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Bell L, Garnett C, Bao Y, Cheng Z, Qian T, Perski O, Potts HWW, Williamson E. How Notifications Affect Engagement With a Behavior Change App: Results From a Micro-Randomized Trial. JMIR Mhealth Uhealth 2023; 11:e38342. [PMID: 37294612 PMCID: PMC10337295 DOI: 10.2196/38342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 10/08/2022] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Drink Less is a behavior change app to help higher-risk drinkers in the United Kingdom reduce their alcohol consumption. The app includes a daily notification asking users to "Please complete your drinks and mood diary," yet we did not understand the causal effect of the notification on engagement nor how to improve this component of Drink Less. We developed a new bank of 30 new messages to increase users' reflective motivation to engage with Drink Less. This study aimed to determine how standard and new notifications affect engagement. OBJECTIVE Our objective was to estimate the causal effect of the notification on near-term engagement, to explore whether this effect changed over time, and to create an evidence base to further inform the optimization of the notification policy. METHODS We conducted a micro-randomized trial (MRT) with 2 additional parallel arms. Inclusion criteria were Drink Less users who consented to participate in the trial, self-reported a baseline Alcohol Use Disorders Identification Test score of ≥8, resided in the United Kingdom, were aged ≥18 years, and reported interest in drinking less alcohol. Our MRT randomized 350 new users to test whether receiving a notification, compared with receiving no notification, increased the probability of opening the app in the subsequent hour, over the first 30 days since downloading Drink Less. Each day at 8 PM, users were randomized with a 30% probability of receiving the standard message, a 30% probability of receiving a new message, or a 40% probability of receiving no message. We additionally explored time to disengagement, with the allocation of 60% of eligible users randomized to the MRT (n=350) and 40% of eligible users randomized in equal number to the 2 parallel arms, either receiving the no notification policy (n=98) or the standard notification policy (n=121). Ancillary analyses explored effect moderation by recent states of habituation and engagement. RESULTS Receiving a notification, compared with not receiving a notification, increased the probability of opening the app in the next hour by 3.5-fold (95% CI 2.91-4.25). Both types of messages were similarly effective. The effect of the notification did not change significantly over time. A user being in a state of already engaged lowered the new notification effect by 0.80 (95% CI 0.55-1.16), although not significantly. Across the 3 arms, time to disengagement was not significantly different. CONCLUSIONS We found a strong near-term effect of engagement on the notification, but no overall difference in time to disengagement between users receiving the standard fixed notification, no notification at all, or the random sequence of notifications within the MRT. The strong near-term effect of the notification presents an opportunity to target notifications to increase "in-the-moment" engagement. Further optimization is required to improve the long-term engagement. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/18690.
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Affiliation(s)
- Lauren Bell
- Department of Medical Statistics, The London School of Hygiene and Tropical Medicine, London, United Kingdom
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
| | - Claire Garnett
- Research Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Yihan Bao
- Department of Statistics and Data Science, Yale University, New Haven, CT, United States
| | - Zhaoxi Cheng
- Department of Biostatistics, Harvard University, Cambridge, MA, United States
| | - Tianchen Qian
- Department of Statistics, University of California Irvine, Irvine, CA, United States
| | - Olga Perski
- Research Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Henry W W Potts
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Elizabeth Williamson
- Department of Medical Statistics, The London School of Hygiene and Tropical Medicine, London, United Kingdom
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Mavodza CV, Bernays S, Mackworth-Young CRS, Nyamwanza R, Nzombe P, Dauya E, Chikwari CD, Tembo M, Apollo T, Mugurungi O, Madzima B, Nguwo D, Ferrand RA, Busza J. Fidelity, Feasibility and Adaptation of a Family Planning Intervention for Young Women in Zimbabwe: Provider Perspectives and Experiences. GLOBAL IMPLEMENTATION RESEARCH AND APPLICATIONS 2023. [PMCID: PMC10037356 DOI: 10.1007/s43477-023-00075-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
The CHIEDZA (Community-based Interventions to improve HIV outcomes in youth: a cluster randomised trial in Zimbabwe) trial evaluated an integrated package of HIV and sexual and reproductive health services for young people aged 16–24 years in Zimbabwe. The family planning component aimed to improve access to information, services, and contraceptives delivered by trained youth-friendly providers within a community-based setting for young women. Responsively adapting the intervention was a part of the intervention design’s rationale. We investigated the factors influencing implementation fidelity, quality, and feasibility using provider experiences and perspectives. We conducted provider interviews (N = 42), non-participant (N = 18), and participant observation (N = 30) of intervention activities. The data was analyzed thematically. CHIEDZA providers were receptive to providing the family planning intervention, but contexts outside of the intervention created challenges to the intervention’s fidelity. Strategic adaptations were required to ensure service quality within a youth-friendly context. These adaptations strengthened service delivery but also resulted in longer wait times, more frequent visits, and variability of Long-Acting Reversible contraceptives (LARCS) provision which depended on target-driven programming by partner organization. This study was a practical example of how tracking adaptations is vital within process evaluation methods in implementation science. Anticipating that changes will occur is a necessary pre-condition of strong evaluations and tracking adaptations ensures that lessons on feasibility of design, contextual factors, and health system factors are responded to during implementation and can improve quality. Some contextual factors are unpredictable, and implementation should be viewed as a dynamic process where responsive adaptations are necessary, and fidelity is not static. Trial registration ClinicalTrials.gov Identifier: NCT03719521.
