.7 to 24.0 and 19.4 for NR knowledge; 95% CI=11.4 to 27.4), as did self-confidence scores on 12 essential BEmONC procedures (mean difference, 4.2 out of 48; CI=0.7 to 7.7). Increases were unaffected by health worker cadre and previous smartphone use. Qualitative interviews supported the feasibility and acceptability of the SDA and mLearning, and the potential for it to impact maternal and neonatal mortality in the DRC.

Conclusion:

Use of the Safe Delivery App supported increased health worker knowledge and self-confidence in the management of obstetric and newborn emergencies after 3 months. SDA and mLearning were found to be feasible and acceptable to health workers and key stakeholders in the DRC.

The role of an mHealth intervention in improving knowledge and skills of accredited social health activists in tribal areas of Gujarat, India: a nested study within an implementation research trial

AIM

To evaluate the effectiveness of an mHealth intervention in improving knowledge and skills of accredited social health activists in improving maternal, newborn and child health care in India.

METHODS

This was a nested cross-sectional study within a cluster randomised controlled trial. The intervention was a mobile phone application which has inbuilt health education videos, algorithms to diagnose complications and training tools to educate accredited social health activists. A total of 124 were randomly selected from the control (n = 61) and intervention (n = 63) arms of the larger study after six months of training in Bharuch and Narmada districts of Gujarat.

RESULTS

The knowledge of accredited social health activists regarding pregnancy (OR: 2.51, CI: 1.12-5.64) and newborn complications (OR: 2.57, CI: 1.12-5.92) was significantly higher in the intervention arm compared to the control arm. The knowledge of complications during delivery (OR: 1.36, CI: 0.62-2.98) and the postpartum (OR: 1.06, CI: 0.48-2.33) period was similar in both groups. The activists from the intervention arm demonstrated better skills for measuring temperature (OR: 4.25, CI: 1.66-10.89) of newborns compared to the control group.

CONCLUSION

The results suggest potential benefits of this mHealth intervention for improving knowledge and skills of accredited social health activists.

Does short message service improve focused antenatal care visit and skilled birth attendance? A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

In low resource circumstances, non-adherence for available health services is a major cause of inefficiency in health care delivery. MHealth has been projected as a possible solution to support women during pregnancy, birth and puerperium period, to increase the uptake of essential maternal services.

OBJECTIVES

This systematic review and meta-analysis study was aimed to determine the effectiveness of short message services (SMS)on Focused Antenatal Care (FANC) visits and the attendance of skilled birth professionals in Low and Middle Income Countries (LMICs).

METHODS

We searched a broad body of literature from electronic databases-Cochrane review, CINAHL, PsycINFO, PubMed and Google Scholar to collect comprehensive evidence on the role of SMS on FANC visits and skilled birth attendance. We extracted data from randomized clinical trials (RCTs) only. Meta-analyses were conducted using random-effects models with inverse variance method in Review Manager (RevMan) computer software. Qualities of the included studies were determined by GRADEpro, and risk of bias was assessed using Cochrane Collaboration risk of bias tool.

RESULTS

Of the 1224 non-duplicated articles screened, only 7 RCT studies representing 8324 participants met eligibility criteria and included in this synthesis. On aggregate, there were statistically significant associations in experimental group in that pregnant mothers who received text messaging had a 174% increase in FANC visits (OR = 2.74 (95% CI: 1.41, 5.32) and 82% in skilled birth attendance (OR = 1.82 (95% CI; 1.33, 2.49). The I2 test result indicated high heterogeneity I2 = 78% (P < .001). The overall qualities of included studies were moderate, and had low risk of bias.

CONCLUSIONS

SMS has positive effects for the uptake of FANC visits and skilled birth attendance in LMICs. A short messaging service targeting pregnant woman is an invaluable, affordable intervention to improve maternal healthcare seeking behaviors.

Randomized controlled trial on effectiveness of mHealth (mobile/smartphone) based Preterm Home Care Program on developmental outcomes of preterms: Study protocol

AIM

To describe a randomized controlled trial protocol designed to evaluate the effectiveness of mobile health based Preterm Home Care Program (mHealthPHCP) known as "NeoRaksha" mobile health application in improving parent-infant-interaction, growth and development of preterms.

DESIGN

A prospective, randomized controlled clinical trial. The protocol is approved and funded by Department of Biotechnology, Government of India on 2 August 2016.

METHODS

A total of 300 preterm-mother dyads admitted to neonatal intensive care unit of a tertiary care hospital will be recruited and randomized to intervention and control group. The intervention group would receive mobile health based Preterm Home Care Program and the control group would receive standard preterm care. Intervention group will be followed up at home by community health workers known as Accredited Social Health Activist who will be trained in using the NeoRaksha mobile health application. Preterms outcomes will be assessed during follow-up at hospital.

DISCUSSION

Supporting continuity of preterm care is vital as parents and preterms experience transition from Neonatal Intensive Care unit to their home. Empowering mothers and community health workers by integrating mobile technology into health care can help promote healthy preterms, enhance development outcomes and follow-up, which in turn can reduce the mortalities, morbidities, and disabilities associated with prematurity.

IMPACT

The results of this study could open up new horizons in integrating hospital and home based preterm care through technology, which paves way to scale up the model across the countries.

Short message service communication improves exclusive breastfeeding and early postpartum contraception in a low- to middle-income country setting: a randomised trial

OBJECTIVE

To assess the effect of short message service (SMS) communication on facility delivery, exclusive breastfeeding (EBF), and contraceptive use.

DESIGN

Mobile WACh was a three-arm unblinded individually randomised controlled trial.

SETTING

A public sector maternal child health (MCH) clinic in Nairobi, Kenya.

POPULATION

Three hundred women attending antenatal care were randomised, 100 to each arm, and followed for 24 weeks postpartum. Pregnant women, at least 14 years old with access to a mobile phone and able to read SMS were eligible for participation.

METHODS

Women were randomised (1:1:1) to receive one-way SMS versus two-way SMS with a nurse versus control. Weekly SMS content was tailored for maternal characteristics and pregnancy or postpartum timing.

MAIN OUTCOME MEASURES

Facility delivery, EBF, and contraceptive use were compared separately between each intervention arm and the control arm by Kaplan-Meier analysis and chi-square tests using intent-to-treat analyses.

RESULTS

The overall facility delivery rate was high (98%) and did not differ by arm. Compared with controls, probability of EBF was higher in the one-way SMS arm at 10 and 16 weeks, and in the two-way SMS arm at 10, 16, and 24 weeks (P < 0.005 for all). Contraceptive use was significantly higher in both intervention arms by 16 weeks (one-way SMS: 72% and two-way SMS: 73%; P = 0.03 and P = 0.02 versus 57% control, respectively); however, this difference was not significant when correcting for multiple comparisons.

CONCLUSION

One-way and two-way SMS improved EBF practices and early contraceptive use. Two-way SMS had an added benefit on sustained EBF, providing evidence that SMS messaging influences uptake of interventions that improve maternal and neonatal health.

