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Ebbs D, Taricia M, Funaro MC, O’Daniel M, Cappello M. Prehospital use of point-of-care tests by community health workers: a scoping review. Front Public Health 2024; 12:1360322. [PMID: 38721545 PMCID: PMC11076783 DOI: 10.3389/fpubh.2024.1360322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/06/2024] [Indexed: 05/15/2024] Open
Abstract
Introduction Point-of-Care Tests (POCTs) are utilized daily in resource abundant regions, however, are limited in the global south, particularly in the prehospital setting. Few studies exist on the use of non-malarial POCTs by Community Health Workers (CHWs). The purpose of this scoping review is to delineate the current diversity in and breadth of POCTs evaluated in the prehospital setting. Methods A medical subject heading (MeSH) analysis of known key articles was done by an experienced medical librarian and scoping searches were performed in each database to capture "point of care testing" and "community health workers." This review was guided by the PRISMA Extension for scoping reviews. Results 2735 publications were returned, 185 were nominated for full-text review, and 110 studies were confirmed to meet study criteria. Majority focused on malaria (74/110; 67%) or HIV (25/110; 23%); 9/110 (8%) described other tests administered. Results from this review demonstrate a broad geographic range with significant heterogeneity in terminology for local CHWs. Conclusion The use of new POCTs is on the rise and may improve early risk stratification in limited resource settings. Current evidence from decades of malaria POCTs can guide future implementation strategies.
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Affiliation(s)
- Daniel Ebbs
- Department of Pediatrics, Yale University, New Haven, CT, United States
| | - Max Taricia
- Department of Pediatrics, Yale University, New Haven, CT, United States
| | - Melissa C. Funaro
- Department of Medicine, Harvey Cushing/John Hay Whitney Medical Library, New Haven, CT, United States
| | - Maggie O’Daniel
- University of North Carolina at Greensboro, Greensboro, NC, United States
| | - Michael Cappello
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
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Singh K, Walters MR. Use of mHealth in promoting maternal and child health in "BIMARU" states of India "A health system strengthening strategy": Systematic literature review. PLOS DIGITAL HEALTH 2024; 3:e0000403. [PMID: 38306391 PMCID: PMC10836675 DOI: 10.1371/journal.pdig.0000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
Low-middle income countries like India bear a heavier burden of maternal, childcare, and child mortality rates when compared with high-income countries, which highlights the disparity in global health. Numerous societal, geopolitical, economic, and institutional issues have been linked to this inequality. mHealth has the potential to ameliorate these challenges by providing health services and health-related information with the assistance of frontline workers in the provision of prepartum, delivery, and postnatal care to improve maternal and child health outcomes in hard-to-reach areas in low- and middle-income countries (LMICs). However, there is limited evidence to support how mHealth can strengthen maternal and child health in India. The scoping review guideline in the Cochrane Handbook was used to retrieve studies from 4 international databases: CINAHL, Embase, Medline Ovid, and PubMed. This search strategy used combined keywords (MeSH terms) related to maternal and child healthcare, mHealth, and BIMARU in conjunction with database-controlled vocabulary. Out of 278 records, 8 publications were included in the review. The included articles used mHealth for data collection, eLearning, communication, patient monitoring, or tracking to deliver maternal and neonatal care. The results of these papers reflected a favourable effect of mHealth on the target population and found that it altered their attitudes and behaviours about healthcare. Higher job satisfaction and self-efficiency were reported by mHealth user care providers. Multiple barriers to the acceptance of mHealth exist, but the majority of the evidence points towards the feasibility of the intervention in a clinical setting. The mHealth has positive potential for improving maternal and child health outcomes in low-resource settings in India's BIMARU states by strengthening the healthcare system. The results of the study could be used in the tailoring of an effective mHealth intervention and implementation strategy in a similar context. However, there is a need for economic evaluation in the future to bridge the knowledge gap regarding the cost-effectiveness of mHealth interventions.
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Affiliation(s)
- Khushbu Singh
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Matthew R Walters
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, Scotland, United Kingdom
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Thomas V, Kalidindi B, Waghmare A, Bhatia A, Raj T, Balsari S. The Vinyasa Tool for mHealth Solutions: Supporting Human-Centered Design in Nascent Digital Health Ecosystems. JMIR Form Res 2023; 7:e45250. [PMID: 37607881 PMCID: PMC10580130 DOI: 10.2196/45250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/18/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND mHealth (mobile health) systems have been deployed widely in low- and middle-income countries (LMICs) for health system strengthening, requiring considerable resource allocation. However, most solutions have not achieved scale or sustainability. Poor usability and failure to address perceived needs are among the principal reasons mHealth systems fail to achieve acceptance and adoption by health care workers. A human-centered design approach to improving mHealth system use requires an exploration of users' perceptions of mHealth systems, including the environmental, user-related, and technological aspects of a system. At present, there is a dearth of contextually intelligent tools available to mHealth developers that can guide such exploration before full-scale development and deployment. OBJECTIVE To develop a tool to aid optimization of mHealth solutions in LMICs to facilitate human-centered design and, consequently, successful adoption. METHODS We collated findings and themes from key qualitative studies on mHealth deployment in LMICs. We then used the Informatics Stack framework by Lehmann to label, sort, and collate findings and themes into a list of questions that explore the environment, users, artifacts, information governance, and interoperability of mHealth systems deployed in LMICs. RESULTS We developed the Vinyasa Tool to aid qualitative research about the need and usability of mHealth solutions in LMICs. The tool is a guide for focus group discussions and key informant interviews with community-based health care workers and primary care medical personnel who use or are expected to use proposed mHealth solutions. The tool consists of 71 questions organized in 11 sections that unpack and explore multiple aspects of mHealth systems from the perspectives of their users. These include the wider world and organization in which an mHealth solution is deployed; the roles, functions, workflow, and adoption behavior of a system's users; the security, privacy, and interoperability afforded by a system; and the artifacts of an information system-the data, information, knowledge, algorithms, and technology that constitute the system. The tool can be deployed in whole or in part, depending on the context of the study. CONCLUSIONS The Vinyasa Tool is the first such comprehensive qualitative research instrument incorporating questions contextualized to the LMIC setting. We expect it to find wide application among mHealth developers, health system administrators, and researchers developing and deploying mHealth tools for use by patients, providers, and administrators. The tool is expected to guide users toward human-centered design with the goal of improving relevance, usability, and, therefore, adoption.
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Affiliation(s)
- Verghese Thomas
- Division of Medical Informatics, St John's Research Institute, Bangalore, India
| | - Bharat Kalidindi
- Division of Medical Informatics, St John's Research Institute, Bangalore, India
| | - Abijeet Waghmare
- Division of Medical Informatics, St John's Research Institute, Bangalore, India
| | - Abhishek Bhatia
- Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Tony Raj
- Division of Medical Informatics, St John's Research Institute, Bangalore, India
- Department of Physiology, St John's Medical College, Bangalore, India
| | - Satchit Balsari
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
- François-Xavier Bagnoud Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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Joshi V, Joshi NK, Bhardwaj P, Singh K, Ojha D, Jain YK. The Health Impact of mHealth Interventions in India: Systematic Review and Meta-Analysis. Online J Public Health Inform 2023; 15:e50927. [PMID: 38046564 PMCID: PMC10689051 DOI: 10.2196/50927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 02/03/2023] [Indexed: 12/05/2023] Open
Abstract
Background Considerable use of mobile health (mHealth) interventions has been seen, and these interventions have beneficial effects on health and health service delivery processes, especially in resource-limited settings. Various functionalities of mobile phones offer a range of opportunities for mHealth interventions. Objective This review aims to assess the health impact of mHealth interventions in India. Methods This systematic review and meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies conducted in India, and published between April 1, 2011, and March 31, 2021, were considered. A literature search was conducted using a combination of MeSH (Medical Subject Headings) terms in different databases to identify peer-reviewed publications. Thirteen out of 1350 articles were included for the final review. Risk of bias was assessed using the Risk of Bias 2 tool for RCTs and Risk Of Bias In Non-randomised Studies - of Interventions tool (for nonrandomized trials), and a meta-analysis was performed using RevMan for 3 comparable studies on maternal, neonatal, and child health. Results The meta-analysis showed improved usage of maternal and child health services including iron-folic acid supplementation (odds ratio [OR] 14.30, 95% CI 6.65-30.75), administration of both doses of the tetanus toxoid (OR 2.47, 95% CI 0.22-27.37), and attending 4 or more antenatal check-ups (OR 1.82, 95% CI 0.65-5.09). Meta-analysis for studies concerning economic evaluation and chronic diseases could not be performed due to heterogeneity. However, a positive economic impact was observed from a societal perspective (ReMiND [reducing maternal and newborn deaths] and ImTeCHO [Innovative Mobile Technology for Community Health Operation] interventions), and chronic disease interventions showed a positive impact on clinical outcomes, patient and provider satisfaction, app usage, and improvement in health behaviors. Conclusions This review provides a comprehensive overview of mHealth technology in all health sectors in India, analyzing both health and health care usage indicators for interventions focused on maternal and child health and chronic diseases. Trial Registration PROSPERO 2021 CRD42021235315; https://tinyurl.com/yh4tp2j7.
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Affiliation(s)
- Vibha Joshi
- Resource Centre Health Technology Assessment All India Institute of Medical Sciences Jodhpur Jodhpur India
| | - Nitin Kumar Joshi
- School of Public Health All India Institute of Medical Sciences Jodhpur Jodhpur India
- Department of Community Medicine and Family Medicine All India Institute of Medical Sciences Jodhpur Jodhpur India
| | - Pankaj Bhardwaj
- School of Public Health All India Institute of Medical Sciences Jodhpur Jodhpur India
- Department of Community Medicine and Family Medicine All India Institute of Medical Sciences Jodhpur Jodhpur India
| | - Kuldeep Singh
- Resource Centre Health Technology Assessment All India Institute of Medical Sciences Jodhpur Jodhpur India
| | - Deepika Ojha
- Resource Centre Health Technology Assessment All India Institute of Medical Sciences Jodhpur Jodhpur India
| | - Yogesh Kumar Jain
- School of Public Health All India Institute of Medical Sciences Jodhpur Jodhpur India
- Department of Community Medicine and Family Medicine All India Institute of Medical Sciences Jodhpur Jodhpur India
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Saif-Ur-Rahman KM, Islam MS, Alaboson J, Ola O, Hasan I, Islam N, Mainali S, Martina T, Silenga E, Muyangana M, Joarder T. Artificial intelligence and digital health in improving primary health care service delivery in LMICs: A systematic review. J Evid Based Med 2023; 16:303-320. [PMID: 37691394 DOI: 10.1111/jebm.12547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
AIM Technology including artificial intelligence (AI) may play a key role to strengthen primary health care services in resource-poor settings. This systematic review aims to explore the evidence on the use of AI and digital health in improving primary health care service delivery. METHODS Three electronic databases were searched using a comprehensive search strategy without providing any restriction in June 2023. Retrieved articles were screened independently using the "Rayyan" software. Data extraction and quality assessment were conducted independently by two review authors. A narrative synthesis of the included interventions was conducted. RESULTS A total of 4596 articles were screened, and finally, 48 articles were included from 21 different countries published between 2013 and 2021. The main focus of the included studies was noncommunicable diseases (n = 15), maternal and child health care (n = 11), primary care (n = 8), infectious diseases including tuberculosis, leprosy, and HIV (n = 7), and mental health (n = 6). Included studies considered interventions using AI, and digital health of which mobile-phone-based interventions were prominent. m-health interventions were well adopted and easy to use and improved the record-keeping, service deliver, and patient satisfaction. CONCLUSION AI and the application of digital technologies improve primary health care service delivery in resource-poor settings in various ways. However, in most of the cases, the application of AI and digital health is implemented through m-health. There is a great scope to conduct further research exploring the interventions on a large scale.
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Affiliation(s)
- K M Saif-Ur-Rahman
- College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland
- Evidence Synthesis Ireland and Cochrane Ireland, University of Galway, Galway, Ireland
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Shariful Islam
- School of Public Health, University of Queensland, Brisbane, Australia
| | - Joan Alaboson
- Department of Psychology, Maynooth University, Kildare, Ireland
| | - Oluwadara Ola
- Sacred Heart Hospital, Abeokuta, Ogun State, Nigeria
| | - Imran Hasan
- Laboratory of Gut-Brain Signaling, Laboratory Sciences and Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Nazmul Islam
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shristi Mainali
- Department of Operations, Marie Stopes International, Kathmandu, Nepal
| | - Tina Martina
- General Hospital of Haji Padjonga, South Sulawesi, Indonesia
| | - Eva Silenga
- Department of Mother and Child Health, Ministry of Health, Lusaka, Zambia
| | - Mubita Muyangana
- Lewanika School of Nursing and Midwifery, Ministry of Health, Mongu, Zambia
| | - Taufique Joarder
- SingHealth Duke-NUS Global Health Institute, National University of Singapore, Singapore
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Hirst JE, Votruba N, Billot L, Arora V, Rajan E, Thout SR, Peiris D, Patel A, Norton R, Mullins E, Sharma A, Kennedy S, Jha V, Praveen D. A community-based intervention to improve screening, referral and follow-up of non-communicable diseases and anaemia amongst pregnant and postpartum women in rural India: study protocol for a cluster randomised trial. Trials 2023; 24:510. [PMID: 37559158 PMCID: PMC10410790 DOI: 10.1186/s13063-023-07510-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/12/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Medical complications during pregnancy, including anaemia, gestational diabetes mellitus and hypertensive disorders of pregnancy place women are at higher risk of long-term complications. Scalable and low-cost strategies to integrate non-communicable disease screening into pregnancy care are needed. We aim to determine the effectiveness and implementation components of a community-based, digitally enabled approach, "SMARThealth Pregnancy," to improve health during pregnancy and the first year after birth. METHODS A pragmatic, parallel-group, cluster randomised, type 2 hybrid effectiveness-implementation trial of a community-based, complex intervention in rural India to decrease anaemia (primary outcome, defined as haemoglobin < 12g/dL) and increase testing for haemoglobin, glucose and blood pressure (secondary outcomes) in the first year after birth. Primary Health Centres (PHCs) are the unit of randomisation. PHCs are eligible with (1) > 1 medical officer and > 2 community health workers; and (2) capability to administer intravenous iron sucrose. Thirty PHCs in Telangana and Haryana will be randomised 1:1 using a matched-pair design accounting for cluster size and distance from the regional centre. The intervention comprises (i) an education programme for community health workers and PHC doctors; (ii) the SMARThealth Pregnancy app for health workers to support community-based screening, referral and follow-up of high-risk cases; (iii) a dashboard for PHC doctors to monitor high-risk women in the community; (iv) supply chain monitoring for consumables and medications and (v) stakeholder engagement to co-develop implementation and sustainability pathways. The comparator is usual care with additional health worker education. Secondary outcomes include implementation outcomes assessed by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), clinical endpoints (anaemia, diabetes, hypertension), clinical service delivery indicators (quality of care score), mental health and lactation practice (PHQ9, GAD7, EuroQoL-5D, WHO IYCF questionnaire). DISCUSSION Engaging women with screening after a high-risk pregnancy is a challenge and has been highlighted as a missed opportunity for the prevention of non-communicable diseases. The SMARThealth Pregnancy trial is powered for the primary outcome and will address gaps in the evidence around how pregnancy can be used as an opportunity to improve women's lifelong health. If successful, this approach could improve the health of women living in resource-limited settings around the world. TRIAL REGISTRATION ClinicalTrials.gov NCT05752955. Date of registration 3 March 2023.