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Affiliation(s)
- Constancia V. Mavodza
- grid.418347.d0000 0004 8265 7435The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
- grid.8991.90000 0004 0425 469XDepartment of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Bernays
- grid.8991.90000 0004 0425 469XDepartment of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- grid.1013.30000 0004 1936 834XSchool of Public Health, University of Sydney, Sydney, Australia
| | - Constance R. S. Mackworth-Young
- grid.418347.d0000 0004 8265 7435The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
- grid.8991.90000 0004 0425 469XDepartment of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Rangarirayi Nyamwanza
- grid.418347.d0000 0004 8265 7435The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
| | - Portia Nzombe
- grid.418347.d0000 0004 8265 7435The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
| | - Ethel Dauya
- grid.418347.d0000 0004 8265 7435The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
| | - Chido Dziva Chikwari
- grid.418347.d0000 0004 8265 7435The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
- grid.8991.90000 0004 0425 469XDepartment of Infectious Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mandikudza Tembo
- grid.418347.d0000 0004 8265 7435The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
- grid.8991.90000 0004 0425 469XDepartment of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tsitsi Apollo
- grid.415818.1HIV and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Owen Mugurungi
- grid.415818.1HIV and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | | | - Rashida Abbas Ferrand
- grid.418347.d0000 0004 8265 7435The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, 10 Seagrave Road, Avondale, Harare, Zimbabwe
- grid.8991.90000 0004 0425 469XDepartment of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Joanna Busza
- grid.8991.90000 0004 0425 469XDepartment of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Mensah IK. Understanding the Drivers of Ghanaian Citizens' Adoption Intentions of Mobile Health Services. Front Public Health 2022; 10:906106. [PMID: 35774576 PMCID: PMC9237369 DOI: 10.3389/fpubh.2022.906106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/02/2022] [Indexed: 11/23/2022] Open
Abstract
Mobile health (m-health) application development and diffusion in developing countries have always been a challenge; therefore, research that seeks to provide an elucidation of the drivers of m-Health adoption is vital. Mobile health information systems and applications can contribute to the delivery of a good healthcare system. This study examined the factors influencing citizens' adoption of mobile health services. The Technology Acceptance Model (TAM) was used as the research underpinning for this study, while the data gathered were analyzed with SmartPLS through the use of the structural equation modeling technique. The results showed that perceived usefulness and ease of use were both significant predictors of the behavioral intention to use and recommend the adoption of mobile health services. Also, perceived risk was negative but significant in predicting the intention to use and recommend adoption. Mobile self-efficacy was found to significantly determine the behavioral intention to use, intention to recommend, perceived usefulness, and perceived ease of use of mobile health services. Besides, word-of-mouth showed a positive impact on both the intention to use and recommend. Contrary to expectations, the intention to use had no significant impact on the recommendation intention. The theoretical and practical implications of these findings are thoroughly examined.
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Affiliation(s)
- Isaac Kofi Mensah
- Department of Business Administration, School of Economics and Management, Jiangxi University of Science and Technology, Ganzhou, China
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Owoyemi A, Osuchukwu JI, Azubuike C, Ikpe RK, Nwachukwu BC, Akinde CB, Biokoro GW, Ajose AB, Nwokoma EI, Mfon NE, Benson TO, Ehimare A, Irowa-Omoregie D, Olaniran S. Digital Solutions for Community and Primary Health Workers: Lessons From Implementations in Africa. Front Digit Health 2022; 4:876957. [PMID: 35754461 PMCID: PMC9215204 DOI: 10.3389/fdgth.2022.876957] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
The agenda for Universal Health Coverage has driven the exploration of various innovative approaches to expanding health services to the general population. As more African countries have adopted digital health tools as part of the strategic approach to expanding health services, there is a need for defining a standard framework for implementation across board. Therefore, there is a need to review and employ an evidence-based approach to inform managing challenges, adopting best approaches, and implement informed recommendations. We reviewed a variety of digital health tools applied to different health conditions in primary care settings and highlighted the challenges faced, approaches that worked and relevant recommendations. These include limited coverage and network connectivity, lack of technological competence, lack of power supply, limited mobile phone usage and application design challenges. Despite these challenges, this review suggests that mHealth solutions could attain effective usage when healthcare workers receive adequate onsite training, deploying applications designed in an intuitive and easy to understand approach in a manner that fits into the users existing workflows, and involvement of the stakeholders at all levels in the design, planning, and implementation stages of the interventions.