SOURCE OF FUNDING

Funding was provided by the National Institutes of Health (K12HD001264 to JAU, R01HD080460, K24HD054314 to GJS, and K01AI116298 to ALD), the National Science Foundation (Graduate Research Fellowship to TP and BD), as well as the University of Washington Global Center for Integrated Health of Women Adolescents and Children (Global WACh).

TWEETABLE ABSTRACT

The Mobile WACh RCT demonstrates that SMS improved practice of exclusive breastfeeding and early postpartum contraception.

Free contraception and behavioural nudges in the postpartum period: evidence from a randomised control trial in Nairobi, Kenya

Background

Short birth intervals are a major risk factor for poor maternal and newborn outcomes. Utilisation of modern contraceptive methods during the postpartum period can reduce risky birth intervals but contraceptive coverage during this critical period remains low.

Methods

We conducted a randomised controlled experiment to test whether vouchers for free contraception, provided with and without behavioural ‘nudges’, could increase modern contraceptive use in the postpartum period. 686 pregnant women attending antenatal care in two private maternity hospitals in Nairobi, Kenya, were enrolled in the study. The primary outcomes were the use of modern contraceptive methods at nearly 3 months and 6 months after expected delivery date (EDD). We tested the impact of a standard voucher that could be redeemed for free modern contraception, a deadline voucher that expired 2 months after delivery and both types of vouchers with and without a short message service (SMS) reminder, relative to a control group that received no voucher and no SMS reminder.

Results

By nearly 6 months after EDD, we find that the combination of the standard voucher with an SMS reminder increased the probability of reporting utilisation of a modern contraceptive method by 25 percentage points (pp) (95% CI 6 pp to 44 pp) compared with the control group. Estimated impacts in other treatment arms were not statistically significantly different from the control group.

Conclusions

Reducing financial barriers to postpartum contraception alone may not be enough to encourage take-up. Programmes targeting the postpartum period should consider addressing behavioural barriers to take-up.

The State of Digital Interventions for Demand Generation in Low- and Middle-Income Countries: Considerations, Emerging Approaches, and Research Gaps

The recent introduction of digital health into generating demand for health commodities and services has provided practitioners with an expanded universe of potential tools to strengthen demand and ensure service delivery receipt. However, considerable gaps remain in our understanding of which interventions are effective, which characteristics mediate their benefit for different target populations and health domains, and what is necessary to ensure effective deployment. This paper first provides an overview of the types of digital health interventions for demand generation, including untargeted client communication, client-to-client communication, on-demand information services, personal health tracking, client financial transactions, and targeted client communication. It then provides a general overview of 118 studies published between January 1, 2010, and October 3, 2017, that used digital interventions to generate demand for health interventions. The majority (61%) of these studies used targeted client communication to provide health education or reminders to improve treatment adherence, and the most frequently (27%) studied health condition was HIV/AIDS. Intervention characteristics that have been found to have some effect on gains in demand generation include modality, directionality, tailoring, phrasing, and schedule. The paper also explores new emergent digital approaches that expand the potential effect of traditional demand generation in terms of personalization of content and services, continuity of care, and accountability tracking. Applying existing frameworks for monitoring and evaluation and reporting, research on emerging approaches will need to consider not only their feasibility but also their effectiveness in achieving demand generation outcomes. We propose a research agenda to help guide the field of digital demand generation studies and programs within a broader health systems strengthening agenda, including establishing and documenting the influence of intervention characteristics within different populations and health domains and examining the long-term effects and cost-effectiveness of digital demand generation interventions, as well as equity in access to such interventions.

Integrating mHealth at point of care in low- and middle-income settings: the system perspective

While the field represents a wide spectrum of products and services, many aspects of mHealth have great promise within resource-poor settings: there is an extensive range of cheap, widely available tools which can be used at the point of care delivery. However, there are a number of conditions which need to be met if such solutions are to be adequately integrated into existing health systems; we consider these from regulatory, technological and user perspectives. We explore the need for an appropriate legislative and regulatory framework, to avoid ‘work around’ solutions, which threaten patient confidentiality (such as the extensive use of instant messaging services to deliver sensitive clinical information and seek diagnostic and management advice). In addition, we will look at other confidentiality issues such as the need for applications to remove identifiable information (such as photos) from users’ devices. Integration is dependent upon multiple technological factors, and we illustrate these using examples such as products made available specifically for adoption in low- and middle-income countries. Issues such as usability of the application, signal loss, data volume utilization, need to enter passwords, and the availability of automated or in-app context-relevant clinical advice will be discussed. From a user perspective, there are three groups to consider: experts, front-line clinicians, and patients. Each will accept, to different degrees, the use of technology in care – often with cultural or regional variation – and this is central to integration and uptake. For clinicians, ease of integration into daily work flow is critical, as are familiarity and acceptability of other technology in the workplace. Front-line staff tend to work in areas with more challenges around cell phone signal coverage and data availability than ‘back-end’ experts, and the effect of this is discussed.

Resilience after withdrawing a technology-based medication adherence support intervention from people living with HIV in rural Uganda

Technology-based interventions for behavior change, such as adherence monitors and SMS text messages, can improve adherence to HIV antiretroviral therapy. It is unclear, however, how the effects of such interventions are maintained when interventions are withdrawn. We explored resiliency of people living with HIV in coping with adherence to antiretroviral therapy (ART) after withdrawing an adherence support intervention of real-time adherence monitors linked to SMS text messages at study closure. This is a qualitative study conducted with former participants of a pilot randomized controlled trial after study closure. Between April 2016 and November 2016, we used convenient sampling to interview 28 of the 62 participants from the pilot trial, which was conducted in rural Uganda. Interviews elicited information on experiences of taking ART in the absence of the intervention, coping strategies, and changes in social support interactions. Data were analyzed inductively using content analysis. Most participants demonstrated resilience through learning adherence from the intervention; and internalizing the habit of medication adherence. They seemed to have a sense of self-esteem, positive thinking, and access to supportive relationships. Other participants employed adaptive coping strategies, such as using alternative cues (e.g., alarms), accessing spiritual support, and adjusting their medication time to their routine. A few participants lacked resiliency, lost the habit and struggled with adherence. They were dependent on the intervention, appeared isolated and psychologically stressed, and were unable to overcome challenges associated with poor social support systems. Intervention-related benefits may or may not persist after the intervention is withdrawn. Contingent on individuals" underlying characteristics and relationships, participants manifested resiliency through learning and internalization, as well as using alternative coping strategies. Such resiliency could facilitate the use of short-term interventions, which are particularly important for resource-limited settings. Participants should be referred to available additional support at study closure when needed.

Mobile Health Technology Knowledge and Practices Among Patients of Safety-Net Health Systems in Washington State and Washington, DC

Purpose

Mobile health technology (mHealth) can reduce health disparities, but research on the health behaviors of low-income patients is needed. This study evaluates mHealth knowledge and practices of low-resource safety-net patients.