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Affiliation(s)
- Jane Elizabeth Hirst
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK.
- The George Institute for Global Health, Imperial College London, London, UK.
| | - Nicole Votruba
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
- The George Institute for Global Health, Imperial College London, London, UK
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Kensington, Australia
| | | | - Eldho Rajan
- The George Institute for Global Health, New Delhi, India
| | | | - David Peiris
- The George Institute for Global Health, Newtown, Australia
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Kensington, Australia
| | - Robyn Norton
- The George Institute for Global Health, Imperial College London, London, UK
- The George Institute for Global Health, University of New South Wales, Kensington, Australia
| | - Edward Mullins
- The George Institute for Global Health, Imperial College London, London, UK
| | - Ankita Sharma
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Stephen Kennedy
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, India
- University of New South Wales, Kensington, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Devarsetty Praveen
- The George Institute for Global Health, New Delhi, India
- University of New South Wales, Kensington, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
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Nagraj S, Kennedy S, Jha V, Norton R, Hinton L, Billot L, Rajan E, Mohammed Abdul A, Phalswal A, Arora V, Praveen D, Hirst J. A Mobile Clinical Decision Support System for High-Risk Pregnant Women in Rural India (SMARThealth Pregnancy): Pilot Cluster Randomized Controlled Trial. JMIR Form Res 2023; 7:e44362. [PMID: 37471135 PMCID: PMC10401191 DOI: 10.2196/44362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 06/01/2023] [Accepted: 06/13/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of death in women in India. Early identification is crucial to reducing deaths. Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) carry independent risks for future CVD, and antenatal care is a window to screen and counsel high-risk women. In rural India, community health workers (CHWs) deliver antenatal and postnatal care. We developed a complex intervention (SMARThealth Pregnancy) involving mobile clinical decision support for CHWs and evaluated it in a pilot cluster randomized controlled trial (cRCT). OBJECTIVE The aim of the study is to co-design a theory-informed intervention for CHWs to screen, refer, and counsel pregnant women at high risk of future CVD in rural India and evaluate its feasibility and acceptability. METHODS In phase 1, we used qualitative methods to explore community priorities for high-risk pregnant women in rural areas of 2 diverse states in India. In phase 2, informed by behavior change theory and human-centered design, we used these qualitative data to develop the intervention components and implementation strategies for SMARThealth Pregnancy in an iterative process with end users. In phase 3, using mixed methods, we evaluated the intervention in a cRCT with an embedded qualitative substudy across 4 primary health centres: 2 in Jhajjar district, Haryana, and 2 in Guntur district, Andhra Pradesh. RESULTS SMARThealth Pregnancy embedded a total of 15 behavior change techniques and included (1) community awareness programs; (2) targeted training, including point-of-care blood pressure and hemoglobin measurement; and (3) mobile clinical decision support for CHWs to screen women in their homes. The intervention focused on 3 priority conditions: anemia, HDP, and GDM. The evaluation involved a total of 200 pregnant women, equally randomized to intervention or enhanced standard care (control). Recruitment was completed within 5 months, with minimal loss to follow-up (4/200, 2%) at 6 weeks postpartum. A total of 4 primary care doctors and 54 CHWs in the intervention clusters took part in the study. Fidelity to intervention practices was 100% prepandemic. Over half the study population was affected by moderate to severe anemia at baseline. The prevalence of HDP (2.5%) and GDM (2%) was low in our study population. Results suggest a possible improvement in mean hemoglobin (anemia) in the intervention group, although an adequately powered trial is needed. The model of home-based care was feasible and acceptable for pregnant or postpartum women and CHWs, who perceived improvements in quality of care, self-efficacy, and professional recognition. CONCLUSIONS SMARThealth Pregnancy is an innovative model of home-based care for high-risk pregnant women during the transitions between antenatal and postnatal care and adult health services. The use of theory and co-design during intervention development facilitated acceptability of the intervention and implementation strategies. Our experience has informed the decision to initiate a larger-scale cRCT. TRIAL REGISTRATION ClinicalTrials.gov NCT03968952; https://clinicaltrials.gov/ct2/show/NCT03968952. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.3389/fgwh.2021.620759.
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Affiliation(s)
- Shobhana Nagraj
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
- The George Institute for Global Health, Imperial College London, London, United Kingdom
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Global Surgery Group, University of Oxford, Oxford, United Kingdom
| | - Stephen Kennedy
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Vivekananda Jha
- The George Institute for Global Health, Imperial College London, London, United Kingdom
- The George Institute for Global Health, New Delhi, India
- University of New South Wales, Sydney, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Robyn Norton
- The George Institute for Global Health, Imperial College London, London, United Kingdom
- The George Institute for Global Health, UNSW Sydney, Kensington, Australia
| | - Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Laurent Billot
- The George Institute for Global Health, UNSW Sydney, Kensington, Australia
| | - Eldho Rajan
- The George Institute for Global Health, New Delhi, India
| | | | - Anita Phalswal
- The George Institute for Global Health, New Delhi, India
| | - Varun Arora
- Post Graduate Institute of Medical Science, Rohtak, India
| | - Devarsetty Praveen
- The George Institute for Global Health, New Delhi, India
- University of New South Wales, Sydney, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Jane Hirst
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
- The George Institute for Global Health, Imperial College London, London, United Kingdom
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Wiwatkunupakarn N, Aramrat C, Pliannuom S, Buawangpong N, Pinyopornpanish K, Nantsupawat N, Mallinson PAC, Kinra S, Angkurawaranon C. The Integration of Clinical Decision Support Systems Into Telemedicine for Patients With Multimorbidity in Primary Care Settings: Scoping Review. J Med Internet Res 2023; 25:e45944. [PMID: 37379066 PMCID: PMC10365574 DOI: 10.2196/45944] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/15/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Multimorbidity, the presence of more than one condition in a single individual, is a global health issue in primary care. Multimorbid patients tend to have a poor quality of life and suffer from a complicated care process. Clinical decision support systems (CDSSs) and telemedicine are the common information and communication technologies that have been used to reduce the complexity of patient management. However, each element of telemedicine and CDSSs is often examined separately and with great variability. Telemedicine has been used for simple patient education as well as more complex consultations and case management. For CDSSs, there is variability in data inputs, intended users, and outputs. Thus, there are several gaps in knowledge about how to integrate CDSSs into telemedicine and to what extent these integrated technological interventions can help improve patient outcomes for those with multimorbidity. OBJECTIVE Our aims were to (1) broadly review system designs for CDSSs that have been integrated into each function of telemedicine for multimorbid patients in primary care, (2) summarize the effectiveness of the interventions, and (3) identify gaps in the literature. METHODS An online search for literature was conducted up to November 2021 on PubMed, Embase, CINAHL, and Cochrane. Searching from the reference lists was done to find additional potential studies. The eligibility criterion was that the study focused on the use of CDSSs in telemedicine for patients with multimorbidity in primary care. The system design for the CDSS was extracted based on its software and hardware, source of input, input, tasks, output, and users. Each component was grouped by telemedicine functions: telemonitoring, teleconsultation, tele-case management, and tele-education. RESULTS Seven experimental studies were included in this review: 3 randomized controlled trials (RCTs) and 4 non-RCTs. The interventions were designed to manage patients with diabetes mellitus, hypertension, polypharmacy, and gestational diabetes mellitus. CDSSs can be used for various telemedicine functions: telemonitoring (eg, feedback), teleconsultation (eg, guideline suggestions, advisory material provisions, and responses to simple queries), tele-case management (eg, sharing information across facilities and teams), and tele-education (eg, patient self-management). However, the structure of CDSSs, such as data input, tasks, output, and intended users or decision-makers, varied. With limited studies examining varying clinical outcomes, there was inconsistent evidence of the clinical effectiveness of the interventions. CONCLUSIONS Telemedicine and CDSSs have a role in supporting patients with multimorbidity. CDSSs can likely be integrated into telehealth services to improve the quality and accessibility of care. However, issues surrounding such interventions need to be further explored. These issues include expanding the spectrum of medical conditions examined; examining tasks of CDSSs, particularly for screening and diagnosis of multiple conditions; and exploring the role of the patient as the direct user of the CDSS.
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Affiliation(s)
- Nutchar Wiwatkunupakarn
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
| | - Chanchanok Aramrat
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
| | - Suphawita Pliannuom
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
| | - Nida Buawangpong
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
| | - Kanokporn Pinyopornpanish
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
| | - Nopakoon Nantsupawat
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
| | - Poppy Alice Carson Mallinson
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sanjay Kinra
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chaisiri Angkurawaranon
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
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9
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Bogale TN, Teklehaimanot SM, Fufa Debela T, Enyew DB, Nigusse Bedada A, Dufera Kebebew S, Nigusie Weldeab A, Wolde Daka D, Willems HJ, Bekele TA. Barriers, facilitators and motivators of electronic community health information system use among health workers in Ethiopia. Front Digit Health 2023; 5:1162239. [PMID: 37351371 PMCID: PMC10282640 DOI: 10.3389/fdgth.2023.1162239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/26/2023] [Indexed: 06/24/2023] Open
Abstract
Background The electronic community health information system (eCHIS) has been implemented in Ethiopia to support health services delivered by community health workers. Despite the many benefits of digitizing community health information systems, the implementation of the eCHIS is challenged by many barriers resulting in low uptake. This study assessed the barriers, facilitators, and motivators of eCHIS use among health workers with focus on health extension workers (HEWs) in Ethiopia. Methods Phenomenological approach was used to assess the barriers, facilitators and motivators of eCHIS use in Amhara, Harari, Oromia, Sidama, South West Ethiopia and Southern Nation Nationalities and People's regions of Ethiopia. Data were collected from 15-29 May 2022. A total of 54 face-to-face in-depth interviews were conducted among HEWs, HEW supervisors, health information technicians and managers. The interviews were audiotaped using Open Data Kit, transcribed verbatim and translated into English. OpenCode 4.03 software was used for coding and categorizing the data. Thematic analysis was used to analyze the data. Results The HEWs and other eCHIS users reported lack of infrastructure and resources; poor quality of training, follow-up, and supervision; parallel recording using the manual and electronic system; and HEWs' workload as barriers hindering eCHIS use. Data quality, retrievability, and traceability; tablet portability; encouragement from supervisors; and positive image in the community resulting from HEWs using tablets in their routine activities were the main facilitators of eCHIS use. Conclusion The study identified various barriers that adversely affect the use of eCHIS. An integrated and coordinated approach to eCHIS implementation that encompasses removing the barriers, and reinforcing facilitators is required.
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Affiliation(s)
| | | | - Tilahun Fufa Debela
- Department of Health Service Management, School of Public Health, Jimma University, Jimma, Ethiopia
| | - Daniel Berhanie Enyew
- Department of Health Informatics, School of Public Health, Haramaya University, Haramaya, Ethiopia
| | | | | | - Adane Nigusie Weldeab
- Department of Health Promotion & Health Behavior, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Dawit Wolde Daka
- Department of Health Service Management, School of Public Health, Jimma University, Jimma, Ethiopia
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Gadsden T, Patel A, Praveen D, Palagyi A. Transfer or tailor? Implementing a technology-supported intervention for noncommunicable diseases across contexts. HEALTH CARE SCIENCE 2023; 2:75-78. [PMID: 38939743 PMCID: PMC11080842 DOI: 10.1002/hcs2.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 06/29/2024]
Affiliation(s)
- Thomas Gadsden
- The George Institute for Global HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Anushka Patel
- The George Institute for Global HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Devarsetty Praveen
- The George Institute for Global HealthUniversity of New South WalesSydneyNew South WalesAustralia
- The George Institute for Global HealthHyderabadIndia
- Prasanna School of Public HealthManipal Academy of Higher EducationManipalKarnatakaIndia
| | - Anna Palagyi
- The George Institute for Global HealthUniversity of New South WalesSydneyNew South WalesAustralia
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11
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Ajisegiri WS, Abimbola S, Tesema AG, Odusanya OO, Peiris D, Joshi R. "We just have to help": Community health workers' informal task-shifting and task-sharing practices for hypertension and diabetes care in Nigeria. Front Public Health 2023; 11:1038062. [PMID: 36778542 PMCID: PMC9909193 DOI: 10.3389/fpubh.2023.1038062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/09/2023] [Indexed: 01/27/2023] Open
Abstract
Introduction Nigeria's skilled health professional health workforce density is insufficient to achieve its national targets for non-communicable diseases (NCD) which include 25% reduction in the prevalence of diabetes and hypertension, particularly at the primary health care (PHC) level. This places a great demand on community health workers (CHWs) who constitute the majority of PHC workers. Traditionally, CHWs are mainly involved in infectious diseases programmes, and maternal and child health services. Their involvement with prevention and control of NCDs has been minimal. With government prioritization of PHC for combating the rising NCD burden, strengthening CHWs' skills and competencies for NCD care delivery is crucial. Methods We conducted a mixed methods study to explore the roles and practices of CHWs in the delivery of hypertension and diabetes care at PHC facilities in four states (two each in northern and southern regions) in Nigeria. We reviewed the National Standing Orders that guide CHWs' practices at the PHC facilities and administered a survey to 76 CHWs and conducted 13 focus groups (90 participants), and in-depth individual interviews with 13 CHWs and 7 other local and state government stakeholders. Results Overall, we found that despite capacity constraints, CHWs frequently delivered services beyond the scope of practice stipulated in the National Standing Orders. Such informal task-shifting practices were primarily motivated by a need to serve the community. Discussion While these practices may partially support health system functions and address unmet need, they may also lead to variable care quality and safety. Several factors could mitigate these adverse impacts and strengthen CHW roles in the health system. These include a stronger enabling policy environment to support NCD task-sharing, investment in continuous capacity building for CHWs, improved guidelines that can be implemented at the point of care, and improved coordination processes between PHC and higher-level facilities.