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Affiliation(s)
- Ayomide Owoyemi
- Department of Biomedical and Health Information Sciences, Chicago, IL, United States
- *Correspondence: Ayomide Owoyemi
| | | | - Clark Azubuike
- Social and Behavioral Sciences Department, T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | | | - Blessing C. Nwachukwu
- Department of Biomedical and Health Information Sciences, Chicago, IL, United States
| | | | - Grace W. Biokoro
- Department of Human and Health Sciences, Northern Illinois University, DeKalb, IL, United States
| | - Abisoye B. Ajose
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | | | - Nehemiah E. Mfon
- Department of Obstetrics and Gynecology, National Hospital, Abuja, Nigeria
| | - Temitope O. Benson
- Institute for Computational and Data Sciences, University at Buffalo, State University of New York, Albany, NY, United States
| | - Anthony Ehimare
- Department of Health Informatics, Swansea University, Wales, United Kingdom
| | | | - Seun Olaniran
- Department of Integrated Information Technology, College of Engineering and Computing, University of South Carolina, Columbia, SC, United States
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Avoka CK, McArthur E, Banke-Thomas A. Interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub-Saharan Africa: A systematic review. Trop Med Int Health 2022; 27:494-509. [PMID: 35322914 PMCID: PMC9321161 DOI: 10.1111/tmi.13747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective The objective of the study was to review the evidence on interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub‐Saharan Africa (SSA). Methods A systematic search of PubMed, Embase, Cochrane Register and CINAHL Plus was conducted to identify studies on obstetric emergency referral in SSA. Studies were included based on pre‐defined eligibility criteria. Details of reported referral interventions were extracted and categorised. The Joanna Biggs Institute Critical Appraisal checklists were used for quality assessment of included studies. A formal narrative synthesis approach was used to summarise findings guided by the WHO's referral system flow. Results A total of 14 studies were included, with seven deemed high quality. Overall, 7 studies reported referral decision‐making interventions including training programmes for health facility and community health workers, use of a triage checklist and focused obstetric ultrasound, which resulted in improved knowledge and practice of recognising danger signs for referral. 9 studies reported on referral communication using mobile phones and referral letters/notes, resulting in increased communication between facilities despite telecommunication network failures. Referral decision making and communication interventions achieved a perceived reduction in maternal mortality. 2 studies focused on referral feedback, which improved collaboration between health facilities. Conclusion There is limited evidence on how well referral interventions work in sub‐Saharan Africa, and limited consensus regarding the framework underpinning the expected change. This review has led to the proposition of a logic model that can serve as the base for future evaluations which robustly expose the (in)efficiency of referral interventions.
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Affiliation(s)
- Cephas K Avoka
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Aduragbemi Banke-Thomas
- School of Human Sciences, University of Greenwich, London, UK.,LSE Health, London School of Economics and Political Science, London, UK
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Chan NHM, Merali HS, Mistry N, Kealey R, Campbell DM, Morris SK, Data S. Development of a novel mobile application, HBB Prompt, with human factors and user-centred design for Helping Babies Breathe skills retention in Uganda. BMC Med Inform Decis Mak 2021; 21:39. [PMID: 33541340 PMCID: PMC7863544 DOI: 10.1186/s12911-021-01406-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Helping Babies Breathe (HBB) is a life-saving program that has helped reduce neonatal morbidity and mortality, but knowledge and skills retention after training remains a significant challenge for sustainability of impact. User-centred design (UCD) can be used to develop solutions to target knowledge and skills maintenance. METHODS We applied a process of UCD beginning with understanding the facilitators of, and barriers to, learning and retaining HBB knowledge and skills. HBB Master Trainers and frontline HBB providers participated in a series of focus group discussions (FGDs) to uncover the processes of skills acquisition and maintenance to develop a mobile application called "HBB Prompt". Themes derived from each FGD were identified and implications for development of the HBB Prompt app were explored, including feasibility of incorporating strategies into the format of an app. Data analysis took place after each iteration in Phase 1 to incorporate feedback and improve subsequent versions of HBB Prompt. RESULTS Six HBB trainers and seven frontline HBB providers participated in a series of FGDs in Phase 1 of this study. Common themes included lack of motivation to practise, improving confidence in ventilation skills, ability to achieve the Golden Minute, fear of forgetting knowledge or skills, importance of feedback, and peer-to-peer learning. Themes identified that were not feasible to address pertained to health system challenges. Feedback about HBB Prompt was generally positive. Based on initial and iterative feedback, HBB Prompt was created with four primary functions: Training Mode, Simulation Mode, Quizzes, and Dashboard/Scoreboard. CONCLUSIONS Developing HBB Prompt with UCD to help improve knowledge and skills retention was feasible and revealed key concepts, including drivers for successes and challenges faced for learning and maintaining HBB skills. HBB Prompt will be piloted in Phase 2 of this study, where knowledge and skills retention after HBB training will be compared between an intervention group with HBB Prompt and a control group without the app. Trial registration Clinicaltrials.gov (NCT03577054). Retrospectively registered July 5, 2018, https://clinicaltrials.gov/ct2/show/study/NCT03577054 .