Methods

We administered a 47-item questionnaire to 164 low-income patients accessing services at community health centers in the state of Washington and Washington, DC. Predictor variables included demographic factors: age, race, ethnicity, income. Outcome variables were smartphone knowledge (smartphones as a wellness tool), medical app knowledge (availability of medical-based apps), smartphone practices (ever used smartphones for wellness), health apps practices (ever used health-based apps), and medical apps practices (ever used medical-based apps). Multivariate logistic regression assessed relationships between predictor and outcome variables.

Results

Mean age was 35.2 years (median: 34), and study cohort (N=159) consisted of mostly women (68%), white race (36%), and income of <$20,000/year (63%). Outcomes: 71% and 58% reported knowledge of using smartphones for wellness and knowledge of medical apps, respectively; 76% used smartphones for wellness, with adults 50+ years of age significantly less likely than younger adults (odds ratio [OR]: 0.94, 95% confidence interval [CI]: 0.88-0.99); 48% used health apps, with adults 50+ years of age less likely than younger adults (OR: 0.95, 95% CI: 0.91-0.99) and respondents earning <$20,000/year less likely than higher earners (OR: 3.13, 95% CI: 1.02-9.57); and 58% used medical apps, with Hispanics/Latinos significantly more likely than non-Hispanics/Latinos (OR: 6.38, 95% CI: 1.04-39.02).

Conclusions

Safety-net patients use mobile devices for health promotion. Age and income are important predictive factors, suggesting a more tailored design of the technology is required for broad engagement and health equity.

Informational interventions on paternal outcomes during the perinatal period: A systematic review

PROBLEM

The perinatal period is a stressful transition for new parents.

BACKGROUND

Various forms of educational interventions are available and are found to be efficacious in improving maternal and child outcomes. Such interventions for fathers were scarce and western-centric. Fathers should be educated as they have an impact on maternal and child outcomes.

AIM

This review aims to evaluate the efficacy of quantitatively-studied informational support-focused interventions for fathers using paternal outcomes only.

METHODS

The search was carried out in six databases: Cumulative Index to Nursing and Allied Health Literature, PubMed, Scopus, Embase, Psychological Information Database, and MedNar. Cochrane Collaboration's tools were used to assess the eligibility of the studies.

FINDINGS

A total of 17 studies with 18 interventions were identified and included in the narrative synthesis. Most interventions were delivered to the Western population during the antenatal or postpartum period. The method of delivery for these interventions was mainly face-to-face, with inconclusive findings on various paternal psychosocial outcomes.

DISCUSSION

Limited father-inclusive interventions were available. Technology-based longitudinal studies with interventions carried out across the perinatal period with longer follow-up periods were recommended for interventions providing informational support for fathers. Future studies can also examine paternal physical health and behavioural outcomes. Interventions in culturally-diverse populations should be designed and tested for their efficacies as fathers have different informational needs, especially in Asia.

CONCLUSION

Informational interventions for fathers were found to be lacking and recommendations for future studies on educational interventions for fathers were discussed.

Mobile health and the performance of maternal health care workers in low- and middle-income countries: A realist review

Introduction

Maternal health and the performance of health workers is a key concern in low- and middle-income countries. Mobile health technologies are reportedly able to improve workers' performance. However, how this has been achieved for maternal health workers in low-resource settings is not fully substantiated. To address this gap by building theoretical explanations, two questions were posed: How does mobile health influence the performance of maternal health care workers in low- and middle-income countries? What mechanisms and contextual factors are associated with mobile health use for maternal health service delivery in low- and middle-income countries?

Methods

Guided by established guidelines, a realist review was conducted. Five databases were searched for relevant English language articles published between 2009 and 2016. A three-stage framework was developed and populated with explanatory configurations of Intervention-Context-Actors-Mechanism-Outcome. Articles were analyzed retroductively, with identified factors grouped into meaningful clusters.

Results

Of 1254 records identified, 23 articles representing 16 studies were retained. Four main mechanisms were identified: usability and empowerment explaining mobile health adoption, third-party recognition explaining mobile health utilization, and empowerment of health workers explaining improved competence. Evidence was skewed toward the adoption and utilization stage of the framework, with weak explanations for performance outcomes.

Conclusions

Findings suggest that health workers can be empowered to adopt and utilize mobile health in contexts where it is aligned to their needs, workload, training, and skills. In turn, mobile health can empower health workers with skills and confidence when it is perceived as useful and easy to use, in contexts that foster recognition from clients, peers, or supervisors.

Assessing the perspectives of users and beneficiaries of a community health worker mHealth tracking system for mothers and children in Rwanda

INTRODUCTION

Mobile Health (mHealth) programs have increasingly been used to tackle maternal and child health problems in low and middle income countries. However, few studies have evaluated how these programs have been perceived by intended users and beneficiaries. Therefore, we explored perceptions of healthcare officials and beneficiaries regarding RapidSMS Rwanda, an mHealth system used by Community Health Workers (CHWs) that was scaled up nationwide in 2013.

METHODS

We conducted key informant interviews and focus group discussions with key stakeholders, providers, and beneficiaries of maternal and child health services at both the national and community levels. Semi-structured interviews were used to assess perceptions about the impact of and challenges facing the RapidSMS system. Interviews and focus group discussions were recorded (with the exception of one), transcribed verbatim, and analyzed.

RESULTS

We conducted a total of 28 in-depth interviews and 10 focus group discussions (93 total participants). A majority of respondents believed that RapidSMS contributed to reducing maternal and child mortality rates. RapidSMS was generally accepted by both CHWs and parents. Participants identified insufficient training, a lack of equipment, and low CHW motivation as the main challenges facing RapidSMS.

CONCLUSION

Our findings suggest that an mHealth program can be well accepted by both policymakers, health providers, and the community. We also found significant technical challenges that have likely reduced its impact. Addressing these challenges will serve to strengthen future mHealth programs.

eHealth as the Next-Generation Perinatal Care: An Overview of the Literature

Background

Unrestricted by time and place, electronic health (eHealth) provides solutions for patient empowerment and value-based health care. Women in the reproductive age are particularly frequent users of internet, social media, and smartphone apps. Therefore, the pregnant patient seems to be a prime candidate for eHealth-supported health care with telemedicine for fetal and maternal conditions.

Objective

This study aims to review the current literature on eHealth developments in pregnancy to assess this new generation of perinatal care.

Methods

We conducted a systematic literature search of studies on eHealth technology in perinatal care in PubMed and EMBASE in June 2017. Studies reporting the use of eHealth during prenatal, perinatal, and postnatal care were included. Given the heterogeneity in study methods, used technologies, and outcome measurements, results were analyzed and presented in a narrative overview of the literature.

Results

The literature search provided 71 studies of interest. These studies were categorized in 6 domains: information and eHealth use, lifestyle (gestational weight gain, exercise, and smoking cessation), gestational diabetes, mental health, low- and middle-income countries, and telemonitoring and teleconsulting. Most studies in gestational diabetes and mental health show that eHealth applications are good alternatives to standard practice. Examples are interactive blood glucose management with remote care using smartphones, telephone screening for postnatal depression, and Web-based cognitive behavioral therapy. Apps and exercise programs show a direction toward less gestational weight gain, increase in step count, and increase in smoking abstinence. Multiple studies describe novel systems to enable home fetal monitoring with cardiotocography and uterine activity. However, only few studies assess outcomes in terms of fetal monitoring safety and efficacy in high-risk pregnancy. Patients and clinicians report good overall satisfaction with new strategies that enable the shift from hospital-centered to patient-centered care.

