Using Mobile Health to Enhance Outcomes of Noncommunicable Diseases Care in Rural Settings and Refugee Camps: Randomized Controlled Trial

The Effectiveness of Telemedicine in Hypertension Management of Adults in Rural Communities: A Systematic Review and Meta-Analysis

BACKGROUND

Telemedicine has emerged as an effective approach for managing hypertension, particularly in rural areas where healthcare access is limited. This review evaluates telemedicine's role in providing essential remote healthcare services for hypertension management.

OBJECTIVE

We determined the effectiveness of telemedicine versus the usual care in hypertension management among adults living in rural settings.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs) focusing on adults aged 18 and older with hypertension (blood pressure ≥ 140/90 mmHg) using telehealth services in rural or community-based settings. We searched nine databases, including PubMed, ScienceDirect, and ProQuest, up to April 2024, without restrictions on language or publication year, focusing only on human subjects. Five pairs of reviewers independently screened and selected studies using predefined eligibility criteria. Methodological quality was assessed using the Revised Cochrane Collaboration Risk of Bias tool, and data synthesis was performed using a random-effects model due to study heterogeneity. Evidence quality was evaluated using the GRADE approach.

RESULTS

Nine randomized trials were included. Pooled data showed no clinically significant differences between telehealth and control groups in improving systolic blood pressure (SBP), diastolic blood pressure (DBP), and their changes over time. The mean difference (MD) of SBP in five trials was 0.78 mmHg lower (95% CI: 2.49 lower to 0.94 higher), and the SBP change showed a mean reduction of 2.29 mmHg (95% CI: 4.76 lower to 0.19 higher). DBP in five trials had a mean increase of 0.46 mmHg (95% CI: 0.73 lower to 1.64 higher), and DBP change in six trials showed a mean decrease of 0.83 mmHg (95% CI: 2.34 lower to 0.68 higher). Additionally, telehealth showed varying impacts on BMI and HbA1c levels, with one study reporting a higher BMI increase in the intervention group, while two other studies indicated that mobile health improved HbA1c levels and controlled blood pressure as effectively as standard care.

LIMITATIONS

Study heterogeneity, selection, and performance biases, as well as varying healthcare contexts, limited the generalizability of findings.

CONCLUSION

Telemedicine is as effective as usual care in managing hypertension among adults in rural settings, providing a viable solution for improving healthcare access in these areas. Future research should address biases and explore long-term impacts to optimize telemedicine's effectiveness in diverse populations.

Barriers and facilitators to primary healthcare utilization among immigrants and refugees of low and middle-income countries: a scoping review

INTRODUCTION

Primary health care (PHC) is the most common model for providing primary care, and PHC services are the most common points of care that immigrants and refugees attend as a first step. Most immigrants travel to low- and middle-income countries (LMICs), yet only a few studies have examined their health conditions and their access to PHC in these countries. We have attempted to identify the barriers and facilitators that immigrants and refugees encounter when using PHC in these countries.

METHODS

We searched PubMed, Scopus, Web of Science, Embase, ProQuest, Google Scholar, Microsoft Academic, and OpenGrey in this scoping review from its inception to the end of October 2023. Moreover, we manually searched key journals, reference lists, and citations from included studies to identify any missed studies. We extracted data from each selected study using a predefined form. Finally, a thematic analysis approach was utilized to synthesize the collected data from the included qualitative studies.

RESULTS

17 qualitative studies were included in this review, which were from Iran (n = 3), Brazil (n = 3), Kenya (n = 2), Jordan (n = 2), Eastern Sudan (n = 1), Lebanon (n = 1), Bangladesh (n = 1), India (n = 1), Turkey (n = 1), Thailand (n = 1), and Malaysia (n = 1). Among the most common and important reported barriers are language differences, insufficiency of trained carers, unemployment, inability to pay the costs of hospital and medicines, no insurance coverage for immigrants, no clear referral and care system for immigrants, discrimination against women, and improper residence locations. Insurance coverage, awareness programs, and the study of immigrants' needs, along with their social and financial support from family, are among the most essential facilitators.

CONCLUSION

For LMICs, funding is always a limitation, and increasing PHC utilization is the best choice for improving health. Knowing the challenges and facilitators of PHC utilization from the point of view of each stakeholder is a promising way to decide and make policies that can improve the health of both immigrants and refugees, as well as society as a whole.

Effects of an instructional WhatsApp group on self-care and HbA1c among female patients with Type 2 diabetes mellitus

AIMS AND OBJECTIVES

To assess the effect of an instructional WhatsApp group on self-care and HbA1c levels among female patients with type 2 diabetes mellitus (T2DM).

BACKGROUND

T2DM is a chronic disease that requires effective self-care. WhatsApp is a free application that can be effectively used for patient education.

DESIGN

This study used a quasi-experimental design.

METHODS

A convenience sample of 62 female participants was recruited from the medical outpatient clinic of a tertiary hospital. The Diabetes Self-Care Scale was used to assess the self-care profiles of the participants pre- and post-intervention. HbA1c samples were also collected at baseline and three months after receiving instructions from the WhatsApp group. Sociodemographic and clinical data were collected during the pre-intervention stage.

RESULTS

The mean HbA1c level decreased from 8.61 ± 1.70 to 7.92 ± 1.60 after implementing the WhatsApp group instructions; the values showed a significant difference (t-value = 5.107 and P-value < 0.001). The post-test mean score of total self-care was higher than the pre-test mean score (t-value = 12.359, P-value <0.001), indicating a highly significant difference.

CONCLUSIONS

The study demonstrated that the instructional WhatsApp group is an effective method for improving self-care and HbA1c levels in patients with T2DM. This study suggests the use of WhatsApp group instructions as a teaching method in the healthcare system for the education and follow-up of patients with T2DM.

RELEVANCE TO CLINICAL PRACTICE

The findings support the need to initiate effective and dynamic interventional follow-ups through WhatsApp groups for patients with T2DM to improve their self-care and HbA1c levels and ultimately reduce the burden on hospitals and governments.