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Affiliation(s)
- Natalie Hoi-Man Chan
- Division of Neonatology, British Columbia Women’s Hospital, 1N55-4480 Oak Street, Vancouver, BC V6H 3V4 Canada
| | - Hasan S. Merali
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children’s Hospital, 1280 Main Street West, HSC-2R104, Hamilton, ON L8S 4K1 Canada
| | - Niraj Mistry
- Division of Paediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- Department of Pediatrics, University of Toronto, Toronto, ON Canada
| | - Ryan Kealey
- Interactive Media Lab, University of Toronto, 5 King’s College Road, Toronto, ON M5S 3G8 Canada
- Design Research, TD Bank Group, Toronto, ON Canada
| | - Douglas M. Campbell
- Division of Neonatology, The Hospital for Sick Children, Toronto, ON Canada
- Neonatal Intensive Care Unit, St. Michael’s Hospital, 15014 - 30 Bond St, Toronto, M5B 1W8 ON Canada
- Department of Pediatrics, University of Toronto, Toronto, ON Canada
| | - Shaun K. Morris
- Division of Infectious Diseases and Centre for Global Child Health, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- Department of Pediatrics, University of Toronto, Toronto, ON Canada
| | - Santorino Data
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
- Consortium for Affordable Medical Technologies in Uganda (CAMTech Uganda), Mbarara, Uganda
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Amoakoh HB, Klipstein-Grobusch K, Agyepong IA, Amoakoh-Coleman M, Kayode GA, Reitsma JB, Grobbee DE, Ansah EK. Can an mhealth clinical decision-making support system improve adherence to neonatal healthcare protocols in a low-resource setting? BMC Pediatr 2020; 20:534. [PMID: 33243172 PMCID: PMC7694934 DOI: 10.1186/s12887-020-02378-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 10/07/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND This study assessed health workers' adherence to neonatal health protocols before and during the implementation of a mobile health (mHealth) clinical decision-making support system (mCDMSS) that sought to bridge access to neonatal health protocol gap in a low-resource setting. METHODS We performed a cross-sectional document review within two purposively selected clusters (one poorly-resourced and one well-resourced), from each arm of a cluster-randomized trial at two different time points: before and during the trial. The total trial consisted of 16 clusters randomized into 8 intervention and 8 control clusters to assess the impact of an mCDMSS on neonatal mortality in Ghana. We evaluated health workers' adherence (expressed as percentages) to birth asphyxia, neonatal jaundice and cord sepsis protocols by reviewing medical records of neonatal in-patients using a checklist. Differences in adherence to neonatal health protocols within and between the study arms were assessed using Wilcoxon rank-sum and permutation tests for each morbidity type. In addition, we tracked concurrent neonatal health improvement activities in the clusters during the 18-month intervention period. RESULTS In the intervention arm, mean adherence was 35.2% (SD = 5.8%) and 43.6% (SD = 27.5%) for asphyxia; 25.0% (SD = 14.8%) and 39.3% (SD = 27.7%) for jaundice; 52.0% (SD = 11.0%) and 75.0% (SD = 21.2%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. In the control arm, mean adherence was 52.9% (SD = 16.4%) and 74.5% (SD = 14.7%) for asphyxia; 45.1% (SD = 12.8%) and 64.6% (SD = 8.2%) for jaundice; 53.8% (SD = 16.0%) and 60.8% (SD = 11.7%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. We observed nonsignificant improvement in protocol adherence in the intervention clusters but significant improvement in protocol adherence in the control clusters. There were 2 concurrent neonatal health improvement activities in the intervention clusters and over 12 in the control clusters during the intervention period. CONCLUSION Whether mHealth interventions can improve adherence to neonatal health protocols in low-resource settings cannot be ascertained by this study. Neonatal health improvement activities are however likely to improve protocol adherence. Future mHealth evaluations of protocol adherence must account for other concurrent interventions in study contexts.