Conclusions

This review showed that eHealth interventions have a very broad, multilevel field of application focused on perinatal care in all its aspects. Most of the reviewed 71 articles were published after 2013, suggesting this novel type of care is an important topic of clinical and scientific relevance. Despite the promising preliminary results as presented, we accentuate the need for evidence for health outcomes, patient satisfaction, and the impact on costs of the possibilities of eHealth interventions in perinatal care. In general, the combination of increased patient empowerment and home pregnancy care could lead to more satisfaction and efficiency. Despite the challenges of privacy, liability, and costs, eHealth is very likely to disperse globally in the next decade, and it has the potential to deliver a revolution in perinatal care.

Optimizing Gestational Weight Gain With the Eating4Two Smartphone App: Protocol for a Randomized Controlled Trial

Background

Approximately 50% of women gain excessive weight in pregnancy. Optimizing gestational weight gain is important for the short- and long-term health of the childbearing woman and her baby. Despite this, there is no recommendation for routine weighing in pregnancy, and weight is a topic that many maternity care providers avoid. Resource-intensive interventions have mainly targeted overweight and obese women with variable results. Few studies have examined the way that socioeconomic status might influence the effectiveness or acceptability of an intervention to participants. Given the scale of the problem of maternal weight gain, maternity services will be unlikely to sustain resource intensive interventions; therefore, innovative strategies are required to assist women to manage weight gain in pregnancy.

Objective

The primary aim of the trial was to examine the effectiveness of the Eating4Two smartphone app in assisting women of all body mass index categories to optimize gestational weight gain. Secondary aims include comparing childbirth outcomes and satisfaction with antenatal care and examining the way that relative advantage and disadvantage might influence engagement with and acceptability of the intervention.

Methods

This randomized controlled trial will randomize 1330 women to control or intervention groups in 3 regions of different socioeconomic status. Women will be recruited from clinical and social media sites. The intervention group will be provided with access to the Eating4Two mobile phone app which provides nutrition and dietary information specifically tailored for pregnancy, advice on food serving sizes, and a graph that illustrates women’s weight change in relation to the range recommended by the Institute of Medicine. Women will be encouraged to use the app to prompt conversations with their maternity care providers about weight gain in pregnancy. The control group will receive routine antenatal care.

Results

Recruitment has commenced though the recruitment rate is slower than expected. Additional funds are required to employ research assistants and promote the study in an advertising campaign.

Conclusion

Feasibility testing highlighted the inadequacy of the original recruitment strategy and the need to provide the app in both major platforms (Android and iOS). Smartphone technologies may offer an effective alternative to resource intensive strategies for assisting women to optimize weight gain in pregnancy.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12617000169347; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371470 (Archived by WebCite at http://www.webcitation.org /6zDvgw5bo)

Registered Report Identifier

RR1-10.2196/9920

Multistakeholder Perspectives on Maternal Text Messaging Intervention in Uganda: Qualitative Study

Background

Despite continued interest in the use of mobile health for improving maternal health outcomes, there have been limited attempts to identify relevant program theories.

Objectives

This study had two aims: first, to explicate the assumptions of program designers, which we call the program theory and second, to contrast this program theory with empirical data to gain a better understanding of mechanisms, facilitators, and barriers related to the program outcomes.

Methods

To achieve the aforementioned objectives, we conducted a retrospective qualitative study of a text messaging (short message service) platform geared at improving individual maternal health outcomes in Uganda. Through interviews with program designers (n=3), we elicited 3 main designers’ assumptions and explored these against data from qualitative interviews with primary beneficiaries (n=26; 15 women and 11 men) and health service providers (n=6), as well as 6 focus group discussions with village health team members (n=50) who were all involved in the program.

Results

Our study results highlighted that while the program designers’ assumptions were appropriate, additional mechanisms and contextual factors, such as the importance of incentives for village health team members, mobile phone ownership, and health system factors should have been considered.

Conclusions

Our results indicate that text messages could be an effective part of a more comprehensive maternal health program when context and system barriers are identified and addressed in the program theories.

Use of an electronic Partograph: feasibility and acceptability study in Zanzibar, Tanzania

BACKGROUND

The ePartogram is a tablet-based application developed to improve care for women in labor by addressing documented challenges in partograph use. The application is designed to provide real-time decision support, improve data entry, and increase access to information for appropriate labor management. This study's primary objective was to evaluate the feasibility and acceptability of ePartogram use in resource-constrained clinical settings.

METHODS

The ePartogram was introduced at three facilities in Zanzibar, Tanzania. Following 3 days of training, skilled birth attendants (SBAs) were observed for 2 weeks using the ePartogram to monitor laboring women. During each observed shift, data collectors used a structured observation form to document SBA comfort, confidence, and ability to use the ePartogram. Results were analyzed by shift. Short interviews, conducted with SBAs (n = 82) after each of their first five ePartogram-monitored labors, detected differences over time. After the observation period, in-depth interviews were conducted (n = 15). A thematic analysis of interview transcripts was completed.

RESULTS

Observations of 23 SBAs using the ePartogram to monitor 103 women over 84 shifts showed that the majority of SBAs (87-91%) completed each of four fundamental ePartogram tasks-registering a client, entering first and subsequent measurements, and navigating between screens-with ease or increasing ease on their first shift; this increased to 100% by the fifth shift. Nearly all SBAs (93%) demonstrated confidence and all SBAs demonstrated comfort in using the ePartogram by the fifth shift. SBAs expressed positive impressions of the ePartogram and found it efficient and easy to use, beginning with first client use. SBAs noted the helpfulness of auditory reminders (indicating that measurements were due) and visual alerts (signaling abnormal measurements). SBAs expressed confidence in their ability to interpret and act on these reminders and alerts.

CONCLUSIONS

It is feasible and acceptable for SBAs to use the ePartogram to support labor management and care. With structured training and support during initial use, SBAs quickly became competent and confident in ePartogram use. Qualitative findings revealed that SBAs felt the ePartogram improved timeliness of care and supported decision-making. These findings point to the ePartogram's potential to improve quality of care in resource-constrained labor and delivery settings.

The Effect of a Community Health Worker Utilized Mobile Health Application on Maternal Health Knowledge and Behavior: A Quasi-Experimental Study

Background

Mobile technology (mHealth) is increasingly being used to achieve improved access and quality of maternal care, particularly in rural areas of low- and middle-income countries. In 2011, a mobile application—Mobile for Mothers (MfM)—was implemented in Jharkhand, India to support home visits by community health workers. The objective of this study is to assess the impact of the mHealth intervention on maternal health.