A retrospective analysis of e-prescriptions for non-communicable diseases on a telehealth platform in Malaysia

BACKGROUND

The management of non-communicable diseases (NCDs) has benefited from telehealth services. As these services which include teleconsultation services and e-prescriptions are relatively new in Malaysia, the data generated provide an unprecedented opportunity to study medication use patterns for the management of NCDs in the country. We analyze e-prescriptions from a local telehealth service to identify medication use patterns and potential areas to optimize medication use in relation to clinical practice guidelines.

METHODS

A cross sectional observational study was conducted by retrieving e-prescription records retrospectively from a telehealth service. 739,482 records from January 2019 to December 2021 were extracted using a designated data collection form. Data cleaning, standardization and data analysis were performed using Python version 3.11. The diagnoses were classified according to the International Classification of Disease 10 (ICD-10), while medications were classified using the Anatomical Therapeutic Chemical (ATC) system. Diagnoses, frequency of use for medication classes and individual medications were analyzed and compared to clinical practice guidelines.

RESULTS

The top five NCD diagnoses utilized by the service were hypertension (37.7%), diabetes mellitus (25.1%), ischemic heart disease (24.3%), asthma (14.4%), and dyslipidemia (11.7%). Medications were prescribed mostly in accordance with guideline recommendations. However, angiotensin receptor blockers (ARBs) were significantly more frequently prescribed compared to angiotensin converting enzyme inhibitors (ACEIs). Several medication classes appeared underutilized, including ACEIs in hypertensive patients with diabetes or ischemic heart disease, sodium glucose cotransporter 2 inhibitors in diabetic patients with ischemic heart disease, and metformin in patients with diabetes.

CONCLUSIONS

Telehealth services are currently being utilized for the management of NCDs. Medication use for the management of NCDs through these services are mostly in accordance with guideline recommendations, but there exist areas that would warrant further investigation to ensure optimal clinical and economic outcomes are achieved.

Interventions to improve primary healthcare in rural settings: A scoping review

BACKGROUND

Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations.

OBJECTIVE

Synthesize and categorize studies that examine interventions to improve rural primary care.

ELIGIBILITY CRITERIA

Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison.

SOURCES OF EVIDENCE

Pubmed, CINAHL, Cochrane Library, Embase.

CHARTING METHODS

We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant.

RESULTS

372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017.

CONCLUSIONS

Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Revolutionizing elderly care: Building a healthier aging society through innovative long-term care systems and assessing the long-term care acceptance model

AIM

With a growing elderly population, the demand for caregivers is increasing in Khon Kaen, Thailand, with approximately 17 000 elderly residents. This growing number of older people and a shortage of caregivers could overload the healthcare system.

METHODS

The present study involved 129 healthcare volunteers (caregivers for questionnaires study) and the collection of health data from 290 elderly residents from northeastern Thailand. After training, the volunteers assessed its usefulness through questionnaires. Tool reliability and statistical hypotheses were tested using stratified regression analysis (hierarchical regression) and multiple regression.

RESULTS

The relative mean scores of perceived usefulness, perceived ease of use, attitude toward usage and behavioral intention to use technology were 4.51, 4.29, 4.44 and 4.41, respectively. In addition, perceived usefulness and user attitudes positively affected volunteers' willingness to use the system.

CONCLUSION

The study was developed from the awareness of enhancing community quality and ecosystem through a long-term care system application. Analyzing external factors can enhance technology's future effectiveness. Geriatr Gerontol Int 2024; 24: 477-485.

A scoping review on the barriers to and facilitators of health services utilisation related to refugee settlement in regional or rural areas of the host country

BACKGROUND

Healthcare access and equity are human rights. Worldwide conflicts, violence, and persecution have increased the number of people from refugee or refugee-like backgrounds. Because urban areas are already densely populated, governments have aimed to increase refugee resettlement in rural and/or regional areas. Because of the complex healthcare needs of refugees, this creates challenges for healthcare service providers. Identifying barriers to accessing healthcare in rural areas is therefore important to better inform policy settings and programmes that will provide culturally appropriate patient-centred care to the refugee community.

METHODS

This review scoped 22 papers written in English between 2018 and July 2023 from five countries (Australia, New Zealand, Germany, Bangladesh, and Lebanon) in order to provide an overview of the barriers and possible solutions to facilitate refugees' access to healthcare.

RESULTS

The reviewed literature summarised the perceptions of at least 3,561 different refugees and 259 rural health service providers and/or administrators and identified major challenges. These include communication (illiteracy in the resettlement country language and lack of a suitable interpreter), lack of cultural awareness of health services, discrimination, and access difficulties (transportation, availability of health specialist services, cost). As a consequence, it was identified that improving access to affordable housing, employment through credential recognition, competence-level education for children, facilitating language training, and adapting health information would increase resettlement and encourage access to healthcare.

CONCLUSIONS

Refugees face significant barriers to accessing and engaging with healthcare services. This impacts their integration into rural communities and increases the prevalence of psychosocial issues like feelings of loneliness, low self-esteem, a lack of autonomy, and a lack of empowerment over informed decision-making, especially for women, jobless men, and the elderly. These findings support the need for additional support for refugees and healthcare providers to improve language proficiency and cultural competency. Policymakers need to improve the availability and accessibility of employment, housing accessibility, and service mobility. Additionally, more research is needed to assess the efficacy of emerging innovative programmes that aim to close the gap by delivering culturally appropriate patient-centred care to refugee communities in rural areas.

Community Health Recommendations Driven by mHealth Population Surveillance Data Amongst Burmese Displaced People in Eastern India: A Pilot Usability Assessment of a Mobile Health Application for Data Collection

With recent increases in armed conflict and forced migration, refugee health has become a growing priority amongst those who work in global health. Refugees and forced migrants, also known as displaced persons, face barriers to accessing health services and are often at an increased risk for adverse health outcomes, such as sexual violence, infectious diseases, poor maternal outcomes, and mental health concerns. Mobile health (mHealth) applications have been shown to increase access and improve health outcomes among refugee populations. Our study aims to evaluate the feasibility of using a novel mHealth application to conduct population health surveillance data collection amongst a population of Myanmar citizens who have been forced to relocate to eastern India. The data collected in a low-resource setting through the mHealth application will be used to identify priority areas for intervention which will assist in the development of a tailored intervention plan that best suits our population.