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Affiliation(s)
- Whenayon Simeon Ajisegiri
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Seye Abimbola
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Azeb Gebresilassie Tesema
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Olumuyiwa O. Odusanya
- Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Ikeja, Nigeria
| | - David Peiris
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Rohina Joshi
- School of Population Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- The George Institute for Global Health, New Delhi, India
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12
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Meunier PY, Raynaud C, Guimaraes E, Gueyffier F, Letrilliart L. Barriers and Facilitators to the Use of Clinical Decision Support Systems in Primary Care: A Mixed-Methods Systematic Review. Ann Fam Med 2023; 21:57-69. [PMID: 36690490 PMCID: PMC9870646 DOI: 10.1370/afm.2908] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/08/2022] [Accepted: 10/10/2022] [Indexed: 01/24/2023] Open
Abstract
PURPOSE To identify and quantify the barriers and facilitators to the use of clinical decision support systems (CDSSs) by primary care professionals (PCPs). METHODS A mixed-methods systematic review was conducted using a sequential synthesis design. PubMed/MEDLINE, PsycInfo, Embase, CINAHL, and the Cochrane library were searched in July 2021. Studies that evaluated CDSSs providing recommendations to PCPs and intended for use during a consultation were included. We excluded CDSSs used only by patients, described as concepts or prototypes, used with simulated cases, and decision supports not considered as CDSSs. A framework synthesis was performed according to the HOT-fit framework (Human, Organizational, Technology, Net Benefits), then a quantitative synthesis evaluated the impact of the HOT-fit categories on CDSS use. RESULTS A total of 48 studies evaluating 45 CDSSs were included, and 186 main barriers or facilitators were identified. Qualitatively, barriers and facilitators were classified as human (eg, perceived usefulness), organizational (eg, disruption of usual workflow), and technological (eg, CDSS user-friendliness), with explanatory elements. The greatest barrier to using CDSSs was an increased workload. Quantitatively, the human and organizational factors had negative impacts on CDSS use, whereas the technological factor had a neutral impact and the net benefits dimension a positive impact. CONCLUSIONS Our findings emphasize the need for CDSS developers to better address human and organizational issues, in addition to technological challenges. We inferred core CDSS features covering these 3 factors, expected to improve their usability in primary care.
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Affiliation(s)
- Pierre-Yves Meunier
- Collège universitaire de médecine générale, Université Claude Bernard Lyon 1, Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Camille Raynaud
- Collège universitaire de médecine générale, Université Claude Bernard Lyon 1, Lyon, France
| | - Emmanuelle Guimaraes
- Collège universitaire de médecine générale, Université Claude Bernard Lyon 1, Lyon, France
| | - François Gueyffier
- Laboratoire de biométrie et biologie évolutive, département biostatistiques et modélisation pour la santé et l'environnement, CNRS UMR5558, Université Claude Bernard Lyon 1, Lyon, France
- Fédération de Recherche Santé Lyon Est, PAM Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Laurent Letrilliart
- Collège universitaire de médecine générale, Université Claude Bernard Lyon 1, Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
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13
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Chen W, O’Bryan CM, Gorham G, Howard K, Balasubramanya B, Coffey P, Abeyaratne A, Cass A. Barriers and enablers to implementing and using clinical decision support systems for chronic diseases: a qualitative systematic review and meta-aggregation. Implement Sci Commun 2022; 3:81. [PMID: 35902894 PMCID: PMC9330991 DOI: 10.1186/s43058-022-00326-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 07/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background Clinical decision support (CDS) is increasingly used to facilitate chronic disease care. Despite increased availability of electronic health records and the ongoing development of new CDS technologies, uptake of CDS into routine clinical settings is inconsistent. This qualitative systematic review seeks to synthesise healthcare provider experiences of CDS—exploring the barriers and enablers to implementing, using, evaluating, and sustaining chronic disease CDS systems. Methods A search was conducted in Medline, CINAHL, APA PsychInfo, EconLit, and Web of Science from 2011 to 2021. Primary research studies incorporating qualitative findings were included if they targeted healthcare providers and studied a relevant chronic disease CDS intervention. Relevant CDS interventions were electronic health record-based and addressed one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolaemia. Qualitative findings were synthesised using a meta-aggregative approach. Results Thirty-three primary research articles were included in this qualitative systematic review. Meta-aggregation of qualitative data revealed 177 findings and 29 categories, which were aggregated into 8 synthesised findings. The synthesised findings related to clinical context, user, external context, and technical factors affecting CDS uptake. Key barriers to uptake included CDS systems that were simplistic, had limited clinical applicability in multimorbidity, and integrated poorly into existing workflows. Enablers to successful CDS interventions included perceived usefulness in providing relevant clinical knowledge and structured chronic disease care; user confidence gained through training and post training follow-up; external contexts comprised of strong clinical champions, allocated personnel, and technical support; and CDS technical features that are both highly functional, and attractive. Conclusion This systematic review explored healthcare provider experiences, focussing on barriers and enablers to CDS use for chronic diseases. The results provide an evidence-base for designing, implementing, and sustaining future CDS systems. Based on the findings from this review, we highlight actionable steps for practice and future research. Trial registration PROSPERO CRD42020203716 Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00326-x.
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Jefferson K, Ward M, Pang WH, Arcand J. A feasibility study of a randomized controlled trial protocol to assess the impact of an eHealth intervention on the provision of dietary advice in primary care. Pilot Feasibility Stud 2022; 8:208. [PMID: 36104747 PMCID: PMC9472390 DOI: 10.1186/s40814-022-01168-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/26/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Canadian sodium intakes remain high despite population-wide sodium reduction initiatives, highlighting the need for personal action in reducing dietary sodium. eHealth interventions support patients in dietary change and assist clinicians in decision-making and delivering care, including provision of advice. To date, impact of diet-focused eHealth tools, like the Sodium Calculator (SC) dietary screening tool, on clinical outcomes has received minimal examination. This study assessed feasibility of a randomized controlled trial (RCT) protocol to examine the impact of the SC, a physician-focused intervention, on the quality of dietary sodium reduction advice provided by physicians to their patients with hypertension.
Methods
Primary care physicians from community-based primary care clinics were randomized to one of two groups: (1) ‘usual care’ for dietary sodium counselling or (2) dietary sodium counselling using the SC (‘experimental group’). The primary endpoint was protocol feasibility defined by the following outcomes: process (e.g. recruitment, retention, protocol adherence, acceptability of intervention), resources (e.g. needs, impact on workflow), and management (e.g. staff requirements). Outcomes were assessed using direct observation, interviews, and questionnaires with patients, physicians, and clinic staff.
Results
Seven physicians (n = 4 in experimental group, n = 3 in usual care group) and 65 patients with hypertension (48.5% men, 69.8 ± 10.1 years) successfully participated. The main challenges identified is related to recruitment rate (48% for patients, 20% for physicians) and physician protocol adherence (76%). These improved with minor protocol modifications. There were several areas of protocol success such as no disruption to physician workflow, hiring clinic nurses as research staff, having a physician site lead to support physician recruitment, and a ‘Protocol Prompt Form’ to increase physician protocol adherence. Importantly, there was a high degree of acceptability of the SC intervention among experimental group physicians [n = 3 (75%)].
Conclusions
The modified RCT protocol was considered feasible. The identified successes can be leveraged, and the risks can be mitigated, during implementation of a full-scale RCT. Assessment of this RCT protocol is an important step in understanding the effectiveness of diet-focused eHealth tools to supporting physician self-efficacy in assessing, monitoring, and implementing dietary advice in routine clinical practice and supporting patients in effective behaviour change.
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Kalyesubula R, Conroy AL, Calice-Silva V, Kumar V, Onu U, Batte A, Kaze FF, Fabian J, Ulasi I. Screening for Kidney Disease in Low- and Middle-Income Countries. Semin Nephrol 2022; 42:151315. [DOI: 10.1016/j.semnephrol.2023.151315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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16
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Partogi M, Gaviria-Valencia S, Alzate Aguirre M, Pick NJ, Bhopalwala HM, Barry BA, Kaggal VC, Scott CG, Kessler ME, Moore MM, Mitchell JD, Chaudhry R, Bonacci RP, Arruda-Olson AM. Sociotechnical Intervention for Improved Delivery of Preventive Cardiovascular Care to Rural Communities: Participatory Design Approach. J Med Internet Res 2022; 24:e27333. [PMID: 35994324 PMCID: PMC9446142 DOI: 10.2196/27333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 12/30/2021] [Accepted: 06/27/2022] [Indexed: 11/15/2022] Open
Abstract
Background Clinical practice guidelines recommend antiplatelet and statin therapies as well as blood pressure control and tobacco cessation for secondary prevention in patients with established atherosclerotic cardiovascular diseases (ASCVDs). However, these strategies for risk modification are underused, especially in rural communities. Moreover, resources to support the delivery of preventive care to rural patients are fewer than those for their urban counterparts. Transformative interventions for the delivery of tailored preventive cardiovascular care to rural patients are needed. Objective A multidisciplinary team developed a rural-specific, team-based model of care intervention assisted by clinical decision support (CDS) technology using participatory design in a sociotechnical conceptual framework. The model of care intervention included redesigned workflows and a novel CDS technology for the coordination and delivery of guideline recommendations by primary care teams in a rural clinic. Methods The design of the model of care intervention comprised 3 phases: problem identification, experimentation, and testing. Input from team members (n=35) required 150 hours, including observations of clinical encounters, provider workshops, and interviews with patients and health care professionals. The intervention was prototyped, iteratively refined, and tested with user feedback. In a 3-month pilot trial, 369 patients with ASCVDs were randomized into the control or intervention arm. Results New workflows and a novel CDS tool were created to identify patients with ASCVDs who had gaps in preventive care and assign the right care team member for delivery of tailored recommendations. During the pilot, the intervention prototype was iteratively refined and tested. The pilot demonstrated feasibility for successful implementation of the sociotechnical intervention as the proportion of patients who had encounters with advanced practice providers (nurse practitioners and physician assistants), pharmacists, or tobacco cessation coaches for the delivery of guideline recommendations in the intervention arm was greater than that in the control arm. Conclusions Participatory design and a sociotechnical conceptual framework enabled the development of a rural-specific, team-based model of care intervention assisted by CDS technology for the transformation of preventive health care delivery for ASCVDs.
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Nezamdoust S, Abdekhoda M, Ranjbaran F, Azami-Aghdash S. Adopting mobile health applications by nurses: a scoping review. J Res Nurs 2022; 27:480-491. [PMID: 36131693 PMCID: PMC9483232 DOI: 10.1177/17449871221077080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Background The concept of mobile health has attracted considerable attention across the globe, as it provides both healthcare professionals and patients with a distinct means of information and resources. Aim This study was conducted with the aim of utilising mobile health (mHealth) applications by nurses and presenting a scenario of how and why they are utilised. Methods This study was a scoping review. Data collection was carried out by searching the related keywords in Google Scholar, Scopus, Cochrane, EMBASE, Ovid, and PubMed databases from January 2000 to March 2019. Results Regarding the reasons for using mobile applications by nurses, five objectives were identified, including learning and knowledge enhancement, treatment and improvement of the patient care process, diagnostic process, data and patient management, and health promotion. Effective factors in the nurses' use of mobile applications were categorised into eight themes: ease of use, usefulness, security and confidentiality, feasibility and functionality, design and use-interface, effectiveness, infrastructure, versatility, and social norms. Conclusions Mobile health applications have considerable potential in enhancing nurses' professional activities. This study contributes to both nursing and health policy by providing a scenario of how and why nurses use mobile health applications.
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Affiliation(s)
- Soghra Nezamdoust
- Student, Department of Medical Library and Information Sciences, School of Health Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammadhiwa Abdekhoda
- Associate Professor, Department of Medical Library and Information Sciences, School of Health Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Ranjbaran
- Lecturer, Department English Language Center, University of Technology and Applied Sciences, Nizwa, Oman
| | - Saber Azami-Aghdash
- Assistant Professor, Department of Health Services Management, School of Health Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
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Innovative mobile-health led participatory approach to comprehensive screening and treatment of diabetes (IMPACT diabetes): rationale, design, and baseline characteristics. Int J Diabetes Dev Ctries 2022. [DOI: 10.1007/s13410-022-01082-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abstract
Background
India has 66 million people with diabetes, of which a large proportion do not receive adequate care. The primary health centres can serve as platforms for early detection of diabetes and continuum of care.
Objectives
This project evaluates a community-level technology-enabled system-level intervention based around the community health workers and primary-care physicians. We hypothesize that incorporation of a mobile clinical decision support system, with other process-level changes will improve identification and management of individuals with diabetes in primary care settings.
Methods
A cluster-randomized trial in sixteen villages/peri-urban areas in Andhra Pradesh and Haryana will test the feasibility and preliminary effectiveness of this intervention. The effectiveness of the extended care intervention will be evaluated by the difference in HbA1c (glycosylated hemoglobin) measured at baseline and end-line between the two study arms. Qualitative interviews of physicians, ASHA, and community members will ascertain the intervention acceptability and feasibility.
Results
A total of 1785 adults (females: 53.2%; median age: 50 years) were screened. ASHAs achieved 100% completeness of data for anthropometric, blood-pressure, and blood-glucose measures. At baseline, 63% of the participants were overweight/obese, 27.8% had elevated blood pressure, 20.3% were at high-risk for cardiovascular disease (CVD), and 21.3% had elevated blood glucose. Half of the individuals with diabetes were newly diagnosed.
Conclusion
Technology enabled transfer of simple clinical procedures from physicians to nonphysician health workers can support the provision of healthcare in under-served communities. Community health workers can successfully screen and refer patients with diabetes and/or CVD to physicians in primary healthcare system.