Methods

Households from three subdistricts in the Deoghar district of Jharkhand were selected using a multistage cluster sampling approach. Households from the Sarwan subdistrict received the MfM intervention, those from Devipur subdistrict received other interventions asides MfM from the implementing non-governmental organization (NGO), while households from Mohanpur subdistrict received the current standard of care. Women (n = 2,200) between the ages of 18 and 45 who had delivered a baby in the past 1 year were enrolled into the study. The primary outcomes of interest were maternal health knowledge, antenatal care (ANC) attendance, and delivery in a health facility.

Results

Post-intervention, women in the MfM group had higher maternal health knowledge, were more likely to attend four or more ANC visits, and deliver at the health facility when compared with the NGO and standard care group. After controlling for predictors, women in the intervention group significantly performed better than both the NGO and standard care groups on all three-outcome variables (all P > 0.05).

Conclusion

The results indicate that although the MfM mHealth intervention could influence adherence and practice of recommended maternal health behaviors, it could not overcome key sociocultural determinants of maternal health such as caste and educational status, which are specific to the Indian context. mHealth holds continued promise for maternal health but implementers and policy makers must additionally address health system and sociocultural factors that play a significant role in the uptake of recommended maternal health practices.

Effect of mHealth in improving antenatal care utilization and skilled birth attendance in low- and middle-income countries: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify and synthesize the best available evidence on the effect of mobile health (mHealth) interventions in antenatal care utilization and skilled birth attendance in low- and middle-income countries.More specifically, the review questions are as follows.

Through Patients' Eyes: Regulation, Technology, Privacy, and the Future

Privacy is commonly regarded as a regulatory requirement achieved via technical and organizational management practices. Those working in the field of informatics often play a role in privacy preservation as a result of their expertise in information technology, workflow analysis, implementation science, or related skills. Viewing privacy from the perspective of patients whose protected health information is at risk broadens the considerations to include the perceived duality of privacy; the existence of privacy within a context unique to each patient; the competing needs inherent within privacy management; the need for particular consideration when data are shared; and the need for patients to control health information in a global setting. With precision medicine, artificial intelligence, and other treatment innovations on the horizon, health care professionals need to think more broadly about how to preserve privacy in a health care environment driven by data sharing. Patient-reported privacy preferences, privacy portability, and greater transparency around privacy-preserving functionalities are potential strategies for ensuring that privacy regulations are met and privacy is preserved.

A Mobile Health App-Based Postnatal Educational Program (Home-but not Alone): Descriptive Qualitative Study

Background

The postnatal period poses numerous challenges for new parents. Various educational programs are available to support new parents during this stressful period. However, the usefulness of educational programs must be evaluated to ascertain their credibility.

Objective

The aim of this descriptive, qualitative study was to explore the views of parents of newborns with regard to the content and delivery of a mobile health (mHealth) app–based postnatal educational program.

Methods

A qualitative semistructured interview guide was used to collect data from 17 participants who belonged to the intervention group of a randomized controlled trial. The intervention, a 4-week-long access to a mHealth app–based educational program, was evaluated. The interviews were conducted in English and at the participants’ homes. Thematic analysis was used to analyze the data. The Consolidated Criteria for Reporting Qualitative Research checklist was used to report the findings.

Results

The interviews revealed 4 main themes: (1) positive features of the mHealth app, (2) advice from midwives, (3) experiences gained from using the mHealth app, and (4) recommendations for the future. The participants evaluated the educational program to be a good source of information that was tailored to the local context. The different modes of delivery, including audio and video, accentuated the accessibility of information. The parents evaluated that the facilitator of the featured communication platform, a midwife, provided trustworthy advice. Belongingness to a virtual community beyond the hospital endowed the parents the confidence that they were not alone and were supported by other parents and health care professionals.

Conclusions

According to the parents, the mHealth app–based educational program was helpful in supporting a multi-ethnic sample of parents during the postnatal period. This insight indicates that the program could be implemented in a wide community of parents in the postnatal period. The helpfulness of the educational program is a testament of the potential benefits of using telemedicine among new parents postnatally. Resources can also be dedicated toward extending the duration of access to the app beyond 1 month and developing relevant content for parents across the perinatal period.

Targeting strategies of mHealth interventions for maternal health in low and middle-income countries: a systematic review protocol

INTRODUCTION

Recently, there has been a steady increase in mobile health (mHealth) interventions aimed at improving maternal health of women in low-income and middle-income countries. While there is evidence indicating that these interventions contribute to improvements in maternal health outcomes, other studies indicate inconclusive results. This uncertainty has raised additional questions, one of which pertains to the role of targeting strategies in implementing mHealth interventions and the focus on pregnant women and health workers as target groups. This review aims to assess who is targeted in different mHealth interventions and the importance of targeting strategies in maternal mHealth interventions.

METHODS AND ANALYSIS

We will search for peer-reviewed, English-language literature published between 1999 and July 2017 in PubMed, Web of Knowledge (Science Direct, EMBASE) and Cochrane Central Registers of Controlled Trials. The study scope is defined by the Population, Intervention, Comparison and Outcomes framework: P, community members with maternal or reproductive needs; I, electronic health or mHealth programmes geared at improving maternal or reproductive health; C, other non-electronic health or mHealth-based interventions; O, maternal health measures including family planning, antenatal care attendance, health facility delivery and postnatal care attendance.

ETHICS AND DISSEMINATION

This study is a review of already published or publicly available data and needs no ethical approval. Review results will be published in a peer-reviewed journal and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42017072280.

Development of a Maternal, Newborn and Child mHealth Intervention in Thai Nguyen Province, Vietnam: Protocol for the mMom Project

Background

Ethnic minority women (EMW) living in mountainous areas of northern Vietnam have disproportionately high infant and maternal mortality rates as a result of low maternal health knowledge, poverty, and remoteness from low-capacity health centers.

Objective

The objective of this study was to describe the protocol for the development and evaluation of the mMom intervention, which is an integrated mobile health (mHealth) system designed to improve maternal and infant health knowledge, and behavior among women in remote areas of Thai Nguyen, Vietnam.

Methods

This project featured the following four phases: (1) development of an mHealth platform integrated into the existing health management information system in partnership with the provincial health department; (2) ethnographic fieldwork and intervention content development; (3) intervention piloting and implementation; and (4) evaluation of the intervention’s impact on participants’ maternal health knowledge, behavior, and interactions with the health system.

Results

The mMom project development process resulted in the following: (1) the successful development of the mMom system, including the mHealth platform hardware and integration, the intervention plan and content, and the monitoring and evaluation framework; (2) the piloting and implementation of the intervention as planned; and (3) the implementation of the monitoring and evaluation framework components.

Conclusions

This protocol outlines the development of the mMom intervention and describes critical next steps in understanding the impact of the intervention on participants and the wider health system in Thai Nguyen province, Vietnam.

Effectiveness and Appropriateness of mHealth Interventions for Maternal and Child Health: Systematic Review

Background

The application of mobile health (mHealth) technology in reproductive, maternal, newborn, and child health (RMNCH) is increasing worldwide. However, best practice and the most effective mHealth interventions have not been reviewed systematically.