Access to healthcare services for people with non-communicable diseases during the COVID-19 pandemic in Ibadan, Nigeria: a qualitative study

BACKGROUND

Desirable outcomes for people with non-communicable diseases (NCDs) are achieved when they access routine monitoring and care services. Expectedly, the COVID-19 pandemic severely impacted access to healthcare services, leading to poor health outcomes among people with NCDs. We aimed to [1] explore the delays in accessing healthcare services and [2] understand alternative actions adopted by people with NCDs to overcome these delays.

METHODS

We conducted an exploratory qualitative research guided by the "Three Delays" model to unpack the barriers to healthcare access for people living with NCDs in Ibadan, Nigeria. The "Three Delays" model conceptualizes the reasons for negative/adverse healthcare outcomes related to the patient's decision-making to seek healthcare, reaching an appropriate healthcare facility, and receiving adequate care at the healthcare facility. Twenty-five (25) people with NCDs were purposively selected from the University College Hospital's medical outpatient department to participate in in-depth interviews. Interview recordings were transcribed verbatim and analyzed using a deductive-inductive hybrid thematic analysis.

RESULTS

At the level of individual decision-making, delays were related to fear of contracting COVID-19 in the hospital (considered a hotspot of the COVID-19 pandemic). Regarding reaching an appropriate healthcare facility, delays were mainly attributed to the intra- and inter-city lockdowns, limiting the movements of persons. For those who successfully arrived at the healthcare facilities, delays were related to the unavailability of healthcare professionals, prioritization of COVID-19 patients, and mandatory adherence to COVID-19 protocols, including COVID-19 testing. To overcome the delays mentioned above, people with NCDs resorted to (i) using private healthcare facilities, which were more costly, (ii) using virtual consultation through mobile phone Apps and (iii) self-management, usually by repeating previously prescribed prescriptions to obtain medication.

CONCLUSION

Pandemic conditions provide unique challenges to people with chronic illnesses. Recognizing the need for continuous access to monitoring and care services under such conditions remains critical. Alternative health service provision approaches should be considered in pandemic situations, including remote healthcare services such as Mobile health apps (mHealth) that can help manage and prevent NCDs.

Adoption of Electronic Medical Records for Chronic Disease Care in Kenyan Refugee Camps: Quantitative and Qualitative Prospective Evaluation

Background

Noncommunicable disease (NCD) prevention and control in humanitarian emergencies is a well-recognized need, but there is little evidence to guide responses, leading to varying care delivery. The Sana.NCD mobile health (mHealth) app, initially developed in Lebanon, is the only known mHealth tool for NCD management designed to increase care quality and coverage for providers in humanitarian settings.

Objective

We evaluated a specialized mHealth app consisting of an abbreviated medical record for patients with hypertension or diabetes, adapted for a Kenyan refugee camp setting.

Methods

We tested an adapted version of the Sana.NCD app (diabetes and hypertension medical record) in an 11-month (May 2021 to March 2022) quantitative and qualitative prospective evaluation in Kenya's Hagadera refugee camp. Leveraging the rollout of a general electronic medical record (EMR) system in the Kakuma refugee camp, we compared a specialized NCD management app to a general EMR. We analyzed secondary data collected from the Sana.NCD app for 1539 patients, EMR data for 68 patients with NCD from Kakuma's surgical and outpatient departments, and key informant interviews that focused on Hagadera clinic staff perceptions of the Sana.NCD app.

Results

The Hagadera NCD clinic reported 18,801 consultations, 42.1% (n=7918) of which were reported in the NCD app. The Kakuma EMR reported 350,776 visits, of which 9385 (2.7%) were for NCDs (n=4264, 1.2% hypertension; n=2415, 0.7% diabetes). The completeness of reporting was used as a quality-of-care metric. Age, sex, prescribed medicines, random blood sugar, and smoking status were consistently reported in both the NCD app (>98%) and EMR (100%), whereas comorbidities, complications, hemoglobin A1c, and diet were rarely reported in either platform (≤7% NCD app; 0% EMR). The number of visits, BMI, physical activity, and next visit were frequently reported in the NCD app (≥99%) but not in the EMR (≤15%). In the NCD app, the completeness of reporting was high across the implementation period, with little meaningful change. Although not significantly changed during the study, elevated blood sugar (P=.82) and blood pressure (P=.12) were reported for sizable proportions of patients in the first (302/481, 62.8%, and 599/1094, 54.8%, respectively) and last (374/602, 62.1%, and 720/1395, 51.6%, respectively) study quarters. Providers were satisfied with the app, as it standardized patient information and made consultations easier. Providers also indicated that access to historic patient information was easier, benefiting NCD control and follow-up.

Conclusions

A specialized record for NCDs outperformed a more general record intended for use in all patients in terms of reporting completeness. This CommCare-based NCD app can easily be rolled out in similar humanitarian settings with minimal adaptation. However, the adaptation of technologies to the local context and use case is critical for uptake and ensuring that workflows and time burden do not outweigh the benefits of EMRs.

Artificial intelligence and digital health in improving primary health care service delivery in LMICs: A systematic review

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.

Effect of a Wearable Device-Based Physical Activity Intervention in North Korean Refugees: Pilot Randomized Controlled Trial

BACKGROUND

Effective health interventions for North Korean refugees vulnerable to metabolic disorders are currently unelucidated.

OBJECTIVE

This study aimed to evaluate the effects of digital health interventions in North Korean refugees using a wearable activity tracker (Fitbit device).

METHODS

We conducted a prospective, randomized, open-label study on North Korean refugees aged 19-59 years between June 2020 and October 2021 with a 12-week follow-up period. The participants were randomly assigned to either an intervention group or a control group in a 1:1 ratio. The intervention group received individualized health counseling based on Fitbit data every 4 weeks, whereas the control group wore the Fitbit device but did not receive individualized counseling. The primary and secondary outcomes were the change in the mean daily step count and changes in the metabolic parameters, respectively.