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Joshi R, Behera D, Di Tanna GL, Ameer MA, Yakubu K, Praveen D. Integrated Management of Diabetes and Tuberculosis in Rural India - Results From a Pilot Study. Front Public Health 2022; 10:766847. [PMID: 35619802 PMCID: PMC9127505 DOI: 10.3389/fpubh.2022.766847] [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] [Received: 08/30/2021] [Accepted: 02/21/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction The World Health Organization and International Union against Tuberculosis (TB) recommends screening patients with TB for Diabetes Mellitus (DM) at the initiation of treatment. There are few pilot studies which screen TB patients for DM, but none of them have documented the feasibility of managing TB patients with DM in the Indian healthcare setting. Operational research is needed to determine the best way to manage individuals with both conditions. This pilot study aimed to develop, and field test an integrated, multidisciplinary program addressing the management of individuals with TB and DM and other associated chronic conditions in the Indian primary healthcare setting. Methods This pilot study used a randomized controlled trial design with mixed-methods evaluation and was conducted in Guntur district of Andhra Pradesh, a southern state of India. All the 120 patients newly diagnosed with TB from 10 participating villages were screened for DM and associated cardiovascular risk factors. Non-physician health workers were trained to follow-up patients for a period of 8 months to encourage treatment adherence, monitor treatment response including blood glucose levels and provide lifestyle advice. Results The intervention was well-accepted by the providers and patients. However, there were no statistically significant variations observed for mean blood glucose levels (mean [SD]: 5.3 [−23.3 to 33.8]) of patients for both intervention and control group participants in this feasibility study. Awareness about diabetes and tuberculosis comorbidity and cardiovascular risk increased among the non-physician health workers in the intervention arm of the study. Discussion The co-management of TB-DM is acceptable to both the health providers and patients. With appropriate training, availability of infrastructure and planned intervention implementation, it is feasible to co-manage TB-DM within the existing primary health care system in India.
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Affiliation(s)
- Rohina Joshi
- School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Health Systems Science, The George Institute for Global Health, New Delhi, India
| | | | - Gian Luca Di Tanna
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Mohammed Abdul Ameer
- Health Systems Science, The George Institute for Global Health, New Delhi, India
| | - Kenneth Yakubu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Devarsetty Praveen
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Health Systems Science, The George Institute for Global Health, New Delhi, India.,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
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20
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Distributed application of guideline-based decision support through mobile devices: Implementation and evaluation. Artif Intell Med 2022; 129:102324. [DOI: 10.1016/j.artmed.2022.102324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 11/18/2022]
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21
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Jahan F, Foote E, Rahman M, Shoab AK, Parvez SM, Nasim MI, Hasan R, El Arifeen S, Billah SM, Sarker S, Hoque MM, Shahidullah M, Islam MS, Ashrafee S, Darmstadt GL. Evaluation of community health worker's performance at home-based newborn assessment supported by mHealth in rural Bangladesh. BMC Pediatr 2022; 22:218. [PMID: 35459113 PMCID: PMC9027479 DOI: 10.1186/s12887-022-03282-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In low to middle-income countries where home births are common and neonatal postnatal care is limited, community health worker (CHW) home visits can extend the capability of health systems to reach vulnerable newborns in the postnatal period. CHW assessment of newborn danger signs supported by mHealth have the potential to improve the quality of danger sign assessments and reduce CHW training requirements. We aim to estimate the validity (sensitivity, specificity, positive and negative predictive value) of CHW assessment of newborn infants aided by mHealth compared to physician assessment. METHODS In this prospective study, ten CHWs received five days of theoretical and hands-on training on the physical assessment of newborns including ten danger signs. CHWs assessed 273 newborn infants for danger signs within 48 h of birth and then consecutively for three days. A physician repeated 20% (n = 148) of the assessments conducted by CHWs. Both CHWs and the physician evaluated newborns for ten danger signs and decided on referral. We used the physician's danger sign identification and referral decision as the gold standard to validate CHWs' identification of danger signs and referral decisions. RESULTS The referrals made by the CHWs had high sensitivity (93.3%), specificity (96.2%), and almost perfect agreement (K = 0.80) with the referrals made by the physician. CHW identification of all the danger signs except hypothermia showed moderate to high sensitivity (66.7-100%) compared to physician assessments. All the danger signs assessments except hypothermia showed moderate to high positive predictive value (PPV) (50-100%) and excellent negative predictive value (NPV) (99-100%). Specificity was high (99-100%) for all ten danger signs. CONCLUSION CHW's identification of neonatal danger signs aided by mHealth showed moderate to high validity in comparison to physician assessments. mHealth platforms may reduce CHW training requirements and while maintaining quality CHW physical assessment performance extending the ability of health systems to provide neonatal postnatal care in low-resource communities. TRIAL REGISTRATION clinicaltrials.gov NCT03933423 , January 05, 2019.
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Affiliation(s)
- Farjana Jahan
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
| | - Eric Foote
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Mahbubur Rahman
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abul Kasham Shoab
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sarker Masud Parvez
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Mizanul Islam Nasim
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rezaul Hasan
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sk Masum Billah
- Maternal and Child Health Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Supta Sarker
- Environmental Intervention Unit, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Mahbubul Hoque
- Department of Neonatology, Dhaka Shishu (Children) Hospital, Dhaka, Bangladesh
| | | | - Muhammad Shariful Islam
- National Newborn Health Program (NNHP) and Integrated Management of Childhood Illness (IMCI), Directorate General of Health Services, Dhaka, Bangladesh
| | - Sabina Ashrafee
- National Newborn Health Program (NNHP) and Integrated Management of Childhood Illness (IMCI), Directorate General of Health Services, Dhaka, Bangladesh
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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22
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He X, Peng C, Xu Y, Zhang Y, Wang Z. Global Scientific Research Landscape on Medical Informatics From 2011 to 2020: Bibliometric Analysis. JMIR Med Inform 2022; 10:e33842. [PMID: 35451986 PMCID: PMC9073618 DOI: 10.2196/33842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/26/2021] [Accepted: 01/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background With the emerging information and communication technology, the field of medical informatics has dramatically evolved in health care and medicine. Thus, it is crucial to explore the global scientific research landscape on medical informatics. Objective This study aims to present a visual form to clarify the overall scientific research trends of medical informatics in the past decade. Methods A bibliometric analysis of data retrieved and extracted from the Web of Science Core Collection (WoSCC) database was performed to analyze global scientific research trends on medical informatics, including publication year, journals, authors, institutions, countries/regions, references, and keywords, from January 1, 2011, to December 31, 2020. Results The data set recorded 34,742 articles related to medical informatics from WoSCC between 2011 and 2020. The annual global publications increased by 193.86% from 1987 in 2011 to 5839 in 2020. Journal of Medical Internet Research (3600 publications and 63,932 citations) was the most productive and most highly cited journal in the field of medical informatics. David W Bates (99 publications), Harvard University (1161 publications), and the United States (12,927 publications) were the most productive author, institution, and country, respectively. The co-occurrence cluster analysis of high-frequency author keywords formed 4 clusters: (1) artificial intelligence in health care and medicine; (2) mobile health; (3) implementation and evaluation of electronic health records; (4) medical informatics technology application in public health. COVID-19, which ranked third in 2020, was the emerging theme of medical informatics. Conclusions We summarize the recent advances in medical informatics in the past decade and shed light on their publication trends, influential journals, global collaboration patterns, basic knowledge, research hotspots, and theme evolution through bibliometric analysis and visualization maps. These findings will accurately and quickly grasp the research trends and provide valuable guidance for future medical informatics research.
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Affiliation(s)
- Xuefei He
- Department of Ophthalmology, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Cheng Peng
- Department of Ophthalmology, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Yingxin Xu
- Information Center, The First Hospital of China Medical University, Shenyang, China
| | - Ye Zhang
- Information Center, The First Hospital of China Medical University, Shenyang, China
| | - Zhongqing Wang
- Information Center, The First Hospital of China Medical University, Shenyang, China
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Ajisegiri WS, Abimbola S, Tesema AG, Odusanya OO, Peiris D, Joshi R. The organisation of primary health care service delivery for non-communicable diseases in Nigeria: A case-study analysis. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000566. [PMID: 36962373 PMCID: PMC10021956 DOI: 10.1371/journal.pgph.0000566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/29/2022] [Indexed: 11/19/2022]
Abstract
As chronic diseases, non-communicable diseases (NCDs) require sustained person-centred and community-based care. Given its direct link to communities and households, Primary Health Care (PHC) is well positioned to achieve such care. In Nigeria, the national government has prioritized PHC system strengthening as a means of achieving national NCD targets. However, strengthening PHC systems for NCDs require re-organization of PHC service delivery, based on contextual understanding of existing facilitators and barriers to PHC service delivery for NCDs. We conducted a mixed method case study to explore NCD service delivery with 13 PHC facilities serving as the cases of interest. The study was conducted in two northern and two southern states in Nigeria-and included qualitative interviews with 25 participants, 13 focus group discussion among 107 participants and direct observation at the 13 PHCs. We found that interprofessional role conflict among healthcare workers, perverse incentives to sustain the functioning of PHC facilities in the face of government under-investment, and the perception of PHC as an inferior health system were major barriers to improved organisation of NCD management. Conversely, the presence of physicians at PHC facilities and involvement of civil society organizations in aiding community linkage were key enablers. These marked differences in performance and capacity between PHC facilities in northern compared to southern states, with those in the south better organised to deliver NCD services. PHC reforms that are tailored to the socio-political and economic variations across Nigeria are needed to improve capacity to address NCDs.
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Affiliation(s)
| | - Seye Abimbola
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Azeb Gebresilassie Tesema
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, Australia
- School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Olumuyiwa O Odusanya
- Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Ikeja, Nigeria
| | - David Peiris
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, Australia
| | - Rohina Joshi
- School of Population Health, University of New South Wales (UNSW), Sydney, Australia
- The George Institute for Global Health, New Delhi, India
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24
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Shukla P, Vashist P, Senjam SS, Gupta V, Gupta N. A study to assess the knowledge and skills of Accredited Social Health Activists and its retention after training in community-based primary eye care. Indian J Ophthalmol 2021; 70:36-42. [PMID: 34937205 PMCID: PMC8917609 DOI: 10.4103/ijo.ijo_1020_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose: Community volunteers like Accredited Social Health Activists (ASHAs) could be utilized for linking community and eye care services. Research is needed to effectively utilize them. This study was to assess whether ASHAs could imbibe new knowledge in eye care and conduct vision screening. Methods: Settings and Design: A pre-post-intervention study in South Delhi Integrated Vision Centres. It was conducted from January 2016 to March 2017. One day of conceptual training followed by hands-on training in vision screening was imparted to ASHAs. The knowledge was assessed thrice: before, immediately after, and following 1 year after training. The vision screening skill was assessed twice. Descriptive analysis using percentages, mean and standard deviations. Paired t-test was used for assessing the change in scores. Results: A total of 102 ASHAs were recruited. A significant increase in the knowledge score of ASHAs before (14.96) and after training (25.38) (P < 0.001) was noted. The knowledge score was sustained at 1 year (21.75). The satisfactory skill of vision screening was seen in 88 (86.3%) ASHAs after training, while 79 (77.5%) ASHAs still retained it after 1 year. Conclusion: The potential to involve ASHAs in community-based frontline eye care activities: awareness generation of eye diseases, identification of referrable conditions, and facilitating individuals to seek eye care facilities. This study informs about the duration, frequency, and content of the training. It also provides evidence on the improvement and sustainability of eye care knowledge and skills by ASHAs after conceptual and hands-on training.
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Affiliation(s)
- Pallavi Shukla
- Community Ophthalmology, Dr R P Centre, AIIMS, New Delhi, India
| | - Praveen Vashist
- Community Ophthalmology, Dr R P Centre, AIIMS, New Delhi, India
| | - Suraj S Senjam
- Community Ophthalmology, Dr R P Centre, AIIMS, New Delhi, India
| | - Vivek Gupta
- Community Ophthalmology, Dr R P Centre, AIIMS, New Delhi, India
| | - Noopur Gupta
- Community Ophthalmology, Dr R P Centre, AIIMS, New Delhi, India
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Gupta A, Agrawal R, Gupt A, Guleri R, Bajpayee D, Joshi N, Sarin E, Gupta S, Kumar H. Systems E-approach for women at risk (SEWA)-A digital health solution for detection of high-risk pregnancies. J Family Med Prim Care 2021; 10:3712-3719. [PMID: 34934670 PMCID: PMC8653496 DOI: 10.4103/jfmpc.jfmpc_466_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 11/04/2022] Open
Abstract
Background High-risk pregnancy (HRP) puts current pregnancy at an increased risk of complications. In the absence of pre-existing HRP implementation model of the country, in collaboration with the Government of Himachal Pradesh, a new digital HRP model called the 'SEWA-A System E-approach for Women at risk' was developed. The current article demonstrates a model for the early identification and line listing of high-risk pregnant women (PW) with appropriate referrals and increased engagement with the healthcare workers using a digital tool in the form of the Android App. Methods SEWA was implemented as a pilot intervention in two community development blocks of the Chamba district. The key implementation steps included finalizing protocols for the identification of HRPs, defining processes and roles, mapping health facilities, setting up the communication loop, and developing of digital solutions. The digital app, used by the auxiliary nurse midwife (ANM) and program officers, tracked PW for a year from October 19 to October 20 and recorded the ANC visits, referrals, and birth outcomes. A qualitative assessment was conducted among the health workers to find out their level of acceptance. Results A total of 1,340 high-risk PW were identified. The intervention year saw a rise in the identification of HRP to 27.9% from 3.5% in the previous year. A total of 2,559 conditions were tagged to the identified 1,340 women categorized into current pregnancy (81%), previous pregnancy (16%), and any existing chronic illness (3%). A majority of the women who required urgent referrals were provided referrals. The application recorded 53% of the delivered HRP with a digital birth preparedness plan, prepared and shared with the PW and Accredited Social Health Activists (ASHA), by text message for compliance. Conclusion The SEWA application is a feasible and sustainable solution to complement the competency of the care providers for early identification of the high-risk conditions and reduce the burden of preventable unprecedented deaths around the time of birth.