Objective

A systematic review and meta-analysis of studies of mHealth interventions for RMNCH around the world were conducted to investigate their characteristics as well as the features and effectiveness of mHealth interventions.

Methods

Studies of mHealth interventions for RMNCH between January 2011 and December 2016 were retrieved from 6 databases (PubMed, EMBASE, Global Health, China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, and Wanfang Data Knowledge Service Medium). Comparable studies were included in a random-effects meta-analysis for both exclusive breastfeeding (EBF) and antenatal checks (ANC). Descriptive analyses were conducted for mHealth studies with a range of study designs.

Results

Analyses of 245 studies were included, including 51 randomized controlled trials (RCTs). Results showed that there are increasing numbers of studies on mHealth interventions for RMNCH. Although 2 meta-analysis, one with 2 RCTs on EBF (odds ratio [OR] 2.03, 95% CI 1.34-3.08, I²=25%) and the other with 3 RCTs on ANC (OR 1.43, 95% CI 1.13-1.79, I²=78%), showed that mHealth interventions are more effective than usual care, almost half (43%) of RCTs showed negative or unclear results on mHealth interventions. Functions described in mHealth interventions were diverse, and the health stages covered were broad. However, single function or single stage appeared to be dominant among mHealth interventions compared with multiple functions or stages.

Conclusions

More rigorous evaluations are needed to draw consistent conclusions and to analyze mHealth products with multiple functions, especially those popular in the app markets.

Birth preparedness and complication readiness (BPCR) among pregnant women in hard-to-reach areas in Bangladesh

Background

Birth preparedness and complication readiness aims to reduce delays in care seeking, promote skilled birth attendance, and facility deliveries. Little is known about birth preparedness practices among populations living in hard-to-reach areas in Bangladesh.

Objectives

To describe levels of birth preparedness and complication readiness among recently delivered women, identify determinants of being better prepared for birth, and assess the impact of greater birth preparedness on maternal and neonatal health practices.

Methods

A cross-sectional survey with 2,897 recently delivered women was undertaken in 2012 as part of an evaluation trial done in five hard-to-reach districts in rural Bangladesh. Mothers were considered well prepared for birth if they adopted two or more of the four birth preparedness components. Descriptive statistics and multivariable logistic regression were used for analysis.

Results

Less than a quarter (24.5%) of women were considered well prepared for birth. Predictors of being well-prepared included: husband’s education (OR = 1.3; CI: 1.1–1.7), district of residence, exposure to media in the form of reading a newspaper (OR = 2.2; CI: 1.2–3.9), receiving home visit by a health worker during pregnancy (OR = 1.5; CI: 1.2–1.8), and receiving at least 3 antenatal care visits from a qualified provider (OR = 1.4; CI: 1.0–1.9). Well-prepared women were more likely to deliver at a health facility (OR = 2.4; CI: 1.9–3.1), use a skilled birth attendant (OR = 2.4, CI: 1.9–3.1), practice clean cord care (OR = 1.3, CI: 1.0–1.5), receive post-natal care from a trained provider within two days of birth for themselves (OR = 2.6, CI: 2.0–3.2) or their newborn (OR = 2.6, CI: 2.1–3.3), and seek care for delivery complications (OR = 1.8, CI: 1.3–2.6).

Conclusion

Greater emphasis on BPCR interventions tailored for hard to reach areas is needed to improve skilled birth attendance, care seeking for complications and essential newborn care and facilitate reductions in maternal and neonatal mortality in low performing districts in Bangladesh.

PRENACEL - a mHealth messaging system to complement antenatal care: a cluster randomized trial

Background

The aim of this study was to determine whether PRENACEL (a bi-directional, mobile-phone based, short text message service (SMS)) increases the coverage of recommended antenatal care (ANC) practices.

Methods

A parallel, cluster-randomized trial in which 20 public primary Health Care Units (PHCUs) were randomly allocated to the intervention (10 PHCUs) or control (10 PHCUs) group. The study population included pregnant women aged 18 or above with a gestational age of 20 weeks or less. Pregnant women receiving ANC in intervention PHCUs were invited through leaflets and posters to register in PRENACEL. Women who registered in PRENACEL received a weekly set of short text messages with health education and health promotion content related to pregnancy and childbirth and were also able to clarify ANC queries through SMS. All women received routine ANC. The primary outcome was the proportion of women with high ANC Score, a composite measure of coverage of recommended ANC practices. Chi-square or Fisher’s exact tests and multivariate log-binomial regression were used to analyze the outcomes.

Results

A total of 1210 eligible women received ANC in the participating PHCUs and took part of this study (770 in the intervention group and 440 in the control group). 20.4% (157/770) of intervention-group women registered in PRENACEL, but only 116 read all messages (73.9% of women who registered in PRENACEL, 116/157). The adjusted intention-to-treat analysis suggested no difference between intervention and control groups in the primary outcome (Adjusted Relative Risk (AdjRR): 1.05 (95% Confidence Interval (CI): 1.00–1.09). Both crude and adjusted per-protocol analysis suggested a positive effect of PRENACEL (Crude RR (95% CI): 1.14 (1.06–1.22), AdjRR (95% CI): 1.12 (1.05–1.21). The multivariate analysis also suggests that the PRENACEL group (women who read all SMS) had higher mean ANC score [48.5 (±4.2) vs 45.2 (±8.7), p < 0.01], higher proportion of women with ≥6 ANC visits (96.9% vs. 84.8%, p = 0.01), and higher rates of syphilis testing (40.5% vs. 24.8%, p = 0.03) and HIV testing (46.6% vs. 25.7%, p < 0.01) during ANC.

Conclusions

A bi-directional, mobile-phone based, short text message service is potentially useful to improve the coverage of recommended ANC practices, including syphilis and HIV testing.

Trial registration

Clinical trial registry: RBR-54zf73, U1111–1163-7761.

Resumo

Introdução

O objetivo deste estudo foi determinar se o PRENACEL, um serviço bidirecional de mensagens curtas de texto (SMS) com base na telefonia celular, aumenta a cobertura das práticas recomendadas de cuidados pré-natais (PN).

Métodos

um ensaio paralelo, aleatorizado por conglomerados, no qual 20 unidades básicas de saúde (UBS) foram alocadas aleatoriamente para o grupo de intervenção (10 UBS) ou controle (10 UBS). A população estudada incluiu gestantes com idade igual ou superior a 18 anos com idade gestacional de 20 semanas ou menos. As gestantes que receberam PN em UBS intervenção foram convidadas através de folhetos e cartazes para se inscreverem no PRENACEL. As mulheres que se registraram no PRENACEL receberam um conjunto semanal de SMS com conteúdo de educação e promoção da saúde relacionadas à gravidez e parto e também puderam esclarecer dúvidas relacionadas ao PN através de SMS. Todas as mulheres receberam PN de rotina. O desfecho primário foi a proporção de mulheres com um alto escore de PN, uma medida da cobertura das principais práticas recomendadas no PN.

