Development and Implementation of a Mobile Phone-Based Prevention of Mother-To-Child Transmission of HIV Cascade Analysis Tool: Usability and Feasibility Testing in Kenya and Mozambique

Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial

BACKGROUND

Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique.

METHODS

This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective.

DISCUSSION

SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

Refining the Performance of Routine Information System Management (PRISM) framework for data use at the local level: An integrative review

INTRODUCTION

Foundational to a well-functioning health system is a strong routine health information system (RHIS) that informs decisions and actions at all levels of the health system. In the context of decentralization across low- and middle-income countries, RHIS has the promise of supporting sub-national health staff to take data-informed actions to improve health system performance. However, there is wide variation in how "RHIS data use" is defined and measured in the literature, impeding the development and evaluation of interventions that effectively promote RHIS data use.

METHODS

An integrative review methodology was used to: (1) synthesize the state of the literature on how RHIS data use in low- and middle-income countries is conceptualized and measured; (2) propose a refined RHIS data use framework and develop a common definition for RHIS data use; and (3) propose improved approaches to measure RHIS data use. Four electronic databases were searched for peer-reviewed articles published between 2009 and 2021 investigating RHIS data use.

RESULTS

A total of 45 articles, including 24 articles measuring RHIS data use, met the inclusion criteria. Less than half of included articles (42%) explicitly defined RHIS data use. There were differences across the literature whether RHIS data tasks such as data analysis preceded or were a part of RHIS data use; there was broad consensus that data-informed decisions and actions were essential steps within the RHIS data use process. Based on the synthesis, the Performance of Routine Information System Management (PRISM) framework was refined to specify the steps of the RHIS data use process.

CONCLUSION

Conceptualizing RHIS data use as a process that includes data-informed actions emphasizes the importance of actions in improving health system performance. Future studies and implementation strategies should be designed with consideration for the different support needs for each step of the RHIS data use process.

Centering Frontline Health Care Workers in Digital Innovation Design to Inform the Optimization of an App for Improved Male Circumcision Follow-up in South Africa: Qualitative Usability Study

BACKGROUND

Voluntary medical male circumcision (VMMC) is a safe and effective HIV prevention strategy. However, adherence to recommended in-person, postoperative follow-up is inefficient for procedures with few adverse events. Two-way texting (2wT)-based follow-up appears to be a safe and an efficient alternative to scheduled clinic visits for low-risk patients who underwent VMMC. To ensure that 2wT responds to the needs of health care workers (HCWs) and patients, HCWs were closely involved in app design using a human-centered design (HCD) approach.

OBJECTIVE

Embedded within an ongoing randomized controlled trial of 2wT in South Africa and complementary HCD processes of 2wT app optimization, this qualitative study aimed to use key informant interviews (KIIs) to explore the thoughts, suggestions, and opinions on and perceptions of 2wT's usability and acceptability among HCWs involved in 2wT implementation in both urban and rural South Africa.

METHODS

A total of 7 HCWs using 2wT in Gauteng and the North West province participated in KIIs regarding the usability and acceptability of 2wT. HCWs were asked for their opinions on 2wT as a viable, useful, appropriate, and accessible method of postoperative VMMC care. They were also asked about 2wT-related working, exploring areas where 2wT could add to or reduce their daily tasks. The KII data were explored, coded, and analyzed by 3 qualitative researchers using thematic content analysis and the ATLAS.ti (ATLAS.ti Scientific Software Development GmbH) software.

RESULTS

Most HCWs felt confident, comfortable, satisfied, and well supported using a 2wT-based follow-up as an alternative to in-person clinical reviews. They felt that 2wT was easy to use and required little technical support after initial mentoring on how to use the 2wT system. Few noted safety concerns, as men can receive clinical guidance, reassurance, and referral via 2wT. Although fewer in-person visits reduced the in-person review workload and eased clinical flow, HCWs noted the added burden of having to interact with clients via SMS text messages on evenings or weekends. HCWs reinforced the need for enhanced postoperative counseling to ensure that 2wT patients could recognize and understood how to respond to early signs of complications. HCWs suggested a rotation to spread the evening and weekend workload and ensure swift patient responses.

CONCLUSIONS

In this formative qualitative study focused on HCWs, 2wT was a highly usable alternative to in-person postoperative reviews for patients who underwent VMMC in South Africa. The HCD processes likely improved the usability and acceptability of 2wT for HCWs. HCWs supported the scale-up of 2wT given the distance from the clinic to the men's homes and the potential for reducing workload. To ensure success, providers urged sensitizing patients to the fact that 2wT augments, but does not replace, the existing after-hours and emergency care services.