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Affiliation(s)
| | | | - Anadi Gupt
- Department of Health and Family Welfare, National Health Mission, Himachal Pradesh, India
| | - Rajesh Guleri
- Department of Health and Family Welfare, Himachal Pradesh, India
| | | | | | | | - Sachin Gupta
- Advisor (Maternal and Child Health), U.S. Agency for International Development, American Embassy, New Delhi, India
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Deo S, Singh P. Community health worker-led, technology-enabled private sector intervention for diabetes and hypertension management among urban poor: a retrospective cohort study from large Indian metropolitan city. BMJ Open 2021; 11:e045246. [PMID: 34385229 PMCID: PMC8362730 DOI: 10.1136/bmjopen-2020-045246] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES We assessed the effectiveness of community health workers (CHWs)-led, technology-enabled programme as a large-scale, real-world solution for screening and long-term management of diabetes and hypertension in low-income and middle-income countries. DESIGN Retrospective cohort design. SETTING Forty-seven low-income neighbourhoods of Hyderabad, a large Indian metropolis. PARTICIPANTS Participants (aged ≥20 years) who subscribed to an ongoing community-based chronic disease management programme employing CHWs and technology to manage diabetes and hypertension. PRIMARY AND SECONDARY OUTCOME MEASURES We used deidentified programme data between 1 March 2015 and 8 October 2018 to measure participants' pre-enrolment and post-enrolment retention rate and within time-interval mean difference in participants' fasting blood glucose and blood pressure using Kaplan-Meier and mixed-effect regression models, respectively. RESULTS 51 126 participants were screened (median age 41 years; 65.2% women). Participant acquisition rate (screening to enrolment) was 4%. Median (IQR) retention period was 163.3 days (87.9-288.8), with 12 months postenrolment retention rate as 16.5% (95% CI 14.7 to 18.3). Reduction in blood glucose and blood pressure levels varied by participants' retention in the programme. Adjusted mean difference from baseline ranged from -14.0 mg/dL (95% CI -18.1 to -10.0) to -27.9 mg/dL (95% CI -47.6 to -8.1) for fasting blood glucose; -2.7 mm Hg (95% CI -7.2 to 2.7) to -7.1 mm Hg (95% CI -9.1 to -4.9) for systolic blood pressure and -1.7 mm Hg (95% CI -4.6 to 1.1) to -4.2 mm Hg (95% CI -4.9 to -3.6) for diastolic blood pressure. CONCLUSIONS CHW-led, technology-enabled private sector interventions can feasibly screen individuals for non-communicable diseases and effectively manage those who continue on the programme in the long run. However, changes in the model (eg, integration with the public health system to reduce out-of-pocket expenditure) may be needed to increase its adoption by individuals and thereby improve its cost-effectiveness.
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Affiliation(s)
- Sarang Deo
- Operations Management, Indian School of Business, Hyderabad, Telangana, India
| | - Preeti Singh
- Max Institute of Healthcare Management, Indian School of Business, Mohali, India
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27
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Schierhout G, Praveen D, Patel B, Li Q, Mogulluru K, Ameer MA, Patel A, Clifford GD, Joshi R, Heritier S, Maulik P, Peiris D. Why do strategies to strengthen primary health care succeed in some places and fail in others? Exploring local variation in the effectiveness of a community health worker managed digital health intervention in rural India. BMJ Glob Health 2021; 6:bmjgh-2021-005003. [PMID: 34312146 PMCID: PMC8314716 DOI: 10.1136/bmjgh-2021-005003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Digital health interventions (DHIs) have huge potential as support modalities to identify and manage cardiovascular disease (CVD) risk in resource-constrained settings, but studies assessing them show modest effects. This study aims to identify variation in outcomes and implementation of SMARTHealth India, a cluster randomised trial of an ASHA-managed digitally enabled primary healthcare (PHC) service strengthening strategy for CVD risk management, and to explain how and in what contexts the intervention was effective. Methods We analysed trial outcome and implementation data for 18 PHC centres and collected qualitative data via focus groups with ASHAs (n=14) and interviews with ASHAs, PHC facility doctors and fieldteam mangers (n=12) Drawing on principles of realist evaluation and an explanatory mixed-methods design we developed mechanism-based explanations for observed outcomes. Results There was substantial between-cluster variation in the primary outcome (overall: I2=62.4%, p<=0.001). The observed heterogeneity in trial outcomes was not attributable to any single factor. Key mechanisms for intervention effectiveness were community trust and acceptability of doctors’ and ASHAs’ new roles, and risk awareness. Enabling local contexts were seen to evolve over time and in response to the intervention. These included obtaining legitimacy for ASHAs’ new roles from trusted providers of curative care; ASHAs’ connections to community and to qualified providers; their responsiveness to community needs; and the accessibility, quality and appropriateness of care provided by higher level medical providers, including those outside of the implementing (public) subsystem. Conclusion Local contextual factors were significant influences on the effectiveness of this DHI-enabled PHC service strategy intervention. Local adaptions need to be planned for, monitored and responded to over time. By identifying plausible explanations for variation in outcomes between clusters, we identify potential strategies to strengthen such interventions.
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Affiliation(s)
- Gill Schierhout
- The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, New South Wales, Australia
| | - Devarsetty Praveen
- The George Institute for Global Health India, Hyderabad, India .,UNSW Sydney, Sydney, New South Wales, Australia
| | - Bindu Patel
- The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, New South Wales, Australia
| | - Qiang Li
- The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, New South Wales, Australia
| | - Kishor Mogulluru
- The George Institute for Global Health India, New Delhi, Delhi, India
| | | | - Anushka Patel
- The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, New South Wales, Australia
| | - Gari D Clifford
- Department of Biomedical Informatics and Biomedical Engineering, Emory University, Atlanta, Georgia, USA.,Department of Biomedical Informatics and Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Rohina Joshi
- The George Institute for Global Health, Newtown, New South Wales, Australia.,The George Institute for Global Health India, New Delhi, Delhi, India
| | | | - Pallab Maulik
- UNSW, Sydney, New South Wales, Australia.,George Institute for Global Health India, New Delhi, India
| | - David Peiris
- The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, New South Wales, Australia
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28
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Nagraj S, Kennedy SH, Jha V, Norton R, Hinton L, Billot L, Rajan E, Arora V, Praveen D, Hirst JE. SMARThealth Pregnancy: Feasibility and Acceptability of a Complex Intervention for High-Risk Pregnant Women in Rural India: Protocol for a Pilot Cluster Randomised Controlled Trial. Front Glob Womens Health 2021; 2:620759. [PMID: 34816187 PMCID: PMC8594020 DOI: 10.3389/fgwh.2021.620759] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 05/03/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: India is in the process of a major epidemiological transition towards non-communicable diseases. Cardiovascular disease (CVD) is the leading cause of death in women in India. Predisposing independent risk factors include pregnancy-related conditions, e.g., hypertensive disorders of pregnancy (HDP) and gestational diabetes (GDM) - also associated with significant perinatal mortality and morbidity. Early identification, referral and management of pregnant women at increased risk of future CVD may offer opportunities for prevention. In rural India, Community Health Workers (CHWs) provide most antenatal and postnatal care. Innovative solutions are required to address integrated care for rural women during transitions between antenatal, postnatal and general health services. The George Institute's SMARThealth Programme has shown that CHWs in rural India screening non-pregnant adults for cardiovascular risk, using a decision support system, is feasible. Building on this, we developed a targeted training programme for CHWs and a complex system-level intervention that uses mobile clinical decision support for CHWs and primary care doctors to screen high-risk pregnant women. In addition to addressing HDP and GDM, the intervention also screens for anaemia in pregnancy. Methods/Design: A pilot study will be undertaken in two diverse rural districts of India: Jhajjar (Haryana) and Guntur (Andhra Pradesh). Two Primary Health Centre clusters will be randomised to intervention or control groups at each study site. The primary objective of this pilot study is to explore the feasibility and acceptability of the SMARThealth Pregnancy intervention. Secondary objectives are to estimate: (a) prevalence rates of moderate to severe anaemia, HDPs and GDM at the study sites; (b) referral and follow-up rates, and (c) mean haemoglobin and blood pressure values at the routine 6 week postnatal visit. A process evaluation will be conducted to explore the acceptability of the SMARThealth Pregnancy intervention for pregnant women and healthcare workers using qualitative methods. Discussion: It is anticipated that the findings of this pilot study will help determine the feasibility and acceptability of the SMARThealth Pregnancy intervention, and highlight how the intervention might be further developed for evaluation in a larger, cluster randomised controlled trial. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03968952.
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Affiliation(s)
- Shobhana Nagraj
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
- The George Institute, Imperial College London, London, United Kingdom
| | - Stephen H. Kennedy
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Vivekananda Jha
- The George Institute, Imperial College London, London, United Kingdom
- The George Institute for Global Health, New Delhi, India
- University of New South Wales, Kensington, NSW, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Robyn Norton
- The George Institute, Imperial College London, London, United Kingdom
- The George Institute for Global Health, UNSW Sydney, Kensington, NSW, Australia
| | - Lisa Hinton
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Laurent Billot
- The George Institute for Global Health, UNSW Sydney, Kensington, NSW, Australia
| | - Eldho Rajan
- The George Institute for Global Health, New Delhi, India
| | - Varun Arora
- Post Graduate Institute of Medical Science, Rohtak, India
| | - Devarsetty Praveen
- The George Institute for Global Health, New Delhi, India
- University of New South Wales, Kensington, NSW, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Jane E. Hirst
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
- The George Institute, Imperial College London, London, United Kingdom
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29
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Usmanova G, Lalchandani K, Srivastava A, Joshi CS, Bhatt DC, Bairagi AK, Jain Y, Afzal M, Dhoundiyal R, Benawri J, Chaudhary T, Mishra A, Wadhwa R, Sridhar P, Bahl N, Gaikwad P, Sood B. The role of digital clinical decision support tool in improving quality of intrapartum and postpartum care: experiences from two states of India. BMC Pregnancy Childbirth 2021; 21:278. [PMID: 33827459 PMCID: PMC8028806 DOI: 10.1186/s12884-021-03710-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background Computerized clinical decision support (CDSS) –digital information systems designed to improve clinical decision making by providers – is a promising tool for improving quality of care. This study aims to understand the uptake of ASMAN application (defined as completeness of electronic case sheets), the role of CDSS in improving adherence to key clinical practices and delivery outcomes. Methods We have conducted secondary analysis of program data (government data) collected from 81 public facilities across four districts each in two sates of Madhya Pradesh and Rajasthan. The data collected between August –October 2017 (baseline) and the data collected between December 2019 – March 2020 (latest) was analysed. The data sources included: digitized labour room registers, case sheets, referral and discharge summary forms, observation checklist and complication format. Descriptive, univariate and multivariate and interrupted time series regression analyses were conducted. Results The completeness of electronic case sheets was low at postpartum period (40.5%), and in facilities with more than 300 deliveries a month (20.9%). In multivariate logistic regression analysis, the introduction of technology yielded significant improvement in adherence to key clinical practices. We have observed reduction in fresh still births rates and asphyxia, but these results were not statistically significant in interrupted time series analysis. However, our analysis showed that identification of maternal complications has increased over the period of program implementation and at the same time referral outs decreased. Conclusions Our study indicates CDSS has a potential to improve quality of intrapartum care and delivery outcome. Future studies with rigorous study design is required to understand the impact of technology in improving quality of maternity care. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03710-y.
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Affiliation(s)
- Gulnoza Usmanova
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | | | - Ashish Srivastava
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | | | | | | | - Yashpal Jain
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | - Mohammed Afzal
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | - Rashmi Dhoundiyal
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | - Jyoti Benawri
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | - Tarun Chaudhary
- Department of Health and Family Welfare, NHM, Jaipur, Rajasthan, 302001, India
| | - Archana Mishra
- Maternal Health, NHM, Bhopal, Madhya Pradesh, 462011, India
| | - Rajni Wadhwa
- Project Management Unit, ASMAN: Alliance for Saving Mothers and Newborns, Mumbai, 400021, India
| | | | - Nupur Bahl
- Reliance Foundation, Mumbai, 400021, India
| | | | - Bulbul Sood
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
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30
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Odendaal W, Lewin S, McKinstry B, Tomlinson M, Jordaan E, Mazinu M, Haig P, Thorson A, Atkins S. Using a mHealth system to recall and refer existing clients and refer community members with health concerns to primary healthcare facilities in South Africa: a feasibility study. Glob Health Action 2020; 13:1717410. [PMID: 32036781 PMCID: PMC7034483 DOI: 10.1080/16549716.2020.1717410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Lay health workers (LHWs) are critical in linking communities and primary healthcare (PHC) facilities. Effective communication between facilities and LHWs is key to this role. We implemented a mobile health (mHealth) system to improve communication and continuity of care for chronically ill clients. The system focused on requests from facility staff to LHWs to follow up clients and LHW referrals of people who needed care at a facility. We implemented the system in two rural and semi-rural sub-districts in South Africa. Objective: To assess the feasibility of the mHealth system in improving continuity of care for clients in PHC in South Africa. Method: We implemented the intervention in 15 PHC facilities. The clerks issued recalls to LHWs using a tablet computer. LHWs used smartphones to receive these requests, communicate with clerks and refer people to a facility. We undertook a mixed-methods evaluation to assess the feasibility of the mHealth system. We analysed recall and referral data using descriptive statistics. We used thematic content analysis to analyse qualitative data from semi-structured interviews with facility staff and a researcher fieldwork journal. Results: Across the sub-districts, 2,204 clients were recalled and 628 (28%) of these recalls were successful. LHWs made 1,085 referrals of which 485 (45%) were successful. The main client group referred and recalled were children under 5 years. Qualitative data showed the impacts of facility conditions and interpersonal relationships on the mHealth system. Conclusion: Using mHealth for recalls and referrals is probably feasible and can improve communication between LHWs and facility staff. However, the low success rates highlight the need to assess facility capacity beforehand and to integrate mHealth with existing health information systems. mHealth may improve communication between LHWs and facility staff, but its success depends on the health system capacity to incorporate these interventions.
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Affiliation(s)
- Willem Odendaal
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
| | - Simon Lewin
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Brian McKinstry
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Mark Tomlinson
- Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Stellenbosch, South Africa.,School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Esme Jordaan
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa.,Statistics and Population Studies, University of the Western Cape, Cape Town, South Africa
| | - Mikateko Mazinu
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Pam Haig
- Family South Africa (FAMSA) Karoo, Oudsthoorn, South Africa
| | - Anna Thorson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Salla Atkins
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,New Social Research and Faculty of Social Sciences, Tampere University, Tampere, Finland
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Acceptability and Barriers to Use of the ASMAN Provider-Facing Electronic Platform for Peripartum Care in Public Facilities in Madhya Pradesh and Rajasthan, India: A Qualitative Study Using the Technology Acceptance Model-3. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228333. [PMID: 33187163 PMCID: PMC7696182 DOI: 10.3390/ijerph17228333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022]
Abstract
The evolving field of mobile health (mHealth) is revolutionizing collection, management, and quality of clinical data in health systems. Particularly in low- and middle-income countries (LMICs), mHealth approaches for clinical decision support and record-keeping offer numerous potential advantages over paper records and in-person training and supervision. We conducted a content analysis of qualitative in-depth interviews using the Technology Acceptance Model 3 (TAM-3) to explore perspectives of providers and health managers in Madhya Pradesh and Rajasthan, India who were using the ASMAN (Alliance for Saving Mothers and Newborns) platform, a package of mHealth technologies to support management during the peripartum period. Respondents uniformly found ASMAN easy to use and felt it improved quality of care, reduced referral rates, ensured timely referral when needed, and aided reporting requirements. The TAM-3 model captured many determinants of reported respondent use behavior, including shifting workflow and job performance. However, some barriers to ASMAN digital platform use were structural and reported more often in facilities where ASMAN use was less consistent; these affect long-term impact, sustainability, and scalability of ASMAN and similar mHealth interventions. The transitioning of the program to the government, ensuring availability of dedicated funds, human resource support, and training and integration with government health information systems will ensure the sustainability of ASMAN.