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Affiliation(s)
- Hannah Brown Amoakoh
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, The Netherlands
- School of Public Health, University of Ghana, P.O. Box LG13, Legon Accra, Ghana
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, The Netherlands
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Irene Akua Agyepong
- Research and Development Division, Ghana Health Service, Dodowa Accra, Ghana
| | | | - Gbenga A. Kayode
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, The Netherlands
- International Research Centre of Excellence, Institute of Human Virology, Abuja, Nigeria
| | - J. B. Reitsma
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | - Diederick E. Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, The Netherlands
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Källander K, Ward C, Smith H, Bhattarai R, KC A, Timsina D, Lamichhane B, Maurel A, Ram Shrestha P, Baral S, McWhorter C, LaBarre P, de Cola MA, Baker K. Usability and acceptability of an automated respiratory rate counter to assess childhood pneumonia in Nepal. Acta Paediatr 2020; 109:1207-1220. [PMID: 31762072 PMCID: PMC7318335 DOI: 10.1111/apa.15108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/20/2019] [Accepted: 11/22/2019] [Indexed: 01/03/2023]
Abstract
AIM Pneumonia is the leading cause of child death after the neonatal period, resulting from late care seeking and inappropriate treatment. Diagnosis involves counting respiratory rate (RR); however, RR counting remains challenging for health workers and miscounting, and misclassification of RR is common. We evaluated the usability of a new automated RR counter, the Philips Children's Respiratory Monitor (ChARM), to Female Community Health Volunteers (FCHVs), and its acceptability to FCHVs and caregivers in Nepal. METHODS A cross-sectional study was conducted in Jumla district, Nepal. About 133 FCHVs were observed between September and December 2018 when using ChARM during 517 sick child consultations, 264 after training and 253 after 2 months of routine use of ChARM. Acceptability of the ChARM was explored using semi-structured interviews. RESULTS FCHV adherence to guidelines after 2 months of using ChARM routinely was 52.8% (95% CI 46.6-58.9). The qualitative findings suggest that ChARM is acceptable to FCHVs and caregivers; however, capacity constraints such as older age and low literacy and impacted device usability were mentioned. CONCLUSION Further research on the performance, cost-effectiveness and implementation feasibility of this device is recommended, especially among low-literate CHWs.
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Affiliation(s)
- Karin Källander
- Malaria Consortium London UK
- Programme Division Health Section UNICEF New York NY USA
- Department of Public Health Sciences Karolinska Institutet Stockholm Sweden
| | | | | | | | - Ashish KC
- Health & Nutrition Section UNICEF Nepal Kathmandu Nepal
- Department of Women's and Children's Health International Maternal and Child Health (IMCH) Uppsala University Uppsala Sweden
| | | | - Bikash Lamichhane
- Department of Health Services Ministry of Health & Population Kathmandu Nepal
| | | | | | | | - Cindy McWhorter
- UNICEF Supply DivisionProduct Innovation CentreCopenhagen Denmark
| | - Paul LaBarre
- UNICEF Supply DivisionProduct Innovation CentreCopenhagen Denmark
| | | | - Kevin Baker
- Malaria Consortium London UK
- Department of Public Health Sciences Karolinska Institutet Stockholm Sweden
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Odendaal WA, Anstey Watkins J, Leon N, Goudge J, Griffiths F, Tomlinson M, Daniels K. Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis. Cochrane Database Syst Rev 2020; 3:CD011942. [PMID: 32216074 PMCID: PMC7098082 DOI: 10.1002/14651858.cd011942.pub2] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Mobile health (mHealth), refers to healthcare practices supported by mobile devices, such as mobile phones and tablets. Within primary care, health workers often use mobile devices to register clients, track their health, and make decisions about care, as well as to communicate with clients and other health workers. An understanding of how health workers relate to, and experience mHealth, can help in its implementation. OBJECTIVES To synthesise qualitative research evidence on health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services, and to develop hypotheses about why some technologies are more effective than others. SEARCH METHODS We searched MEDLINE, Embase, CINAHL, Science Citation Index and Social Sciences Citation Index in January 2018. We searched Global Health in December 2015. We screened the reference lists of included studies and key references and searched seven sources for grey literature (16 February to 5 March 2018). We re-ran the search strategies in February 2020. We screened these records and any studies that we identified as potentially relevant are awaiting classification. SELECTION CRITERIA We included studies that used qualitative data collection and analysis methods. We included studies of mHealth programmes that were part of primary healthcare services. These services could be implemented in public or private primary healthcare facilities, community and workplace, or the homes of clients. We included all categories of health workers, as well as those persons who supported the delivery and management of the mHealth programmes. We excluded participants identified as technical staff who developed and maintained the mHealth technology, without otherwise being involved in the programme delivery. We included studies conducted in any country. DATA COLLECTION AND ANALYSIS We assessed abstracts, titles and full-text papers according to the inclusion criteria. We found 53 studies that met the inclusion criteria and sampled 43 of these for our analysis. For the 43 sampled studies, we extracted information, such as country, health worker category, and the mHealth technology. We used a thematic analysis process. We used GRADE-CERQual to assess our confidence in the findings. MAIN RESULTS Most of the 43 included sample studies were from low- or middle-income countries. In many of the studies, the mobile devices had decision support software loaded onto them, which showed the steps the health workers had to follow when they provided health care. Other uses included in-person and/or text message communication, and recording clients' health information. Almost half of the studies looked at health workers' use of mobile devices for mother, child, and newborn health. We have moderate or high confidence in the following findings. mHealth changed how health workers worked with each other: health workers appreciated being more connected to colleagues, and thought that this improved co-ordination and quality of care. However, some described problems when senior colleagues