Scoping review of health information technology usability methods leveraged in Africa

OBJECTIVE

The aim of this study was to explore the state of health information technology (HIT) usability evaluation in Africa.

MATERIALS AND METHODS

We searched three electronic databases: PubMed, Embase, and Association for Computing Machinery. We categorized the stage of evaluations, the type of interactions assessed, and methods applied using Stead's System Development Life Cycle (SDLC) and Bennett and Shackel's usability models.

RESULTS

Analysis of 73 of 1002 articles that met inclusion criteria reveals that HIT usability evaluations in Africa have increased in recent years and mainly focused on later SDLC stage (stages 4 and 5) evaluations in sub-Saharan Africa. Forty percent of the articles examined system-user-task-environment (type 4) interactions. Most articles used mixed methods to measure usability. Interviews and surveys were often used at each development stage, while other methods, such as quality-adjusted life year analysis, were only found at stage 5. Sixty percent of articles did not include a theoretical model or framework.

DISCUSSION

The use of multistage evaluation and mixed methods approaches to obtain a comprehensive understanding HIT usability is critical to ensure that HIT meets user needs.

CONCLUSIONS

Developing and enhancing usable HIT is critical to promoting equitable health service delivery and high-quality care in Africa. Early-stage evaluations (stages 1 and 2) and interactions (types 0 and 1) should receive special attention to ensure HIT usability prior to implementing HIT in the field.

Providing "a beam of light to see the gaps": determinants of implementation of the Systems Analysis and Improvement Approach applied to the pediatric and adolescent HIV cascade in Kenya

Background

Children and adolescents living with HIV have poorer rates of HIV testing, treatment, and virologic suppression than adults. Strategies that use a systems approach to optimize these multiple, linked steps simultaneously are critical to close these gaps.

Methods

The Systems Analysis and Improvement Approach (SAIA) was adapted and piloted for the pediatric and adolescent HIV care and treatment cascade (SAIA-PEDS) at 6 facilities in Kenya. SAIA-PEDS includes three tools: continuous quality improvement (CQI), flow mapping, and pediatric cascade analysis (PedCAT). A predominately qualitative evaluation utilizing focus group discussions (N = 6) and in-depth interviews (N = 19) was conducted with healthcare workers after implementation to identify determinants of implementation. Data collection and analysis were grounded in the Consolidated Framework for Implementation Research (CFIR).

Results

Overall, the adapted SAIA-PEDS strategy was acceptable, and the three tools complemented one another and provided a relative advantage over existing processes. The flow mapping and CQI tools were compatible with existing workflows and resonated with team priorities and goals while providing a structure for group problem solving that transcended a single department’s focus. The PedCAT was overly complex, making it difficult to use. Leadership and hierarchy were complex determinants. All teams reported supportive leadership, with some describing in detail how their leadership was engaged and enthusiastic about the SAIA-PEDS process, by providing recognition, time, and resources. Hierarchy was similarly complex: in some facilities, leadership stifled rapid innovation by insisting on approving each change, while at other facilities, leadership had strong and supportive oversight of processes, checking on the progress frequently and empowering teams to test innovative ideas.

Conclusion

CQI and flow mapping were core components of SAIA-PEDS, with high acceptability and consistent use, but the PedCAT was too complex. Leadership and hierarchy had a nuanced role in implementation. Future SAIA-PEDS testing should address PedCAT complexity and further explore the modifiability of leadership engagement to maximize implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00304-3.

A Review of Usability Evaluation Methods and Their Use for Testing eHealth HIV Interventions

PURPOSE OF REVIEW

To provide a comprehensive review of usability testing of eHealth interventions for HIV.

RECENT FINDINGS

We identified 28 articles that assessed the usability of eHealth interventions for HIV, most of which were published within the past 3 years. The majority of the eHealth interventions for HIV was developed on a mobile platform and focused on HIV prevention as the intended health outcome. Usability evaluation methods included eye-tracking, questionnaires, semi-structured interviews, contextual interviews, think-aloud protocols, cognitive walkthroughs, heuristic evaluations and expert reviews, focus groups, and scenarios. A wide variety of methods is available to evaluate the usability of eHealth interventions. Employing multiple methods may provide a more comprehensive assessment of the usability of eHealth interventions as compared with inclusion of only a single evaluation method.

Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis

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.

Cascade Analysis: An Adaptable Implementation Strategy Across HIV and Non-HIV Delivery Platforms

BACKGROUND

Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement.

METHODS

The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV.

RESULTS

CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW.

DISCUSSION

CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.