RESULTS

The trial was completed by 52 North Korean refugees, of whom 27 and 25 were in the intervention and control groups, respectively. The mean age was 43 (SD 10) years, and 41 (78.8%) participants were women. Most participants (44/52, 95.7%) had a low socioeconomic status. After the intervention, the daily step count in the intervention group increased, whereas that in the control group decreased. However, there were no significant differences between the 2 groups (+83 and -521 steps in the intervention and control groups, respectively; P=.500). The effects of the intervention were more prominent in the participants with a lower-than-average daily step count at baseline (<11,667 steps/day). After the 12-week study period, 85.7% (12/14) and 46.7% (7/15) of the participants in the intervention and control groups, respectively, had an increased daily step count (P=.05). The intervention prevented the worsening of the metabolic parameters, including BMI, waist circumference, fasting blood glucose level, and glycated hemoglobin level, during the study period.

CONCLUSIONS

The wearable device-based physical activity intervention did not significantly increase the average daily step count in the North Korean refugees in this study. However, the intervention was effective among the North Korean refugees with a lower-than-average daily step count; therefore, a large-scale, long-term study of this intervention type in an underserved population is warranted.

TRIAL REGISTRATION

Clinical Research Information Service KCT0007999; https://cris.nih.go.kr/cris/search/detailSearch.do/23622.

The Effectiveness of Enhanced Primary Healthcare (EnPHC) interventions on Type 2 diabetes management in Malaysia: Difference-in-differences (DID) analysis

AIMS

To evaluate the effectiveness of the Enhanced Primary Healthcare (EnPHC) interventions on process of care and intermediate clinical outcomes among type 2 diabetes patients.

METHODS

This was a quasi-experimental controlled study conducted in 20 intervention and 20 control public primary care clinics in Malaysia from November 2016 to June 2019. Type 2 diabetes patients aged 30 years and above were selected via systematic random sampling. Outcomes include process of care and intermediate clinical outcomes. Difference-in-differences analyses was conducted.

RESULTS

We reviewed 12,017 medical records of patients with type 2 diabetes. Seven process of care measures improved: HbA1c tests (odds ratio (OR) 3.31, 95% CI 2.13, 5.13); lipid test (OR 4.59, 95% CI 2.64, 7.97), LDL (OR 4.33, 95% CI 2.16, 8.70), and urine albumin (OR 1.99, 95% CI 1.12, 3.55) tests; BMI measured (OR 15.80, 95% CI 4.78, 52.24); cardiovascular risk assessment (OR 174.65, 95% CI 16.84, 1810.80); and exercise counselling (OR 1.18, 95% CI 1.04, 1.33). We found no statistically significant changes in intermediate clinical outcomes (i.e. HbA1c, LDL, HDL and BP control).

CONCLUSIONS

EnPHC interventions was successful in enhancing the quality of care, in terms of process of care, by changing healthcare providers behaviour.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

Digital health in fragile states in the Middle East and North Africa (MENA) region: A scoping review of the literature

INTRODUCTION

Conflict, fragility and political violence, that are taking place in many countries in the Middle East and North Africa (MENA) region have devastating effects on health. Digital health technologies can contribute to enhancing the quality, accessibility and availability of health care services in fragile and conflict-affected states of the MENA region. To inform future research, investments and policy processes, this scoping review aims to map out the evidence on digital health in fragile states in the MENA region.

METHOD

We conducted a scoping review following the Joanna Briggs Institute (JBI) guidelines. We conducted descriptive analysis of the general characteristics of the included papers and thematic analysis of the key findings of included studies categorized by targeted primary users of different digital health intervention.

RESULTS

Out of the 10,724 articles identified, we included 93 studies. The included studies mainly focused on digital health interventions targeting healthcare providers, clients and data services, while few studies focused on health systems or organizations managers. Most of the included studies were observational studies (49%). We identified no systematic reviews. Most of the studies were conducted in Lebanon (32%) followed by Afghanistan (13%) and Palestine (12%). The first authors were mainly affiliated with institutions from countries outside the MENA region (57%), mainly United Kingdom and United States. Digital health interventions provided a platform for training, supervision, and consultation for health care providers, continuing education for medical students, and disease self-management. The review also highlighted some implementation considerations for the adoption of digital health such as computer literacy, weak technological infrastructure, and privacy concerns.

CONCLUSION

This review showed that digital health technologies can provide promising solutions in addressing health needs in fragile and conflict-affected states. However, rigorous evaluation of digital technologies in fragile settings and humanitarian crises are needed to inform their design and deployment.

Do health education initiatives assist socioeconomically disadvantaged populations? A systematic review and meta-analyses

BACKGROUND

Health education interventions are considered critical for the prevention and management of conditions of public health concern. Although the burden of these conditions is often greatest in socio-economically disadvantaged populations, the effectiveness of interventions that target these groups is unknown. We aimed to identify and synthesize evidence of the effectiveness of health-related educational interventions in adult disadvantaged populations.

METHODS

We pre-registered the study on Open Science Framework https://osf.io/ek5yg/ . We searched Medline, Embase, Emcare, and the Cochrane Register from inception to 5/04/2022 to identify studies evaluating the effectiveness of health-related educational interventions delivered to adults in socio-economically disadvantaged populations. Our primary outcome was health related behaviour and our secondary outcome was a relevant biomarker. Two reviewers screened studies, extracted data and evaluated risk of bias. Our synthesis strategy involved random-effects meta-analyses and vote-counting.

RESULTS

We identified 8618 unique records, 96 met our criteria for inclusion - involving more than 57,000 participants from 22 countries. All studies had high or unclear risk of bias. For our primary outcome of behaviour, meta-analyses found a standardised mean effect of education on physical activity of 0.05 (95% confidence interval (CI) = -0.09-0.19), (5 studies, n = 1330) and on cancer screening of 0.29 (95% CI = 0.05-0.52), (5 studies, n = 2388). Considerable statistical heterogeneity was present. Sixty-seven of 81 studies with behavioural outcomes had point estimates favouring the intervention (83% (95% CI = 73%-90%), p < 0.001); 21 of 28 studies with biomarker outcomes showed benefit (75% (95%CI = 56%-88%), p = 0.002). When effectiveness was determined based on conclusions in the included studies, 47% of interventions were effective on behavioural outcomes, and 27% on biomarkers.