Resultados

um total de 1.210 mulheres participaram deste estudo (770 no grupo de intervenção e 440 no grupo de controle). 20,4% (157/770) das mulheres do grupo de intervenção demonstraram interesse e foram registradas no PRENACEL, mas apenas 116 leram as mensagens (73,9%, 116/157). A análise ajustada de intenção de tratamento sugeriu ausência de efeito da intervenção no desfecho primário (Risco Relativo (RR) ajustado: 1,05, Intervalo de Confiança (IC) de 95%: 1,00–1,09). A análise por protocolo sugeriu um efeito positivo do PRENACEL [RR bruto (IC 95%): 1,14 (1,06–1,22), RR ajustado (IC 95%): 1,12 (1,05–1,21)]. A análise multivariada sugeriu que as mulheres que leram os SMS apresentaram a maior média do escore de PN [48,5 (±4,2) vs 45,2 (±8,7), p < 0,01], maior proporção de mulheres com ≥6 consultas (96,9% vs. 84,8%, p = 0,01) e maiores taxas de teste de sífilis (40,5% vs. 24,8%, p = 0,03) e HIV (46,6% vs. 25,7%, p < 0,01) durante o PN.

Conclusões

o sistema PRENACEL é potencialmente útil para melhorar a cobertura das práticas recomendadas de PN, incluindo testes de sífilis e HIV.

Electronic supplementary material

The online version of this article (10.1186/s12978-017-0407-1) contains supplementary material, which is available to authorized users.

Effects of the Informed Health Choices podcast on the ability of parents of primary school children in Uganda to assess claims about treatment effects: a randomised controlled trial

BACKGROUND

As part of the Informed Health Choices project, we developed a podcast called The Health Choices Programme to help improve the ability of people to assess claims about the benefits and harms of treatments. We aimed to evaluate the effects of the podcast on the ability of parents of primary school children in Uganda to assess claims about the effects of treatments.

METHODS

We did this randomised controlled trial in central Uganda. We recruited parents of children aged 10-12 years who were in their fifth year of school at 35 schools that were participating in a linked trial of the Informed Health Choices primary school resources. The parents were randomly allocated (1:1), via a web-based random number generator with block sizes of four and six, to listen to either the Informed Health Choices podcast (intervention group) or typical public service announcements about health issues (control group). Randomisation was stratified by parents' highest level of formal education attained (primary school, secondary school, or tertiary education) and the allocation of their children's school in the trial of the primary school resources (intervention vs control). The primary outcome, measured after listening to the entire podcast, was the mean score and the proportion of parents with passing scores on a test with two multiple choice questions for each of nine key concepts essential to assessing claims about treatments (18 questions in total). We did intention-to-treat analyses. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201606001676150.

FINDINGS

We recruited parents between July 21, 2016, and Oct 7, 2016. We randomly assigned 675 parents to the podcast group (n=334) or the public service announcement group (n=341); 561 (83%) participants completed follow-up. The mean score for parents in the podcast group was 67·8% (SD 19·6) compared with 52·4% (17·6) in the control group (adjusted mean difference 15·5%, 95% CI 12·5-18·6; p<0·0001). In the podcast group, 203 (71%) of 288 parents had a predetermined passing score (≥11 of 18 correct answers) compared with 103 (38%) of 273 parents in the control group (adjusted difference 34%, 95% CI 26-41; p<0·0001). No adverse events were reported.

INTERPRETATION

Listening to the Informed Health Choices podcast led to a large improvement in the ability of parents to assess claims about the effects of treatments. Future studies should assess the long-term effects of use of the podcast, the effects on actual health choices and outcomes, and how transferable our findings are to other countries.

FUNDING

Research Council of Norway.

Attendance at antenatal clinics in inner-city Johannesburg, South Africa and its associations with birth outcomes: analysis of data from birth registers at three facilities

Background

Antenatal care (ANC) clinics serve as key gateways to screening and treatment interventions that improve pregnancy outcomes, and are especially important for HIV-infected women. By disaggregating data on access to ANC, we aimed to identify variation in ANC attendance by level of care and across vulnerable groups in inner-city Johannesburg, and document the impact of non-attendance on birth outcomes.

Methods

This record review of routine health service data involved manual extraction of 2 years of data from birth registers at a primary-, secondary- and tertiary-level facility within inner-city Johannesburg. Information was gathered on ANC attendance, HIV testing and status, pregnancy duration, delivery mode and birth outcomes. Women with an unknown attendance status were considered as not having attended clinic, but effects of this assumption were tested in sensitivity analyses. Multiple logistic regression was used to identify associations between ANC attendance and birth outcomes.

Results

Of 31,179 women who delivered, 88.7% (27,651) had attended ANC (95% CI = 88.3–89.0). Attendance was only 77% at primary care (5813/7543), compared to 89% at secondary (3661/4113) and 93% at tertiary level (18,177/19,523). Adolescents had lower ANC attendance than adults (85%, 1951/2295 versus 89%, 22,039/24,771). Only 37% of women not attending ANC had an HIV test (1308/3528), compared with 93% of ANC attenders (25,756/27,651). Caesarean section rates were considerably higher in women who had attended ANC (40%, 10,866/27,344) than non-attenders (13%, 422/3360). Compared to those who had attended ANC, non-attenders were 1.6 fold more likely to have a preterm delivery (95% CI adjusted odds ratio [aOR] = 1.4–1.8) and 1.4 fold more likely to have a stillbirth (aOR 95% CI = 1.1–1.9). Similar results were seen in analyses where missing data on ANC attendance was classified in different ways.

Conclusion

Inner-city Johannesburg has an almost 5% lower ANC attendance rate than national levels. Attendance is particularly concerning in the primary care clinic that serves a predominantly migrant population. Adolescents had especially low rates, perhaps owing to stigma when seeking care. Interventions to raise ANC attendance, especially among adolescents, may help improve birth outcomes and HIV testing rates, bringing the country closer to achieving maternal and child health targets and eliminating HIV in children.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4347-z) contains supplementary material, which is available to authorized users.

The effect of a clinical decision-making mHealth support system on maternal and neonatal mortality and morbidity in Ghana: study protocol for a cluster randomized controlled trial

BACKGROUND

Mobile health (mHealth) presents one of the potential solutions to maximize health worker impact and efficiency in an effort to reach the Sustainable Development Goals 3.1 and 3.2, particularly in sub-Saharan African countries. Poor-quality clinical decision-making is known to be associated with poor pregnancy and birth outcomes. This study aims to assess the effect of a clinical decision-making support system (CDMSS) directed at frontline health care providers on neonatal and maternal health outcomes.

METHODS/DESIGN

A cluster randomized controlled trial will be conducted in 16 eligible districts (clusters) in the Eastern Region of Ghana to assess the effect of an mHealth CDMSS for maternal and neonatal health care services on maternal and neonatal outcomes. The CDMSS intervention consists of an Unstructured Supplementary Service Data (USSD)-based text messaging of standard emergency obstetric and neonatal protocols to providers on their request. The primary outcome of the intervention is the incidence of institutional neonatal mortality. Outcomes will be assessed through an analysis of data on maternal and neonatal morbidity and mortality extracted from the District Health Information Management System-2 (DHIMS-2) and health facility-based records. The quality of maternal and neonatal health care will be assessed in two purposively selected clusters from each study arm.