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Hoque MR, Rahman MS, Nipa NJ, Hasan MR. Mobile health interventions in developing countries: A systematic review. Health Informatics J 2020; 26:2792-2810. [PMID: 32691659 DOI: 10.1177/1460458220937102] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This study reviews the quality of evidence reported in mobile health intervention literature in the context of developing countries. A systematic search of renowned databases was conducted to find studies related to mobile health applications published between a period of 2013 and 2018. After a methodological screening, a total of 31 studies were included for data extraction and synthesis. The mobile health Evidence Reporting and Assessment checklist developed by the World Health Organization was then used to evaluate the rigor and completeness in evidence reporting. We report several important and interesting findings. First, there is a very low level of familiarity with the mobile health Evidence Reporting and Assessment checklist among the researchers and mobile health intervention designers from developing countries. Second, most studies do not adequately meet the essential criteria of evidence reporting mentioned in the mobile health Evidence Reporting and Assessment checklist. Third, there is a dearth of application of design science-based methods and theory-based frameworks in developing mobile health interventions. Fourth, most of the mobile health interventions are not ready for interoperability and to be integrated into the existing health information systems. Based on these findings, we recommend for robust and inclusive study plans to deliver highly evidence-based reports by mobile health intervention studies that are conducted in the context of developing countries.
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Bufalino VJ, Bleser WK, Singletary EA, Granger BB, O'Brien EC, Elkind MSV, Hamilton Lopez M, Saunders RS, McClellan MB, Brown N. Frontiers of Upstream Stroke Prevention and Reduced Stroke Inequity Through Predicting, Preventing, and Managing Hypertension and Atrial Fibrillation: A Call to Action From the Value in Healthcare Initiative's Predict & Prevent Learning Collaborative. Circ Cardiovasc Qual Outcomes 2020; 13:e006780. [PMID: 32683982 DOI: 10.1161/circoutcomes.120.006780] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.
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Affiliation(s)
| | - William K Bleser
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Elizabeth A Singletary
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Bradi B Granger
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Emily C O'Brien
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY (M.S.V.E.)
| | - Marianne Hamilton Lopez
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Robert S Saunders
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Mark B McClellan
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Nancy Brown
- American Heart Association, Dallas, TX (N.B.)
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Patel A, Praveen D, Maharani A, Oceandy D, Pilard Q, Kohli MPS, Sujarwoto S, Tampubolon G. Association of Multifaceted Mobile Technology-Enabled Primary Care Intervention With Cardiovascular Disease Risk Management in Rural Indonesia. JAMA Cardiol 2020; 4:978-986. [PMID: 31461123 DOI: 10.1001/jamacardio.2019.2974] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Cardiovascular diseases (CVDs) are the leading cause of disease burden in Indonesia. Implementation of effective interventions for CVD prevention is limited. Objective To evaluate whether a mobile technology-supported primary health care intervention, compared with usual care, would improve the use of preventive drug treatment among people in rural Indonesia with a high risk of CVD. Design, Setting, and Participants A quasi-experimental study involving 6579 high-risk individuals in 4 intervention and 4 control villages in Malang district, Indonesia, was conducted between August 16, 2016, and March 31, 2018. Median duration of follow-up was 12.2 months. Residents 40 years or older were invited to participate. Those with high estimated 10-year risk of CVD risk (previously diagnosed CVD, systolic blood pressure [BP] >160 mm Hg or diastolic BP >100 mm Hg, 10-year estimated CVD risk of 30% or more, or 10-year estimated CVD risk of 20%-29% and a systolic BP >140 mm Hg) were followed up. Interventions A multifaceted mobile technology-supported intervention facilitating community-based CVD risk screening with referral, tailored clinical decision support for drug prescription, and patient follow-up. Main Outcomes and Measures The primary outcome was the proportion of individuals taking appropriate preventive CVD medications, defined as at least 1 BP-lowering drug and a statin for all high-risk individuals, and an antiplatelet drug for those with prior diagnosed CVD. Secondary outcomes included mean change in BP from baseline. Results Among 22 635 adults, 3494 of 11 647 in the intervention villages (30.0%; 2166 women and 1328 men; mean [SD] age, 58.3 [10.9] years) and 3085 of 10 988 in the control villages (28.1%; 1838 women and 1247 men; mean [SD] age, 59.0 [11.5] years) had high estimated risk of CVD. Of these, follow-up was completed in 2632 individuals (75.3%) from intervention villages and 2429 individuals (78.7%) from control villages. At follow-up, 409 high-risk individuals in intervention villages (15.5%) were taking appropriate preventive CVD medications, compared with 25 (1.0%) in control villages (adjusted risk difference, 14.1%; 95% CI, 12.7%-15.6%). This difference was driven by higher use of BP-lowering medication in those in the intervention villages (1495 [56.8%] vs 382 [15.7%]; adjusted risk difference, 39.4%; 95% CI, 37.0%-41.7%). The adjusted mean difference in change in systolic BP from baseline was -8.3 mm Hg (95% CI, -10.1 to -6.6 mm Hg). Conclusions and Relevance This study found that a multifaceted mobile technology-supported primary health care intervention was associated with greater use of preventive CVD medication and lower BP levels among high-risk individuals in a rural Indonesian population.
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Affiliation(s)
- Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Devarsetty Praveen
- The George Institute for Global Health, University of New South Wales, Hyderabad, India
| | - Asri Maharani
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Delvac Oceandy
- Division of Cardiovascular Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Department of Biomedicine, Faculty of Medicine, University of Airlangga, Surabaya, Indonesia
| | - Quentin Pilard
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Sujarwoto Sujarwoto
- Department of Public Administration, University of Brawijaya, Malang, Indonesia
| | - Gindo Tampubolon
- Global Development Institute, The University of Manchester, Manchester, United Kingdom
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Chandrashekhar Y, Alexander T, Mullasari A, Kumbhani DJ, Alam S, Alexanderson E, Bachani D, Wilhelmus Badenhorst JC, Baliga R, Bax JJ, Bhatt DL, Bossone E, Botelho R, Chakraborthy RN, Chazal RA, Dhaliwal RS, Gamra H, Harikrishnan SP, Jeilan M, Kettles DI, Mehta S, Mohanan PP, Kurt Naber C, Naik N, Ntsekhe M, Otieno HA, Pais P, Piñeiro DJ, Prabhakaran D, Reddy KS, Redha M, Roy A, Sharma M, Shor R, Adriaan Snyders F, Weii Chieh Tan J, Valentine CM, Wilson BH, Yusuf S, Narula J. Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries. Circulation 2020; 141:2004-2025. [PMID: 32539609 DOI: 10.1161/circulationaha.119.041297] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.
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Affiliation(s)
- Y Chandrashekhar
- Division of Cardiology, University of Minnesota/VA Medical Center, Minneapolis (Y.C.)
| | - Thomas Alexander
- Division of Cardiology, Kovai Medical Center and Hospital, Coimbatore, India (T.A.)
| | - Ajit Mullasari
- Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India (A.M.)
| | - Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K.)
| | - Samir Alam
- Division of Cardiology, American University of Beirut Medical Center, Lebanon (S.A.)
| | - Erick Alexanderson
- Nuclear Cardiology Department, Instituto Nacional de Cardiología Ignacio Chávez, Universidad Nacional Autonoma de Mexico, Mexico City (E.A.)
| | - Damodar Bachani
- Building Healthy Cities, John Snow India Pvt Ltd, New Delhi (D.B.)
| | | | - Ragavendra Baliga
- Division of Cardiology, Ohio State University Wexner Medical Center, Columbus (R. Baliga)
| | - Jeroen J Bax
- Division of Cardiology, Leiden University Medical Center, The Netherlands (J.J.B.)
| | - Deepak L Bhatt
- Division of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.)
| | - Eduardo Bossone
- Department of Cardiology and Cardiac Surgery, Azienda Ospedaliera Universitaria, Salerno, Italy (E.B.)
| | - Roberto Botelho
- Triangulo Heart Institute, Uberlândia, Minas Gerais, Brazil (R. Botelho)
| | | | - Richard A Chazal
- Heart and Vascular Institute for Lee Health, Fort Myers, FL (R.A.C.)
| | - Rupinder Singh Dhaliwal
- Division of Non-Communicable Diseases, Indian Council of Medical Research, New Delhi, India (R.S.D., M.S.)
| | - Habib Gamra
- Department of Cardiology, Fattouma Bourguiba University Hospital, Monastir, Tunisia (H.G.)
| | - Sivadasan Pillai Harikrishnan
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India (S.P.H.)
| | - Mohamed Jeilan
- Division of Cardiology, Aga Khan University Medical College, Nairobi, Kenya (M.J., H.A.O.)
| | - David Ian Kettles
- Division of Cardiology, St. Dominic's Hospital, East London, South Africa (D.I.K.)
| | | | - Padhinhare P Mohanan
- Department of Cardiology, Westfort Hi-Tech Hospital, Thrissur, Kerala, India (P.P.M.)
| | - Christoph Kurt Naber
- Department of Cardiology, St.-Marien-Hospital, Mülheim an der Ruhr, Germany (C.K.N.)
| | - Nitish Naik
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi (N.N., A.R.)
| | - Mpiko Ntsekhe
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, South Africa (M.N.)
| | - Harun Argwings Otieno
- Division of Cardiology, Aga Khan University Medical College, Nairobi, Kenya (M.J., H.A.O.)
| | - Prem Pais
- Division of Clinical Trials, St. John's Research Institute, St. John's Medical College, Bangaluru, India (P.P.)
| | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, Public Health Foundation of India, New Delhi (D.P.)
| | | | - Mustafa Redha
- Ministry of Health of the State of Kuwait, Adan Hospital, Kuwait City (M.R.)
| | - Ambuj Roy
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi (N.N., A.R.)
| | - Meenakshi Sharma
- Division of Non-Communicable Diseases, Indian Council of Medical Research, New Delhi, India (R.S.D., M.S.)
| | - Robert Shor
- Virginia Heart, Inova Alexandria Hospital, Alexandria (R.S.)
| | | | | | | | | | - Salim Yusuf
- Population Health Research Institute, McMaster University School of Medicine, Hamilton, ON, Canada (S.Y.)
| | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York (J.N.)
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Bellad MB, Goudar SS, Mallapur AA, Sharma S, Bone J, Charantimath US, Katageri GM, Ramadurg UY, Mark Ansermino J, Derman RJ, Dunsmuir DT, Honnungar NV, Karadiguddi C, Kavi AJ, Kodkany BS, Lee T, Li J, Nathan HL, Payne BA, Revankar AP, Shennan AH, Singer J, Tu DK, Vidler M, Wong H, Bhutta ZA, Magee LA, von Dadelszen P. Community level interventions for pre-eclampsia (CLIP) in India: A cluster randomised controlled trial. Pregnancy Hypertens 2020; 21:166-175. [PMID: 32554291 PMCID: PMC7471838 DOI: 10.1016/j.preghy.2020.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/27/2020] [Accepted: 05/09/2020] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Pregnancy hypertension is associated with 7.1% of maternal deaths in India. The objective of this trial was to assess whether task-sharing care might reduce adverse pregnancy outcomes related to delays in triage, transport, and treatment. STUDY DESIGN The Indian Community-Level Interventions for Pre-eclampsia (CLIP) open-label cluster randomised controlled trial (NCT01911494) recruited pregnant women in 12 clusters (initial four-cluster internal pilot) in Belagavi and Bagalkote, Karnataka. The CLIP intervention (6 clusters) consisted of community engagement, community health workers (CHW) provided mobile health (mHeath)-guided clinical assessment, initial treatment, and referral to facility either urgently (<4 h) or non-urgently (<24 h), dependent on algorithm-defined risk. Treatment effect was estimated by multi-level logistic regression modelling, adjusted for prognostically-significant baseline variables. Predefined secondary analyses included safety and evaluation of the intensity of mHealth-guided CHW-provided contacts. MAIN OUTCOME MEASURES 20% reduction in composite of maternal, fetal, and newborn mortality and major morbidity. RESULTS All 14,783 recruited pregnancies (7839 intervention, 6944 control) were followed-up. The primary outcome did not differ between intervention and control arms (adjusted odds ratio (aOR) 0.92 [95% confidence interval 0.74, 1.15]; p = 0.47; intraclass correlation coefficient 0.013). There were no intervention-related safety concerns following administration of either methyldopa or MgSO4, and 401 facility referrals. Compared with intervention arm women without CLIP contacts, those with ≥8 contacts suffered fewer stillbirths (aOR 0.19 [0.10, 0.35]; p < 0.001), at the probable expense of survivable neonatal morbidity (aOR 1.39 [0.97, 1.99]; p = 0.072). CONCLUSIONS As implemented, solely community-level interventions focussed on pre-eclampsia did not improve outcomes in northwest Karnataka.
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Affiliation(s)
- Mrutunjaya B Bellad
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India.