did not respond or responded in anger. Some preferred face-to-face connection with colleagues. Some believed that mHealth improved their reporting, while others compared it to "big brother watching". mHealth changed how health workers delivered care: health workers appreciated how mHealth let them take on new tasks, work flexibly, and reach clients in difficult-to-reach areas. They appreciated mHealth when it improved feedback, speed and workflow, but not when it was slow or time consuming. Some health workers found decision support software useful; others thought it threatened their clinical skills. Most health workers saw mHealth as better than paper, but some preferred paper. Some health workers saw mHealth as creating more work. mHealth led to new forms of engagement and relationships with clients and communities: health workers felt that communicating with clients by mobile phone improved care and their relationships with clients, but felt that some clients needed face-to-face contact. Health workers were aware of the importance of protecting confidential client information when using mobile devices. Some health workers did not mind being contacted by clients outside working hours, while others wanted boundaries. Health workers described how some community members trusted health workers that used mHealth while others were sceptical. Health workers pointed to problems when clients needed to own their own phones. Health workers' use and perceptions of mHealth could be influenced by factors tied to costs, the health worker, the technology, the health system and society, poor network access, and poor access to electricity: some health workers did not mind covering extra costs. Others complained that phone credit was not delivered on time. Health workers who were accustomed to using mobile phones were sometimes more positive towards mHealth. Others with less experience, were sometimes embarrassed about making mistakes in front of clients or worried about job security. Health workers wanted training, technical support, user-friendly devices, and systems that were integrated into existing electronic health systems. The main challenges health workers experienced were poor network connections, access to electricity, and the cost of recharging phones. Other problems included damaged phones. Factors outside the health system also influenced how health workers experienced mHealth, including language, gender, and poverty issues. Health workers felt that their commitment to clients helped them cope with these challenges. AUTHORS' CONCLUSIONS Our findings propose a nuanced view about mHealth programmes. The complexities of healthcare delivery and human interactions defy simplistic conclusions on how health workers will perceive and experience their use of mHealth. Perceptions reflect the interplay between the technology, contexts, and human attributes. Detailed descriptions of the programme, implementation processes and contexts, alongside effectiveness studies, will help to unravel this interplay to formulate hypotheses regarding the effectiveness of mHealth.
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Affiliation(s)
- Willem A Odendaal
- South African Medical Research CouncilHealth Systems Research UnitCape TownWestern CapeSouth Africa
- Stellenbosch UniversityDepartment of PsychiatryCape TownSouth Africa
| | | | - Natalie Leon
- South African Medical Research CouncilHealth Systems Research UnitCape TownWestern CapeSouth Africa
- Brown UniversitySchool of Public HealthProvidenceRhode IslandUSA
| | - Jane Goudge
- University of the WitwatersrandCentre for Health Policy, School of Public Health, Faculty of Health SciencesJohannesburgSouth Africa
| | - Frances Griffiths
- University of WarwickWarwick Medical SchoolCoventryUK
- University of the WitwatersrandCentre for Health Policy, School of Public Health, Faculty of Health SciencesJohannesburgSouth Africa
| | - Mark Tomlinson
- Stellenbosch UniversityInstitute for Life Course Health Research, Department of Global HealthCape TownSouth Africa
- Queens UniversitySchool of Nursing and MidwiferyBelfastUK
| | - Karen Daniels
- South African Medical Research CouncilHealth Systems Research UnitCape TownWestern CapeSouth Africa
- University of Cape TownHealth Policy and Systems Division, School of Public Health and Family MedicineCape TownWestern CapeSouth Africa7925
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10
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Saha S, Kotwani P, Pandya A, Patel C, Shah K, Saxena D, Puwar T, Desai S, Patel DM, Sethuraman AV, Ravi JS. Addressing comprehensive primary healthcare in Gujarat through mHealth intervention: Early implementation experience with TeCHO+ programme. J Family Med Prim Care 2020; 9:340-346. [PMID: 32110616 PMCID: PMC7014890 DOI: 10.4103/jfmpc.jfmpc_835_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/07/2019] [Accepted: 12/04/2019] [Indexed: 11/04/2022] Open
Abstract
Background The Health and Family Welfare Department of Gujarat implemented a mHealth Programme called TeCHO+ (Technology for Community Health Operations) in 2018. TeCHO+ is aimed at making progress across all dimensions of the comprehensive primary healthcare services. Objective The objective of this study is to record the document rollout and early implementation experience of TeCHO+ programme in Gujarat. Methods The present participatory process documentation exercise was undertaken in Gujarat. The various steps for process documentation were decided after participation in multiple task force meetings and state/district- and taluka-level action seminars and reviewing the TeCHO+ programme data and progress reports. The perceptions of the health officials and field staff were gathered using key informant interviews from five districts of Gujarat: Bharuch, Narmada, Gandhinagar, Mahisagar, and The Dangs. In addition, stakeholders involved with TeCHO+ Programme were interviewed to understand the process of rollout, implementation challenges, and success. Results In the initial phase, the TeCHO+ application focussed only on updating the Family Health Survey to improve the quality of data captured in the system. FHWs log-in the mobile application daily to access their daily work plan for which SMS alerts were are also generated. Most FHWs were in their 50s and were first-time smartphone users. Although, they were enthusiastic and open to the new technology, initially they faced certain difficulties in operating the application. The programme had a strong troubleshooting mechanism in terms of the use of WhatsApp group, helpline numbers, and voice calls in addition to supportive supervision. Discussion TeCHO+ showed the potential to enhance the quality of the collected data and also service coverage. However, poor technology literacy of old FHWs, the launch of multiple programme memes at the same time, and target-driven task assignments pose major challenges.