CONCLUSIONS

Evidence does not demonstrate consistent, positive impacts of educational interventions on health behaviours or biomarkers in socio-economically disadvantaged populations. Continued investment in targeted approaches, coinciding with development of greater understanding of factors determining successful implementation and evaluation, are important to reduce inequalities in health.

Applications of Medical Digital Technologies for Noncommunicable Diseases for Follow-Up during the COVID-19 Pandemic

BACKGROUND

Noncommunicable chronic diseases (NCDs) are multifaceted, and the health implications of the COVID-19 pandemic are far-reaching, especially for NCDs. Physical distancing and quarantine can lead to the poor management of NCDs because the visual tracking of them has been replaced with medical digital technology, that is, smartphone apps. This study aimed to explore medical digital technology applications for NCDs for follow-up during the COVID-19 pandemic.

METHODS

The participants in this study were 400 adult patients with NCDs; they were selected by systematic random sampling. A descriptive cross-sectional design was used. The study was conducted in the outpatient department of Yanbu General Hospital and primary-care health centers in Yanbu Al-Baher, Al-Madinah Al-Munawwarah, in the Kingdom of Saudi Arabia. The tools used in this study were a structured questionnaire to collect the sociodemographic characteristics of the patients and their health history, an NCD questionnaire to assess follow-up of the patients during the COVID-19 pandemic, and a medical digital technologies questionnaire to explore the medical digital technology applications.

RESULTS

The mean age of the patients was 47.32 ± 14.362 years, and 62.8% of them were female and 372 were male. Of the patients, 69.2% and 57.5% had been diagnosed with diabetes mellitus and hypertension, respectively; 52.4% were followed up monthly, and 29.75% used medical digital technology applications such as Tabeby Online to monitor their health. Furthermore, 71.75% and 75.5% of the patients used the Sehhaty and Tawakkalna medical digital applications, respectively. Overall, 38.7% of the patients were satisfied with using medical digital technology applications used for follow-up during the COVID-19 pandemic.

CONCLUSIONS

The study concluded that the services that use networks, smartphones, and medical digital technology applications on the Saudi Ministry of Health website and mobile applications to improve the quality of the health-care system, and that provide health services for noncommunicable or communicable diseases, are not effective. This is because the patients lack awareness of these services, with most of the chronic patients being elderly with lower levels of education and computer literacy.

Mobile Health Interventions and RCTs: Structured Taxonomy and Research Framework

Mobile Health Interventions (MHIs) have addressed a range of healthcare challenges and have been evaluated using Randomized Controlled Trials (RCTs) to establish clinical effectiveness. Using PRISMA we conducted a systematic literature review of RCTs for MHIs and identified 70 studies which were analyzed and classified using Nickerson-Varshney-Muntermann (NVM) taxonomy. From the resultant iterations of the taxonomy, we extracted insights from the categorized studies. RCTs cover a wide range of health conditions including chronic diseases, general wellness, unhealthy practices, family planning, end-of-life, and post-transplant care. The MHIs that were utilized by the RCTs were varied as well, although most studies did not find significant differences between MHIs and usual care. The challenges for MHI-based RCTs include the use of technologies, delayed outcomes, patient recruitment, patient retention, and complex regulatory requirements. These variances can lead to a higher rate of Type I/Type II errors. Further considerations are the impact of infrastructure, contextual and cultural factors, and reductions in the technological relevancy of the intervention itself. Finally, due to the delayed effect of most outcomes, RCTs of insufficient duration are unable to measure significant, lasting improvements. Using the insights from seventy identified studies, we developed a classification of existing RCTs along with guidelines for MHI-based RCTs and a research framework for future RCTs. The framework offers opportunities for (a) personalization of MHIs, (b) use of richer technologies, and (c) emerging areas for RCTs.

Systematic review of electronic health records to manage chronic conditions among displaced populations

OBJECTIVES

The objective of this study was to assess the impact of electronic health records (EHRs) on health outcomes and care of displaced people with chronic health conditions and determine barriers and facilitators to EHR implementation in displaced populations.

DESIGN

A systematic review protocol was developed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Systematic Reviews.

DATA SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, Health Technology Assessment, Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was searched from inception to 12 April 2021.

ELIGIBILITY CRITERIA FOR SELECTED STUDIES

Inclusion criteria were original research articles, case reports and descriptions of EHR implementation in populations of displaced people, refugees or asylum seekers with related chronic diseases. Grey literature, reviews and research articles unrelated to chronic diseases or the care of refugees or asylum populations were excluded. Studies were assessed for risk of bias using a modified Cochrane, Newcastle-Ottawa and Joanna Briggs Institute tools.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data from each study using Covidence. Due to heterogeneity across study design and specific outcomes, a meta-analysis was not possible. An inductive thematic analysis was conducted using NVivo V.12 (QSR International, Melbourne, Australia). An inductive analysis was used in order to uncover patterns and themes in the experiences, general outcomes and perceptions of EHR implementation.

RESULTS

A total of 32 studies across nine countries were included: 14 in refugee camps/settlements and 18 in asylum countries. Our analysis suggested that EHRs improve health outcomes for chronic diseases by increasing provider adherence to guidelines or treatment algorithms, monitoring of disease indicators, patient counselling and patient adherence. In asylum countries, EHRs resource allocation to direct clinical care and public health services, as well as screening efforts. EHR implementation was facilitated by their adaptability and ability to integrate into management systems. However, barriers to EHR development, deployment and data analysis were identified in refugee settings.

CONCLUSION

Our results suggest that well-designed and integrated EHRs can be a powerful tool to improve healthcare systems and chronic disease outcomes in refugee settings. However, attention should be paid to the common barriers and facilitating actions that we have identified such as utilising a user-centred design. By implementing adaptable EHR solutions, health systems can be strengthened, providers better supported and the health of refugees improved.