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Ashalata A Mallapur
- S Nijalingappa Medical College, HSK (Hanagal Shree Kumareshwar) Hospital and Research Centre, Navanagar, Bagalkot, 587102 Karnataka, India
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Umesh S Charantimath
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Geetanjali M Katageri
- S Nijalingappa Medical College, HSK (Hanagal Shree Kumareshwar) Hospital and Research Centre, Navanagar, Bagalkot, 587102 Karnataka, India
| | - Umesh Y Ramadurg
- S Nijalingappa Medical College, HSK (Hanagal Shree Kumareshwar) Hospital and Research Centre, Navanagar, Bagalkot, 587102 Karnataka, India
| | - J Mark Ansermino
- Centre for International Child Health, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Richard J Derman
- Global Affairs, 1020 Walnut Street, Thomas Jefferson University, Philadelphia 19107, USA
| | - Dustin T Dunsmuir
- Centre for International Child Health, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Narayan V Honnungar
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Chandrashekhar Karadiguddi
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Avinash J Kavi
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Bhalachandra S Kodkany
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Tang Lee
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Jing Li
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Hannah L Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Beth A Payne
- Centre for International Child Health, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Amit P Revankar
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, 588 - 1081 Burrard Street, St. Paul's Hospital, Vancouver V6Z 1Y6, Canada
| | - Domena K Tu
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada; Centre for International Child Health, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Hubert Wong
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, 588 - 1081 Burrard Street, St. Paul's Hospital, Vancouver V6Z 1Y6, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, 525 University Avenue, Suite 702, Toronto M5G 2L3, Canada; Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
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Smith C, van Velthoven MH, Truong ND, Nam NH, Anh VP, AL-Ahdal TMA, Hassan OG, Kouz B, Huy NT, Brewster M, Pakenham-Walsh N. How primary healthcare workers obtain information during consultations to aid safe prescribing in low-income and lower middle-income countries: a systematic review. BMJ Glob Health 2020; 5:e002094. [PMID: 32337085 PMCID: PMC7170426 DOI: 10.1136/bmjgh-2019-002094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 11/04/2022] Open
Abstract
Background We systematically reviewed the evidence on how primary healthcare workers obtain information during consultations to support decision-making for prescribing in low and lower middle-income countries. Methods We searched electronic databases, consulted the Healthcare Information For All network, hand searched reference lists, ran citation searches of included studies and emailed authors of identified papers. Two reviewers extracted data and appraised quality with relevant tools. Results Of 60 497 records found, 23 studies met our inclusion criteria. Fourteen studies were observational and nine were interventional. Frequently mentioned sources of information were books, leaflets, guidelines, aids and the internet. These sources were sometimes out of date and health workers reported being confused which to use. Internet access varied and even when it was available, use was limited by technical issues. Of the five electronic tools that were assessed, four had positive outcomes. Tools assisted prescribers with medicine selection and dosage calculations, which increased prescribing accuracy. The quality of reporting varied but was overall low. Discussion Studies indicated a lack of up-to-date and relevant medicine information in low and lower middle-income settings. Internet-based sources appeared to be useful when it is possible to download content for offline use and to update when there is internet access. Electronic tools showed promise, but their accuracy needs to be validated and they should focus on giving actionable advice to guide prescribers. PROSPERO registration number CRD42018091088.
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Affiliation(s)
- Chris Smith
- School of Tropical Medicine and Global Health (TMGH), Nagasaki University, Nagasaki, Japan
- Department of Clinical Research, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Michelle Helena van Velthoven
- School of Tropical Medicine and Global Health (TMGH), Nagasaki University, Nagasaki, Japan
- Department of Paediatrics, Oxford University, Oxford, Oxfordshire, UK
| | - Nguyen Duc Truong
- Nagasaki University, Nagasaki, Japan
- Obstetrics and Gynecologic Department, FV Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Hai Nam
- Nagasaki University, Nagasaki, Japan
- Department of General Surgery, Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Vũ Phan Anh
- Nagasaki University, Nagasaki, Japan
- Department of Neonatology, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Tareq Mohammed Ali AL-Ahdal
- Nagasaki University, Nagasaki, Japan
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Osama Gamal Hassan
- Nagasaki University, Nagasaki, Japan
- Faculty of Medicine, South Valley University, Qena, Egypt
| | - Basel Kouz
- Nagasaki University, Nagasaki, Japan
- Faculty of Medicine, Damascus University, Damascus, Damascus Governorate, Syria
| | | | - Malcolm Brewster
- Healthcare Information For All (HIFA) network, Global Healthcare Information Network, Charlbury, UK
| | - Neil Pakenham-Walsh
- Healthcare Information For All (HIFA) network, Global Healthcare Information Network, Charlbury, UK
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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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Thomas DS, Daly K, Nyanza EC, Ngallaba SE, Bull S. Health worker acceptability of an mHealth platform to facilitate the prevention of mother-to-child transmission of HIV in Tanzania. Digit Health 2020; 6:2055207620905409. [PMID: 32076575 PMCID: PMC7003162 DOI: 10.1177/2055207620905409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 01/14/2020] [Indexed: 11/16/2022] Open
Abstract
Objectives Health workers (HWs) are increasingly using mobile health (mHealth) technologies in low-resource settings. Understanding HW acceptability of mHealth is critical to increasing the scale of mHealth solutions. We examined pre- and post-pilot clinical knowledge and acceptability of a tablet-based platform, the Tanzania Health Information System (T-HIT), targeting HWs delivering prevention of mother-to-child transmission (PMTCT) of HIV services in seven health facilities in Misungwi District, Tanzania. Methods We developed a survey based on the diffusion of innovation theory and administered it to 27 HWs before and after a 3-month pilot of T-HIT. Using a Wilcoxon signed-rank test, we analyzed changes in acceptability defined as attitudes towards and self-efficacy for system use comparing pre- and post-test assessment scores and changes in knowledge of clinical care. Using analysis of variance, we explored these changes, stratifying health facilities by level of care and by distance from the district hospital. Results Post-pilot scores showed statistically significant improvement from pre-test for the total survey (Z = −2.67, p < 0.008) and for questions concerning system attitude (Z = −2.63, p < 0.008). HWs in hospitals and health centers exhibited a lower initial level of system acceptability in attitude than those in dispensaries and a significant improvement in overall mean acceptability over the pilot (95% CI 0.004–0.0187). HWs working more than 20 km from the hospital had a lower initial level of both system knowledge and acceptability than their less remote counterparts, but demonstrated larger improvements in knowledge and acceptability over time, although this change was not statistically significant. Conclusions The pilot demonstrates that HWs in PMTCT in Misungwi have a high acceptability of mHealth solutions. Using an mHealth solution can facilitate HW delivery of PMTCT care in rural and remote settings. Consideration of acceptability is important for fostering mHealth scale and program sustainability.
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Affiliation(s)
- Deborah Sk Thomas
- Department of Geography and Earth Sciences, University of North Carolina at Charlotte, USA
| | - Kristen Daly
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, USA
| | - Elias C Nyanza
- School of Public Health, Catholic University of Health and Allied Sciences, Tanzania
| | - Sospatro E Ngallaba
- School of Public Health, Catholic University of Health and Allied Sciences, Tanzania
| | - Sheana Bull
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, USA
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Santo K, Redfern J. The Potential of mHealth Applications in Improving Resistant Hypertension Self-Assessment, Treatment and Control. Curr Hypertens Rep 2019; 21:81. [PMID: 31598792 DOI: 10.1007/s11906-019-0986-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review the evidence supporting the use of mobile health (mHealth) apps to improve resistant hypertension self-assessment, treatment and control. RECENT FINDINGS mHealth apps have been used to directly measure blood pressure (BP) levels, either using the oscillometric method with automated inflatable cuffs or using pulse wave signals detected by smartphone technology without the need for cuffs. These app-based BP monitors tend to over or underestimate BP levels when compared to a gold standard aneroid sphygmomanometer. However, the differences in BP measurements are within the acceptable range of 5 mmHg pre-defined by the European Society of Hypertension International Protocol Revision 2010. mHealth apps are also used as tools to support physicians in improving hypertension treatment. App-based clinical decision support systems are innovative solutions, in which patient information is entered in the app and management algorithms provide recommendations for hypertension treatment. The use of these apps has been shown to be feasible and easily integrated into the workflow of healthcare professionals, and, therefore particularly useful in resource-limited settings. In addition, apps can be used to improve hypertension control by facilitating regular BP monitoring, communication between patients and health professionals, and patient education; as well as by reinforcing behaviours through reminders, including medication-taking and appointment reminders. Several studies provided evidence supporting the use of apps for hypertension control. Although some of the results are promising, there is still limited evidence on the benefits of using such mHealth tools, as these studies are relatively small and with a short-term duration. Recent research has shown that mHealth apps can be beneficial in terms of improving hypertension self-assessment, treatment and control, being especially useful to help differentiate and manage true and pseudo-resistant hypertension. However, future research, including large-scale randomised clinical trials with user-centred design, is crucial to further evaluate the potential scalability and effectiveness of such mHealth apps in the resistant hypertension context.
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Affiliation(s)
- Karla Santo
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil.
- Westmead Applied Research Centre, Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
- Cardiovascular Division, The George Institute for Global Health, Sydney, Australia.
| | - Julie Redfern
- Westmead Applied Research Centre, Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cardiovascular Division, The George Institute for Global Health, Sydney, Australia
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Dodd R, Palagyi A, Jan S, Abdel-All M, Nambiar D, Madhira P, Balane C, Tian M, Joshi R, Abimbola S, Peiris D. Organisation of primary health care systems in low- and middle-income countries: review of evidence on what works and why in the Asia-Pacific region. BMJ Glob Health 2019; 4:e001487. [PMID: 31478026 PMCID: PMC6703302 DOI: 10.1136/bmjgh-2019-001487] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/15/2019] [Accepted: 06/23/2019] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION This paper synthesises evidence on the organisation of primary health care (PHC) service delivery in low-income and middle-income countries (LMICs) in the Asia Pacific and identifies evidence of effective approaches and pathways of impact in this region. METHODS We developed a conceptual framework describing key inputs and outcomes of PHC as the basis of a systematic review. We searched exclusively for intervention studies from LMICs of the Asia-Pacific region in an effort to identify 'what works' to improve the coverage, quality, efficiency, equity and responsiveness of PHC. We conducted a narrative synthesis to identify key characteristics of successful interventions. RESULTS From an initial list of 3001 articles, we selected 153 for full-text review and included 111. We found evidence on the impact of non-physician health workers (NPHWs) on coverage and quality of care, though better integration with other PHC services is needed. Community-based services are most effective when well integrated through functional referral systems and supportive supervision arrangements, and have a reliable supply of medicines. Many studies point to the importance of community engagement in improving service demand. Few studies adopted a 'systems' lens or adequately considered long-term costs or implementation challenges. CONCLUSION Based on our findings, we suggest five areas where more practical knowledge and guidance is needed to support PHC systems strengthening: (1) NPHW workforce development; (2) integrating non-communicable disease prevention and control into the basic package of care; (3) building managerial capacity; (4) institutionalising community engagement; (5) modernising PHC information systems.
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Affiliation(s)
- Rebecca Dodd
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Anna Palagyi
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - Marwa Abdel-All
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Devaki Nambiar
- The George Institute for Global Health, New Delhi, India
| | | | - Christine Balane
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Maoyi Tian
- The George Institute for Global Health, Beijing, China
| | - Rohina Joshi
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, Sydney, NSW, Australia
- The George Institute for Global Health, New Delhi, India
| | - Seye Abimbola
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Nagraj S, Hinton L, Praveen D, Kennedy S, Norton R, Hirst J. Women's and healthcare providers' perceptions of long-term complications associated with hypertension and diabetes in pregnancy: a qualitative study. BJOG 2019; 126 Suppl 4:34-42. [PMID: 31257668 PMCID: PMC6771686 DOI: 10.1111/1471-0528.15847] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2019] [Indexed: 12/27/2022]
Abstract
Objectives A diagnosis of hypertensive disorders during pregnancy (HDPs) or gestational diabetes mellitus (GDM) is highly predictive of women at increased risk of developing chronic hypertension, Type 2 diabetes, and cardiovascular disease. This study investigates perceptions of women and healthcare providers in rural India regarding these long‐term risks. Design Qualitative study using modified grounded theory. Setting Two states in rural India: Haryana and Andhra Pradesh. Population Pregnant and postpartum women, community health workers (CHWs), primary care physicians, obstetricians, laboratory technicians, and healthcare officials. Methods In‐depth interviews and focus group discussions explored: (1) priorities for high‐risk pregnant women; (2) detection and management of HDPs and GDM; (3) postpartum management, and (4) knowledge of long‐term sequelae of high‐risk conditions. A thematic analysis was undertaken. Results Seven focus group discussions and 11 in‐depth interviews (n = 71 participants) were performed. The key priority area for high‐risk pregnant women was anaemia. Blood pressure measurement was routinely embedded in antenatal care; however, postpartum follow up and knowledge of the long‐term complications were limited. GDM was not considered a common problem, although significant variations and challenges to GDM screening were identified. Knowledge of the long‐term sequelae of GDM with regard to an increased risk of Type 2 diabetes and cardiovascular disease among doctors was minimal. Conclusions There is a need for improved education, standardisation of testing and postpartum follow up of HDPs and GDM in rural Indian settings. Funding SN is supported by an MRC Clinical Research Training Fellowship (MR/R017182/1). The George Institute for Global Health Global Women's Health programme provided financial support for the research assistant and fieldwork costs in India. Tweetable abstract Improved education and postpartum care of women with hypertension and diabetes in pregnancy in rural India are needed to prevent long‐term risks. Improved education and postpartum care of women with hypertension and diabetes in pregnancy in rural India are needed to prevent long‐term risks.
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Affiliation(s)
- S Nagraj
- The George Institute for Global Health, University of Oxford, Oxford, UK.,Nuffield Department of Women's & Reproductive Health, Level 3 Women's Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - L Hinton
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - D Praveen
- The George Institute for Global Health, Hyderabad, India
| | - S Kennedy
- Nuffield Department of Women's & Reproductive Health, Level 3 Women's Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - R Norton
- The George Institute for Global Health, University of Oxford, Oxford, UK
| | - J Hirst
- The George Institute for Global Health, University of Oxford, Oxford, UK.,Nuffield Department of Women's & Reproductive Health, Level 3 Women's Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
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Determinants of individuals’ intention to use mobile health: insights from India. TRANSFORMING GOVERNMENT- PEOPLE PROCESS AND POLICY 2019. [DOI: 10.1108/tg-04-2019-0027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Purpose
This study aims to examine the determinants of mobile health technology and applications use intention. The factors are delineated from prior literature and theories of individual traits and adoption characteristics, technology acceptance and health belief.
Design/methodology/approach
Data from 409 respondents were collected from Indian participants through a questionnaire survey. The construct “use intention” was measured using individual traits to mobile services, subjective norm, health consciousness, awareness and perceived usefulness, and the model was tested.
Findings
The study found that mobile health technology and the applications awareness and personal innovativeness influence intention to use.
Originality/value
Previous studies have often looked at technology adoption and acceptance models separately and are less adequately discussed in the Indian context. The components that determine mobile health technology and the applications’ acceptance by literature and theories of individual traits and adoption characteristics, technology acceptance and health beliefs were also inadequately discussed. The significant contribution of this research also includes policy recommendations for improving mobile health acceptance in India.