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Affiliation(s)
- Somen Saha
- Indian Institute of Public Health Gandhinagar, NH-147, Palaj Village, Opp. New Air Force Station HQ, Gandhinagar, Gujarat, India
| | - Priya Kotwani
- Indian Institute of Public Health Gandhinagar, NH-147, Palaj Village, Opp. New Air Force Station HQ, Gandhinagar, Gujarat, India
| | - Apurvakumar Pandya
- Indian Institute of Public Health Gandhinagar, NH-147, Palaj Village, Opp. New Air Force Station HQ, Gandhinagar, Gujarat, India
| | - Chintan Patel
- Department of Health and Family Welfare, Government of Gujarat, Block No. 5, Second Floor, Dr. Jivraj Mehta Bhavan, Old Sachivalay, Sector 10-B, Gandhinagar, Gujarat, India
| | - Komal Shah
- Indian Institute of Public Health Gandhinagar, NH-147, Palaj Village, Opp. New Air Force Station HQ, Gandhinagar, Gujarat, India
| | - Deepak Saxena
- Indian Institute of Public Health Gandhinagar, NH-147, Palaj Village, Opp. New Air Force Station HQ, Gandhinagar, Gujarat, India
| | - Tapasvi Puwar
- Indian Institute of Public Health Gandhinagar, NH-147, Palaj Village, Opp. New Air Force Station HQ, Gandhinagar, Gujarat, India
| | - Shrey Desai
- Society for Education Welfare and Action-Rural, SEWA RURAL, Jhagadia, District - Bharuch, Gujarat, India
| | - Dashrath M Patel
- Department of Health and Family Welfare, Government of Gujarat, Block No. 5, Second Floor, Dr. Jivraj Mehta Bhavan, Old Sachivalay, Sector 10-B, Gandhinagar, Gujarat, India
| | - A V Sethuraman
- Argusoft India Ltd., A 66, GIDC Sector - 25, Gandhinagar, Gujarat, India
| | - Jayanti S Ravi
- Department of Health and Family Welfare, Government of Gujarat, 7th Block, 7th Floor, Sachivalaya, Gandhinagar, Gujarat, India
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11
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Amoakoh HB, Klipstein-Grobusch K, Agyepong IA, Zuithoff NP, Amoakoh-Coleman M, Kayode GA, Sarpong C, Reitsma JB, Grobbee DE, Ansah EK. The effect of an mHealth clinical decision-making support system on neonatal mortality in a low resource setting: A cluster-randomized controlled trial. EClinicalMedicine 2019; 12:31-42. [PMID: 31388661 PMCID: PMC6677648 DOI: 10.1016/j.eclinm.2019.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/22/2019] [Accepted: 05/28/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND MHealth interventions promise to bridge gaps in clinical care but documentation of their effectiveness is limited. We evaluated the utilization and effect of an mhealth clinical decision-making support intervention that aimed to improve neonatal mortality in Ghana by providing access to emergency neonatal protocols for frontline health workers. METHODS In the Eastern Region of Ghana, sixteen districts were randomized into two study arms (8 intervention and 8 control clusters) in a cluster-randomized controlled trial. Institutional neonatal mortality data were extracted from the District Health Information System-2 during an 18-month intervention period. We performed an intention-to-treat analysis and estimated the effect of the intervention on institutional neonatal mortality (primary outcome measure) using grouped binomial logistic regression with a random intercept per cluster. This trial is registered at ClinicalTrials.gov (NCT02468310 ) and Pan African Clinical Trials Registry (PACTR20151200109073). FINDINGS There were 65,831 institutional deliveries and 348 institutional neonatal deaths during the study period. Overall, 47 ∙ 3% of deliveries and 56 ∙ 9% of neonatal deaths occurred in the intervention arm. During the intervention period, neonatal deaths increased from 4 ∙ 5 to 6 ∙ 4 deaths and, from 3 ∙ 9 to 4 ∙ 3 deaths per 1000 deliveries in the intervention arm and control arm respectively. The odds of neonatal death was 2⋅09 (95% CI (1 ∙ 00;4 ∙ 38); p = 0 ∙ 051) times higher in the intervention arm compared to the control arm (adjusted odds ratio). The correlation between the number of protocol requests and the number of deliveries per intervention cluster was 0 ∙ 71 (p = 0 ∙ 05). INTERPRETATION The higher risk of institutional neonatal death observed in intervention clusters may be due to problems with birth and death registration, unmeasured and unadjusted confounding, and unintended use of the intervention. The findings underpin the need for careful and rigorous evaluation of mHealth intervention implementation and effects. FUNDING Netherlands Foundation for Scientific Research - WOTRO, Science for Global Development; Utrecht University.