Telemedicine use in current urologic oncology clinical practice

INTRODUCTION

In the last fifteen years, there have been important technological advances in telehealth systems and urology, along with other specialties, has been a pioneer in the successful use of this medical care modality. Due to the COVID-19 pandemic, the use of telemedicine has been rapidly embraced by the urology community around the world. A review of the most relevant and updated articles on telemedicine and telehealth in urology has been carried out with the aim of better understanding how it has been implemented to date, as well as reviewing concepts, current regulations, health policies and recommendations for its implementation.

METHODS

A narrative review of the current literature published up to April 2022 on the use of telemedicine in urology was performed. From the search results, 42 publications were obtained for analysis.

RESULTS

Telemedicine in urology has been shown to be useful in a variety of clinical scenarios within urological practice, from benign diseases to advanced cancers. This is due to the positive impact on medical consultation times, lower patient mobility costs, less work absenteeism and greater protection for both the patient and the doctor. The main limitations for the use of telemedicine lie in the impossibility of a correct physical examination, which is essential in certain situations, as well as the lack of accessibility to technology in disadvantaged populations and in elderly patients who have not adapted to the use of technology, as well as the lack of development of health policies to establish their implementation in some countries.

CONCLUSION

Telemedicine is in full growth. There is much information in the current literature on the successful adoption of telemedicine for patients suffering from urological diseases. While the use and implementation of these new practices has been rapid in the urology community, more work is needed to bring more accessible specialty care to underserved and underdeveloped areas. Health policies must promote its development to reduce costs and increase access.

A systematic review of effective strategies for chronic disease management in humanitarian settings; opportunities and challenges

Large number of people with non-communicable diseases (NCDs) face barriers to adequate healthcare in humanitarian settings. We conducted a systematic literature review in MEDLINE/PubMed, Web of Science, EMBASE/DARE, Cochrane, and grey literature from 1990 to 2021 to evaluate effective strategies in addressing NCDs (diabetes, cardiovascular diseases, COPD, cancer) in humanitarian settings. From 2793 articles, 2652 were eliminated through title/abstract screening; 141 articles were reviewed in full; 93 were eliminated for not meeting full criteria. Remaining 48 articles were reviewed qualitatively to assess populations, settings, interventions, outcome, and efficacy and effectiveness; 38 studies addressed treatments, 9 prevention, and 7 epidemiology. Prevention studies broadly addressed capacity-building. Treatment and epidemiology studies largely addressed hypertension and diabetes. Interventions included web-based/mobile health strategies, pharmacy-level interventions, portable imaging, and capacity building including physical clinics, staff training, forging collaborations, guideline development, point-of-care labs, health promotion activities, EMR, and monitoring interventions. Collaboration between academia and implementing agencies was limited. Models of care were largely not well-described and varied between studies due to contextual constraints. Barriers to interventions included financial, logistical, organizational, sociocultural, and security. Cancer care is significantly understudied. Simplified care models adapted to contexts and program evaluations of implemented strategies could address gaps in applied research. Inherent challenges in humanitarian settings pose unavoidable perils to evidence generation which requires a shift in research mindset to match aspirations with practicality, research collaborations at the inception of projects, reworking of desired conventional level of research evidence considering resource-intense constraints (HR, time, cost), and adapted research tools, methods, and procedures.

Accuracy and Validity of a Single Inertial Measurement Unit-Based System to Determine Upper Limb Kinematics for Medically Underserved Populations

Stroke is one of the leading causes of death and disability worldwide, with a disproportionate burden represented by low- and middle-income countries (LMICs). To improve post-stroke outcomes in LMICs, researchers have sought to leverage emerging technologies that overcome traditional barriers associated with stroke management. One such technology, inertial measurement units (IMUs), exhibit great potential as a low-cost, portable means to evaluate and monitor patient progress during decentralized rehabilitation protocols. As such, the aim of the present study was to determine the ability of a low-cost single IMU sensor-based wearable system (named the T’ena sensor) to reliably and accurately assess movement quality and efficiency in physically and neurologically healthy adults. Upper limb movement kinematics measured by the T’ena sensor were compared to the gold standard reference system during three functional tasks, and root mean square errors, Pearson’s correlation coefficients, intraclass correlation coefficients, and the Bland Altman method were used to compare kinematic variables of interest between the two systems for absolute accuracy and equivalency. The T’ena sensor and the gold standard reference system were significantly correlated for all tasks and measures (r range = 0.648—0.947), although less so for the Finger to Nose task (r range = 0.648—0.894). Results demonstrate that single IMU systems are a valid, reliable, and objective method by which to measure movement kinematics during functional tasks. Context-appropriate enabling technologies specifically designed to address barriers to quality health services in LMICs can accelerate progress towards the United Nations Sustainable Development Goal 3.

Vulnerabilities of Arab refugees in primary health care: a scoping review

OBJECTIVE

To map and analyze the vulnerabilities of Arab refugees in the context of primary health care.

METHOD

Scoping review in which studies published in English, Spanish and Portuguese languages from 2011 onwards were reviewed. The following databases were surveyed: Cochrane, Scopus, Health System Evidence, MedLine-PubMed, CINAHL, Embase, Lilacs, Web of Science, SciELO, NYAM Grey Literature, BVS, Capes Thesis and Dissertation Database, Refworld and Journal of Refugee Studies. Data were analyzed in light of the concept of vulnerability.

RESULTS

Of the 854 studies identified, 40 articles were held for analysis and extraction of vulnerability indicators in the individual, social and programmatic dimensions. Regarding the individual dimension, the main indicators identified were unemployment, unstable and overcrowded housing, lack of sanitation and access to water, mental disorders, communicable and chronic noncommunicable diseases, etc. In the programmatic dimension, were identified, mainly, health teams with work overload, lack of preparation to deal with cultural and linguistic barriers, and delays in providing care. In relation to the social dimension, lack of access to schools, to information about health programs in the host countries, and to rights, among others, were found.

CONCLUSION

Vulnerabilities found highlight the disadvantage of refugees regarding health programs, services and system in host countries, in addition to highlighting the deep inequalities that affect this group. It is pointed out the need for programs and policies that promote actions, within the scope of primary health care, which recognize and respond to the health needs of refugees.