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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
- Corresponding author at: School of Public Health, University of Ghana, P.O. Box LG13, Legon, Accra, Ghana; Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands.
| | - 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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Maharani A, Sujarwoto, Praveen D, Oceandy D, Tampubolon G, Patel A. Cardiovascular disease risk factor prevalence and estimated 10-year cardiovascular risk scores in Indonesia: The SMARThealth Extend study. PLoS One 2019; 14:e0215219. [PMID: 31039155 PMCID: PMC6490907 DOI: 10.1371/journal.pone.0215219] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 03/28/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The brunt of cardiovascular disease (CVD) burden globally now resides within low- and middle-income countries, including Indonesia. However, little is known regarding cardiovascular health in Indonesia. This study aimed to estimate the prevalence of elevated CVD risk in a specific region of Indonesia. METHODS We conducted full household screening for cardiovascular risk factors among adults aged 40 years and older in 8 villages in Malang District, East Java Province, Indonesia, in 2016-2017. 10-year cardiovascular risk scores were calculated based on the World Health Organization/International Society of Hypertension's region-specific charts that use age, sex, blood pressure, diabetes status and smoking behaviour. RESULTS Among 22,093 participants, 6,455 (29.2%) had high cardiovascular risk, defined as the presence of coronary heart disease, stroke or other atherosclerotic disease; estimated 10-year CVD risk of ≥ 30%; or estimated 10-year CVD risk between 10% to 29% combined with a systolic blood pressure of > 140 mmHg. The prevalence of high CVD risk was greater in urban (31.6%, CI 30.7-32.5%) than in semi-urban (28.7%, CI 27.3-30.1%) and rural areas (26.2%, CI 25.2-27.2%). Only 11% and 1% of all the respondents with high CVD risk were on blood pressure lowering and statins treatment, respectively. CONCLUSIONS High cardiovascular risk is common among Indonesian adults aged ≥40 years, and rates of preventive treatment are low. Population-based and clinical approaches to preventing CVD should be a priority in both urban and rural areas.
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Affiliation(s)
- Asri Maharani
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, United Kingdom
| | - Sujarwoto
- University of Brawijaya, Malang, Indonesia
| | - Devarsetty Praveen
- The George Institute for Global Health, University of New South Wales, Hyderabad, India
| | - Delvac Oceandy
- Division of Cardiovascular Science, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Department of Biomedicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Gindo Tampubolon
- Manchester Institute for Collaborative Research on Aging, University of Manchester, Manchester, United Kingdom
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Peiris D, Praveen D, Mogulluru K, Ameer MA, Raghu A, Li Q, Heritier S, MacMahon S, Prabhakaran D, Clifford GD, Joshi R, Maulik PK, Jan S, Tarassenko L, Patel A. SMARThealth India: A stepped-wedge, cluster randomised controlled trial of a community health worker managed mobile health intervention for people assessed at high cardiovascular disease risk in rural India. PLoS One 2019; 14:e0213708. [PMID: 30913216 PMCID: PMC6435227 DOI: 10.1371/journal.pone.0213708] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/10/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiovascular diseases (CVD) are rising in India resulting in major health system challenges. METHODS Eighteen primary health centre (PHC) clusters in rural Andhra Pradesh were randomised over three, 6-month steps to an intervention comprising: (1) household CVD risk assessments by village-based community health workers (CHWs) using a mobile tablet device; (2) electronic referral and clinical decision support for PHC doctors; and (3) a tracking system for follow-up care. Independent data collectors screened people aged ≥ 40 years in 54 villages serviced by the PHCs to create a high CVD risk cohort (based on WHO risk charts and blood pressure thresholds). Randomly selected, independent samples, comprising 15% of this cohort, were reviewed at each 6-month step. The primary outcome was the proportion meeting systolic blood pressure (SBP) targets (<140mmHg). FINDINGS Eight-four percent of the eligible population (n = 62,254) were assessed at baseline (18.4% at high CVD risk). Of those at high risk, 75.3% were followed up over two years. CHWs screened 85.9% of the baseline cohort and doctors followed up 70.0% of all high risk referrals. There was no difference in the proportion of people achieving SBP targets (41.2% vs 39.2%; adjusted odds ratio (OR) 1.01 95% CI 0.76-1.35) or receiving BP-lowering medications in the intervention vs control periods respectively. There was a high discordance in risk scores generated by independent data collectors and CHWs, resulting in only 37.2% of the evaluation cohort exposed to the intervention. This discordance was mainly driven by fluctuating BP values (both normal variability and marked seasonal variations). In the pre-specified high risk concordant subgroup, there was greater use of BP-lowering medications in the intervention period (54.3% vs 47.9%, OR 1.22, 95% CI 1.03-1.44) but no impact on BP control. CONCLUSIONS The strategy was well implemented with increased treatment rates among high risk individuals assessed by CHWs, however effects on BP were not demonstrated. Use of guideline-recommended BP thresholds for identifying high risk individuals substantially affected the reproducibility of risk assessment, and thus the ability to reliably evaluate the effectiveness of the intervention. In addition, unanticipated seasonal variation in BP in the context of a stepped-wedge trial highlights the inherent risks of this study design. TRIAL REGISTRATION Clinical Trials Registry of India CTRI/2013/06/ 003753.
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Affiliation(s)
- David Peiris
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Devarsetty Praveen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Hyderabad, India
| | | | | | - Arvind Raghu
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stephen MacMahon
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Public Health Foundation of India, Delhi, India
| | - Gari D. Clifford
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, United States of America
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Rohina Joshi
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, New Delhi, India
| | - Pallab K. Maulik
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
- The George Institute for Global Health, New Delhi, India
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lionel Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Silveira DV, Marcolino MS, Machado EL, Ferreira CG, Alkmim MBM, Resende ES, Carvalho BC, Antunes AP, Ribeiro ALP. Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil: Mixed-Methods Field Study on Usability, Feasibility, and Utility. JMIR Mhealth Uhealth 2019; 7:e9869. [PMID: 30907740 PMCID: PMC6452279 DOI: 10.2196/mhealth.9869] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 11/05/2018] [Accepted: 12/10/2018] [Indexed: 12/12/2022] Open
Abstract
Background Despite being an important cardiovascular risk factor, hypertension has low control levels worldwide. Computerized clinical decision support systems (CDSSs) might be effective in reducing blood pressure with a potential impact in reducing cardiovascular risk. Objective The goal of the research was to evaluate the feasibility, usability, and utility of a CDSS, TeleHAS (tele–hipertensão arterial sistêmica, or arterial hypertension system), in the care of patients with hypertension in the context of a primary care setting in a middle-income country. Methods The TeleHAS app consists of a platform integrating clinical and laboratory data on a particular patient, from which it performs cardiovascular risk calculation and provides evidence-based recommendations derived from Brazilian and international guidelines for the management of hypertension and cardiovascular risk. Ten family physicians from different primary care units in the city of Montes Claros, Brazil, were randomly selected to use the CDSS for the care of hypertensive patients for 6 months. After 3 and 6 months, the feasibility, usability, and utility of the CDSS in the routine care of the health team was evaluated through a standardized questionnaire and semistructured interviews. Results Throughout the study, clinicians registered 535 patients with hypertension, at an average of 1.24 consultations per patient. Women accounted for 80% (8/10) of participant doctors, median age was 31.5 years (interquartile range 27 to 59 years). As for feasibility, 100% of medical users claimed it was possible to use the app in the primary care setting, and for 80% (8/10) of them it was easy to incorporate its use into the daily routine and home visits. Nevertheless, 70% (7/10) of physicians claimed that the time taken to fill out the CDSS causes significant delays in service. Clinicians evaluated TeleHAS as good (8/10, 80% of users), with easy completion and friendly interface (10/10, 100%) and the potential to improve patients’ treatment (10/10, 100%). A total of 90% (9/10) of physicians had access to new knowledge about cardiovascular risk and hypertension through the app recommendations and found it useful to promote prevention and optimize treatment. Conclusions In this study, a CDSS developed to assist the management of patients with hypertension was feasible in the context of a primary health care setting in a middle-income country, with good user satisfaction and the potential to improve adherence to evidence-based practices.
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Affiliation(s)
- Daniel Vitório Silveira
- Telehealth Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
| | - Milena Soriano Marcolino
- Telehealth Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
| | - Elaine Leandro Machado
- Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Camila Gonçalves Ferreira
- Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Maria Beatriz Moreira Alkmim
- Telehealth Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
| | - Elmiro Santos Resende
- Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Medical School, Universidade Federal de Uberlândia, Uberlândia, Brazil
| | - Bárbara Couto Carvalho
- Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - André Pires Antunes
- Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Medical School, Universidade Estadual de Montes Claros, Montes Claros, Brazil
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48
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Scott K, George AS, Ved RR. Taking stock of 10 years of published research on the ASHA programme: examining India's national community health worker programme from a health systems perspective. Health Res Policy Syst 2019; 17:29. [PMID: 30909926 PMCID: PMC6434894 DOI: 10.1186/s12961-019-0427-0] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As India's accredited social health activist (ASHA) community health worker (CHW) programme enters its second decade, we take stock of the research undertaken and whether it examines the health systems interfaces required to sustain the programme at scale. METHODS We systematically searched three databases for articles on ASHAs published between 2005 and 2016. Articles that met the inclusion criteria underwent analysis using an inductive CHW-health systems interface framework. RESULTS A total of 122 academic articles were identified (56 quantitative, 29 mixed methods, 28 qualitative, and 9 commentary or synthesis); 44 articles reported on special interventions and 78 on the routine ASHA program. Findings on special interventions were overwhelmingly positive, with few negative or mixed results. In contrast, 55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints. Over half the articles had a health system perspective, including almost all those on general ASHA work, but only a third of those with a health condition focus. The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication. Research tended to be descriptive, with fewer influence, explanatory or exploratory articles, and no predictive or emancipatory studies. Indian institutions and authors led and partnered on most of the research, wrote all the critical commentaries, and published more studies with negative results. CONCLUSION Published work on ASHAs highlights a range of small-scale innovations, but also showcases the challenges faced by a programme at massive scale, situated in the broader health system. As the programme continues to evolve, critical comparative research that constructively feeds back into programme reforms is needed, particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight.
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Affiliation(s)
| | - Asha S. George
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, Cape Town, 7535 South Africa
| | - Rajani R. Ved
- National Health Systems Resource Centre, New Delhi, India
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Amoakoh HB, Klipstein-Grobusch K, Ansah EK, Grobbee DE, Yveoo L, Agyepong I. How and why front-line health workers (did not) use a multifaceted mHealth intervention to support maternal and neonatal healthcare decision-making in Ghana. BMJ Glob Health 2019; 4:e001153. [PMID: 30997162 PMCID: PMC6441261 DOI: 10.1136/bmjgh-2018-001153] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Hannah Brown Amoakoh
- School of Public Health, University of Ghana, Accra, Ghana.,Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center, 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
| | | | - Diederick E Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Linda Yveoo
- Ghana Health Service, Research and Development Division, Dodowa Research Centre, Accra, Ghana
| | - Irene Agyepong
- Ghana Health Service, Research and Development Division, Dodowa Research Centre, Accra, Ghana
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50
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Ved R, Scott K, Gupta G, Ummer O, Singh S, Srivastava A, George AS. How are gender inequalities facing India's one million ASHAs being addressed? Policy origins and adaptations for the world's largest all-female community health worker programme. HUMAN RESOURCES FOR HEALTH 2019; 17:3. [PMID: 30616656 PMCID: PMC6323796 DOI: 10.1186/s12960-018-0338-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/05/2018] [Indexed: 05/04/2023]
Abstract
BACKGROUND India's accredited social health activist (ASHA) programme consists of almost one million female community health workers (CHWs). Launched in 2005, there is now an ASHA in almost every village and across many urban centres who support health system linkages and provide basic health education and care. This paper examines how the programme is seeking to address gender inequalities facing ASHAs, from the programme's policy origins to recent adaptations. METHODS We reviewed all publically available government documents (n = 96) as well as published academic literature (n = 122) on the ASHA programme. We also drew from the embedded knowledge of this paper's government-affiliated co-authors, triangulated with key informant interviews (n = 12). Data were analysed thematically through a gender lens. RESULTS Given that the initial impetus for the ASHA programme was to address reproductive and child health issues, policymakers viewed volunteer female health workers embedded in communities as best positioned to engage with beneficiaries. From these instrumentalist origins, where the programme was designed to meet health system demands, policy evolved to consider how the health system could better support ASHAs. Policy reforms included an increase in the number and regularity of incentivized tasks, social security measures, and government scholarships for higher education. Residential trainings were initiated to build empowering knowledge and facilitate ASHA solidarity. ASHAs were designated as secretaries of their village health committees, encouraging them to move beyond an all-female sphere and increasing their role in accountability initiatives. Measures to address gender based violence were also recently recommended. Despite these well-intended reforms and the positive gains realized, ongoing tensions and challenges related to their gendered social and employment status remain, requiring continued policy attention and adaptation. CONCLUSIONS Gender trade offs and complexities are inherent to sustaining CHW programmes at scale within challenging contexts of patriarchal norms, health system hierarchies, federal governance structures, and evolving aspirations, capacities, and demands from female CHWs. Although still grappling with significant gender inequalities, policy adaptations have increased ASHAs' access to income, knowledge, career progression, community leadership, and safety. Nonetheless, these transformative gains do not mark linear progress, but rather continued adaptations.
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Affiliation(s)
- R. Ved
- National Health Systems Resource Centre, National Institute of Health & Family Welfare Campus, Baba Gangnath Marg, Munrika, New Delhi, Delhi 110067 India
| | - K. Scott
- Independent researcher, Bangalore, India
- Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, 21205 Maryland USA
| | - G. Gupta
- National Health Systems Resource Centre, National Institute of Health & Family Welfare Campus, Baba Gangnath Marg, Munrika, New Delhi, Delhi 110067 India
| | - O. Ummer
- National Health Systems Resource Centre, National Institute of Health & Family Welfare Campus, Baba Gangnath Marg, Munrika, New Delhi, Delhi 110067 India
| | - S. Singh
- National Health Systems Resource Centre, National Institute of Health & Family Welfare Campus, Baba Gangnath Marg, Munrika, New Delhi, Delhi 110067 India
| | - A. Srivastava
- National Health Systems Resource Centre, National Institute of Health & Family Welfare Campus, Baba Gangnath Marg, Munrika, New Delhi, Delhi 110067 India
| | - A. S. George
- School of Public Health, University of the Western Cape, Robert Sobukwe Rd, Bellville, Cape Town, 7535 South Africa
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