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Affiliation(s)
- Hannah Brown Amoakoh
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht the Netherlands
- School of Public Health, University of Ghana, Accra, Ghana
| | - Kerstin Klipstein-Grobusch
- School of Public Health, University of Ghana, Accra, Ghana
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Nicolaas P.A. Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht the Netherlands
| | | | - Gbenga A. Kayode
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht the Netherlands
- International Research Centre of Excellence, Institute of Human Virology, Abuja, Nigeria
| | - Charity Sarpong
- Regional Health Directorate, Ghana Health Services, Koforidua, Ghana
| | - Johannes B. Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht the Netherlands
| | - Diederick E. Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht the Netherlands
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12
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Amoakoh HB, Klipstein-Grobusch K, Grobbee DE, Amoakoh-Coleman M, Oduro-Mensah E, Sarpong C, Frimpong E, Kayode GA, Agyepong IA, Ansah EK. Using Mobile Health to Support Clinical Decision-Making to Improve Maternal and Neonatal Health Outcomes in Ghana: Insights of Frontline Health Worker Information Needs. JMIR Mhealth Uhealth 2019; 7:e12879. [PMID: 31127719 PMCID: PMC6555115 DOI: 10.2196/12879] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Developing and maintaining resilient health systems in low-resource settings like Ghana requires innovative approaches that adapt technology to context to improve health outcomes. One such innovation was a mobile health (mHealth) clinical decision-making support system (mCDMSS) that utilized text messaging (short message service, SMS) of standard emergency maternal and neonatal protocols via an unstructured supplementary service data (USSD) on request of the health care providers. This mCDMSS was implemented in a cluster randomized controlled trial (CRCT) in the Eastern Region of Ghana. OBJECTIVE This study aimed to analyze the pattern of requests made to the USSD by health workers (HWs). We assessed the relationship between requests made to the USSD and types of maternal and neonatal morbidities reported in health facilities (HFs). METHODS For clusters in the intervention arm of the CRCT, all requests to the USSD during the 18-month intervention period were extracted from a remote server, and maternal and neonatal health outcomes of interest were obtained from the District Health Information System of Ghana. Chi-square and Fisher exact tests were used to compare the proportion and type of requests made to the USSD by cluster, facility type, and location; whether phones accessing the intervention were shared facility phones or individual-use phones (type-of-phone); or whether protocols were accessed during the day or at night (time-of-day). Trends in requests made were analyzed over 3 6-month periods. The relationship between requests made and the number of cases reported in HFs was assessed using Spearman correlation. RESULTS In total, 5329 requests from 72 (97%) participating HFs were made to the intervention. The average number of requests made per cluster was 667. Requests declined from the first to the third 6-month period (44.96% [2396/5329], 39.82% [2122/5329], and 15.22% [811/5329], respectively). Maternal conditions accounted for the majority of requests made (66.35% [3536/5329]). The most frequently accessed maternal conditions were postpartum hemorrhage (25.23% [892/3536]), other conditions (17.82% [630/3536]), and hypertension (16.49% [583/3536]), whereas the most frequently accessed neonatal conditions were prematurity (20.08% [360/1793]), sepsis (15.45% [277/1793]), and resuscitation (13.78% [247/1793]). Requests made to the mCDMSS varied significantly by cluster, type of request (maternal or neonatal), facility type and its location, type-of-phone, and time-of-day at 6-month interval (P<.001 for each variable). Trends in maternal and neonatal requests showed varying significance over each 6-month interval. Only asphyxia and sepsis cases showed significant correlations with the number of requests made (r=0.44 and r=0.79; P<.001 and P=.03, respectively). CONCLUSIONS There were variations in the pattern of requests made to the mCDMSS over time. Detailed information regarding the use of the mCDMSS provides insight into the information needs of HWs for decision-making and an opportunity to focus support for HW training and ultimately improved maternal and neonatal health.
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Affiliation(s)
- Hannah Brown Amoakoh
- Department of Epidemiology, School of Public Health, University of Ghana, Accra, Ghana
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
| | - Kerstin Klipstein-Grobusch
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
| | - Mary Amoakoh-Coleman
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | | | - Charity Sarpong
- Regional Health Directorate, Ghana Health Services, Koforidua, Ghana
| | - Edith Frimpong
- Dodowa Research Centre, Ghana Health Service, Accra, Ghana
| | - Gbenga A Kayode
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
| | | | - Evelyn K Ansah
- Centre for Malaria Research, University of Health and Allied Sciences, Ho, Ghana
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