Supporting Management of Noncommunicable Diseases With Mobile Health (mHealth) Apps: Experimental Study

BACKGROUND

Noncommunicable diseases (NCDs) are the leading global health problem in this century and are the principal causes of death and health care spending worldwide. Mobile health (mHealth) apps can help manage and prevent NCDs if people are willing to use them as supportive tools. Still, many people are reluctant to adopt these technologies. Implementing new apps could result in earlier intervention for many health conditions, preventing more serious complications.

OBJECTIVE

This research project aimed to test the factors that facilitate the adoption of mHealth apps by users with NCDs. We focused on determining, first, what user interface (UI) qualities and complexity levels appeal to users in evaluating mHealth apps. We also wanted to determine whether people prefer that the data collected by an mHealth app be analyzed using a physician or an artificial intelligence (AI) algorithm. The contribution of this work is both theoretical and practical. We examined users' considerations when adopting mHealth apps that promote healthy lifestyles and helped them manage their NCDs. Our results can also help direct mHealth app UI designers to focus on the most appealing aspects of our findings.

METHODS

A total of 347 respondents volunteered to rate 3 models of mHealth apps based on 16 items that measured instrumentality, aesthetics, and symbolism. Respondents rated each model after reading 1 of 2 different scenarios. In one scenario, a physician analyzed the data, whereas, in the other, the data were analyzed by an AI algorithm. These scenarios tested the degree of trust people placed in AI algorithms versus the "human touch" of a human physician regarding analyzing data collected by an mHealth app.

RESULTS

As shown by the responses, the involvement of a human physician in the application had a significant effect (P<.001) on the perceived instrumentality of the simple model. The complex model with more controls was rated significantly more aesthetic when associated with a physician performing data analysis rather than an AI algorithm (P=.03).

CONCLUSIONS

Generally, when participants found a human touch in the mHealth app (connection to a human physician who they assumed would analyze their data), they judged the app more favorably. Simple models were evaluated more positively than complex ones, and aesthetics and symbolism were salient predictors of preference. These trends suggest that designers and developers of mHealth apps should keep the designs simple and pay special attention to aesthetics and symbolic value.

Assessing eHealth literacy among internet users in Lebanon: A cross-sectional study

Objective

Assessing the level of eHealth literacy in a population is essential to designing appropriate public health interventions. This study aimed to assess eHealth literacy among adult internet users in Lebanon, recruited through social media and printed materials. The study examined the relationship between internet use, perceived eHealth literacy, and sociodemographic characteristics.

Methods

A cross-sectional study based on a web-based questionnaire was conducted between January and May 2020. The survey assessed internet use and eHealth literacy using the homonymous scale (eHEALS) in English and Arabic. Cronbach's alpha and factor analyses were used to evaluate eHEALS’ psychometric properties. A generalized linear model was used to identify factors predicting the eHEALS.

Results

A total of 2715 respondents were recruited mostly through Facebook (78%) and printed materials (17%). Most respondents completed the survey in English (82%), were aged 30 ± 11 years, female (60%), Lebanese (84%), unmarried (62%), employed (54%), and with a graduate-level education (53%). Those who completed the eHEALS questionnaire (n = 2336) had a moderate eHealth literacy (M = 28.7, SD = 5.5). eHEALS was significantly higher among older females with a high education level, recruited from Facebook, Instagram, or ResearchGate, and perceived the Internet as a useful and important source of information.

Conclusions

Future internet-delivered public health campaigns in Lebanon should account for moderate-to-low levels of eHealth literacy and find ways to engage older males with low education levels representing neglected segments (e.g. Syrians). To be more inclusive, campaigns should reach neglected population segments through non-digital, community-based outreach activities.

The use of everyday and assistive technology in the lives of older autistic adults

LAY ABSTRACT

Technology has the potential to help people with various support needs live more autonomous lives. This includes autistic individuals. In this article, we look at how older autistic adults use technology in their daily lives. Past research examining technology use and autism has mainly focused on helping children to learn new skills. To date, very little research has been conducted looking at how to create and design technology for use by older autistic adults. This is concerning because older autistic adults will likely have supports needs that match or exceed those of similarly aged non-autistic individuals. In this article, we spoke to autistic adults over 50 years about their daily experiences and how they use technology. We identified some important ways that older autistic adults use technology in their daily lives, as well as a number of support needs and barriers to technology use. Based on the findings, we were able to provide some guidelines and recommendations for technology developers and service providers to assist with designing, creating and using technology with older autistic adults.

Factors influencing the effective management of diabetes during humanitarian crises in low- and middle-income countries: a systematic review

OBJECTIVES

The management of non-communicable chronic diseases such as diabetes mellitus is often poor in humanitarian crisis settings. Poor disease management can have serious long-term consequences. This review sought to identify studies that explored the effectiveness of interventions and the determinants that may improve the management of diabetes in the humanitarian context.

STUDY DESIGN

A systematic review was conducted of all types of studies that implemented diabetes programmes in humanitarian settings.

METHODS

MEDLINE, Embase, CINAHL and Web of Science were searched for relevant articles using multiple search terms for relevant studies published in English between 2000 and June 2020. Quality assessments using valid tools, were conducted. A narrative synthesis of the findings was then performed.

RESULTS

The search yielded 550 citations. After de-duplicating and screening, 19 studies were eligible for inclusion. Most studies were conducted in the Middle East (74%), Asia (16%) and Africa (10%). The interventions reported to improved diabetes care included the mHealth tool, intensive lifestyle intervention, task-shifting, psychosocial support, distribution of glucometers and comprehensive care. Insufficient drug supply, out-of-pocket cost, the complexity of insulin therapy and low adherence to guidelines were identified as barriers.

CONCLUSION

There is a paucity of evidence on optimal diabetes care in acute crisis and natural disaster settings. The review was constrained by the low quality of the studies included. Nevertheless, it is likely that mHealth can be feasibly utilised, as educational SMS messages are cost-effective and electronic medical records can enhance disease monitoring. In addition, a multidisciplinary approach to care improves glycaemic control and is desirable due to the multifaceted nature of the disease and management required. Several key barriers have been identified that need to be tackled. Overall, the evidence base for diabetes care in humanitarian settings remains sparse, and further research is needed.