DISCUSSION

In this trial the effect of a mobile CDMSS on institutional maternal and neonatal health outcomes will be evaluated to generate evidence-based recommendations for the use of mobile CDMSS in Ghana and other West African countries.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02468310 . Registered on 7 September 2015; Pan African Clinical Trials Registry, identifier: PACTR20151200109073 . Registered on 9 December 2015 retrospectively from trial start date.

Cultural and Linguistic Adaptation of a Healthy Diet Text Message Intervention for Hispanic Adults Living in the United States

Hispanics represent a critical target for culturally adapted diet interventions. In this formative research, we translated HealthyYouTXT, an mHealth program developed by the U.S. National Cancer Institute, into HealthyYouTXT en Español, a linguistically and culturally appropriate version for Spanish speakers in the United States. We report a three-stage, mixed-methods process through which we culturally adapted the text messages, evaluated their acceptability, and revised the program based on the findings. In Stage 1, we conducted initial translations and adaptations of the text libraries using an iterative, principle-guided process. In Stage 2, we used mixed methods including focus groups and surveys with 109 Hispanic adults to evaluate the acceptability and cultural appropriateness of the program. We used survey data to evaluate whether self-determination theory (SDT) factors (used to develop HealthyYouTXT) of autonomous motivation, controlled motivation, and amotivation and Hispanic cultural beliefs about familism, fatalism, and destiny predict program interest and its perceived efficacy. Mixed-methods analyses revealed substantial interest in HealthyYouTXT, with most participants desiring to use it and viewing it as highly efficacious. Both cultural beliefs (i.e., beliefs in destiny and, for men, high familism) and SDT motivations (i.e., autonomy) predicted HealthyYouTXT evaluations, suggesting utility in emphasizing them in messages. Higher destiny beliefs predicted lower interest, suggesting that they could impede program use. In Stage 3, we implemented the mixed-methods findings to finalize HealthyYouTXT en Español. The emergent linguistic principles and multistage, multimethods process can be applied in health communication adaptations.

Use of m-Health in polio eradication and other immunization activities in developing countries

INTRODUCTION

Reaching the children that are chronically missed by routine immunization services has been a key pillar of success in achieving progress toward polio eradication. The rapid advancement and accessibility of mobile technology ("mHealth") in low and lower middle income countries provides an important opportunity to apply novel, innovative approaches to provide vaccine services. We sought to document the use and effectiveness of mHealth in immunization programs in low and lower middle income countries. We particularly focused on mHealth approaches used in polio eradication efforts by the Global Polio Eradication Initiative (GPEI) to leverage the knowledge and lessons learned that may be relevant for enhancing ongoing immunization services.

METHODS

In June 2016, the electronic database PubMed was searched for peer reviewed studies that focused on efforts to improve immunization programs (both ongoing immunization services and supplemental immunization activities or campaigns) through mobile technology in low and lower middle income countries.

RESULTS

The search yielded 317 papers of which 25 met the inclusion criteria. One additional article was included from the hand searching process. mHealth was used for reminder and recall, monitoring and surveillance, vaccine acceptance, and campaign strategic planning. Mobile phones were the most common mobile device used. Of the 26 studies, 21 of 26 studies (80.8%) reported that mHealth improved immunization efforts.

CONCLUSION

mHealth interventions can effectively enhance immunization services in low and lower middle income countries. With the growing capacity and access to mobile technology, mHealth can be a powerful and sustainable tool for enhancing the reach and impact of vaccine programs.

Thinking about the environment and theorising change: how could Life History Strategy Theory inform mHealth interventions in low- and middle-income countries?

BACKGROUND

There is a growing body of literature outlining the promise of mobile information and communication technologies to improve healthcare in resource-constrained contexts.

METHODS

We reviewed the literature related to mobile information and communication technologies which aim to improve healthcare in resource-constrained contexts, in order to glean general observations regarding the state of mHealth in high-income countries (HIC) and low- and middle-income countries (LMIC).

RESULTS

mHealth interventions in LMIC often differ substantively from those in HIC, with the former being simpler, delivered through a single digital component (an SMS as opposed to a mobile phone application, or 'app'), and, as a result, targeting only one of the many factors which impact on the activation (or deactivation) of the target behaviour. Almost as a rule, LMIC mHealth interventions lack an explicit theory of change.

CONCLUSION

We highlight the necessity, when designing mHealth interventions, of having a theory of change that encompasses multiple salient perspectives pertaining to human behaviour. To address this need, we explore whether the concept of Life History Strategy could provide the mHealth field with a useful theory of change. Life History Strategy Theory may be particularly useful in understanding some of the problems, paradoxes, and limitations of mHealth interventions found in LMIC. Specifically, this theory illuminates questions regarding 'light-weight' programmes which solely provide information, reminders, and other virtual 'nudges' that may have limited impact on behaviours governed by extrinsic structural factors.

Continuum of Care Services for Maternal and Child Health using mobile technology - a health system strengthening strategy in low and middle income countries

Background

Mobile phone technology is utilized for better delivery of health services worldwide. In low-and-middle income countries mobile phones are now ubiquitous. Thus leveraging mHealth applications in health sector is becoming popular rapidly in these countries. To assess the effectiveness of the Continuum of Care Services (CCS) mHealth platform in terms of strengthening the delivery of maternal and child health (MCH) services in a district in Bihar, a resource-poor state in India.

Methods

The CommCare mHealth platform was customized to CCS as one of the innovations under a project funded by the Bill and Melinda Gates Foundation to improve the maternal and newborn health services in Bihar. The intervention was rolled out in one project district in Bihar, during July 2012. More than 550 frontline workers out of a total of 3000 including Accredited Social Health Activists, Anganwadi Workers, Auxilliary Nurse Midwives and Lady Health Supervisors were trained to use the mHealth platform. The service delivery components namely early registration of pregnant women, three antenatal visits, tetanus toxoid immunization of the mother, iron and folic acid tablet supply, institutional delivery, postnatal home visits and early initiation of breastfeeding were used as indicators for good quality services. The resultant coverage of these services in the implementation area was compared with rest of Bihar and previous year statistics of the same area. The time lag between delivery of a service and its record capture in the maternal and child tracking system (MCTS) database was computed in a random sample of 16,000 beneficiaries. The coverage of services among marginalized and non-marginalized castes was compared to indicate equity of service delivery. Health system strengthening was viewed from the angle of coverage, quality, equity and efficiency of services.

Results

The implementation blocks had higher coverage of all the eight indicator services compared to rest of Bihar and the previous year. There was equity of services across castes for all the indicators. Timely capture of data was also ensured compared to paper-based reporting.

Conclusion

By virtue of its impact on quality, efficiency and equity of service delivery, health care manpower efficiency and governance, the mHealth inclusion at service provision level can be one of the potential strategy to strengthen the health system.