A free, open-source, offline digital health system for refugee care (Preprint)

Background

Objective

Methods

Results

Conclusions

eHealth for service delivery in conflict: a narrative review of the application of eHealth technologies in contemporary conflict settings

The role of eHealth in conflict settings is increasingly important to address geographic, epidemiologic and clinical disparities. This study categorizes various forms of eHealth usage in conflict and aims to identify gaps in evidence to make recommendations for further research and practice. The analysis was carried out via a narrative hermeneutic review methodology. Articles that fulfilled the following screening criteria were reviewed: (1) describing an eHealth intervention in active conflict or ongoing insurgency, (2) an eHealth intervention targeting a conflict-affected population, (3) an e-learning platform for delivery in conflict settings and (4) non-interventional descriptive reviews relating to eHealth in conflict. Of the 489 papers eligible for screening, 46 merited final inclusion. Conflict settings described include Somalia, Sudan, Afghanistan, Syria, Iraq, Pakistan, Chechnya, Gaza and the Democratic Republic of Congo. Thirty-six studies described specific eHealth initiatives, while the remainder were more generic review papers exploring general principles. Analysis resulted in the elucidation of three final categories of current eHealth activity in conflict-affected settings: (1) eHealth for clinical management, (2) e-learning for healthcare in conflict and (3) eHealth for information management in conflict. Obvious disparities in the distribution of technological dividends from eHealth in conflict are demonstrated by this review. Conflict-affected populations are predominantly subject to ad hoc and voluntary initiatives delivered by diaspora and civil society organizations. While the deployment of eHealth technologies in conflict settings is increasingly normalized, there is a need for further clarification of global norms relating to practice in this context.

Improving diabetes control for Syrian refugees in Jordan: a longitudinal cohort study comparing the effects of cash transfers and health education interventions

Background

Cash transfers are an increasingly common intervention in the Syrian refugee response to meet basic needs, though there is little known of their potential secondary impact on health outcomes in humanitarian settings.

Methods

A quasi-experimental prospective cohort study was implemented from October 2018 through January 2020 to assess the effectiveness of multi-purpose cash (MPC), community health volunteer (CHV)-led education, combined with conditional cash transfers (CCT) with respect to health measures among Syrian refugees with type II diabetes in Jordan.

Results

CHV + CCT participants had the highest expenditures at endline and were the only group with statistically significant increases in payments for outpatient diabetes care (25.3%, P < 0.001) and monthly medication costs (13.6%, P < 0.001). Conversely, monthly spending on diabetes medication decreased significantly in the CHV only group (− 18.7%, P = 0.001) yet increased in the MPC and CHV + CCT groups. Expenditures on glucose monitoring increased in all groups but significantly more in the CHV + CCT group (39.2%, P < 0.001).

The proportion of participants reporting regular diabetes care visits increased significantly only in the CHV + CCT group (15.1%, P = 0.002). Specialist visits also increased among CHV + CCT participants (16.8%, P = 0.001), but decreased in CHV only participants (− 27.8%, P < 0.001). Decreases in cost-motivated provider selection (− 22.8%, P < 0.001) and not receiving all needed care because of cost (− 26.2%, P < 0.001) were significant only in the CHV + CCT group.

A small significant decrease in BMI was observed in the CHV + CCT group (− 1.0, P = 0.005). Decreases in HbA1C were significant in all groups with magnitudes ranging from − 0.2 to − 0.7%. The proportion of CHV + CCT participants with normal blood pressure increased significantly from baseline to endline by 11.3% (P = 0.007).

Conclusions

Combined conditional cash and health education were effective in improving expenditures, health service utilization, medication adherence, blood pressure, and diabetes control. The lower cost health education intervention was similarly effective in improving diabetes control, whereas unconditional cash transfers alone were least effective. Study findings suggest that conditional cash or combined cash and health education are promising strategies to support diabetes control among refugees and that where the purpose of MPC is to improve health outcomes, this alone is insufficient to achieve improvements in the health of refugees with diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00380-7.

Models of care for patients with hypertension and diabetes in humanitarian crises: a systematic review

Care for non-communicable diseases, including hypertension and diabetes (HTN/DM), is recognized as a growing challenge in humanitarian crises, particularly in low- and middle-income countries (LMICs) where most crises occur. There is little evidence to support humanitarian actors and governments in designing efficient, effective, and context-adapted models of care for HTN/DM in such settings. This article aimed to systematically review the evidence on models of care targeting people with HTN/DM affected by humanitarian crises in LMICs. A search of the MEDLINE, Embase, Global Health, Global Indexus Medicus, Web of Science, and EconLit bibliographic databases and grey literature sources was performed. Studies were selected that described models of care for HTN/DM in humanitarian crises in LMICs. We descriptively analysed and compared models of care using a conceptual framework and evaluated study quality using the Mixed Methods Appraisal Tool. We report our findings according to PRISMA guidelines. The search yielded 10 645 citations, of which 45 were eligible for this review. Quantitative methods were most commonly used (n = 34), with four qualitative, three mixed methods, and four descriptive reviews of specific care models were also included. Most studies detailed primary care facility-based services for HTN/DM, focusing on health system inputs. More limited references were made to community-based services. Health care workforce and treatment protocols were commonly described framework components, whereas few studies described patient centredness, quality of care, financing and governance, broader health policy, and sociocultural contexts. There were few programme evaluations or effectiveness studies, and only one study reported costs. Most studies were of low quality. We concluded that an increasing body of literature describing models of care for patients with HTN/DM in humanitarian crises demonstrated the development of context-adapted services but showed little evidence of impact. Our conceptual framework could be used for further research and development of NCD models of care.

Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults

BACKGROUND

Cardiovascular disease (CVD) is a major cause of disability and mortality globally. Premature fatal and non-fatal CVD is considered to be largely preventable through the control of risk factors by lifestyle modifications and preventive medication. Lipid-lowering and antihypertensive drug therapies for primary prevention are cost-effective in reducing CVD morbidity and mortality among high-risk people and are recommended by international guidelines. However, adherence to medication prescribed for the prevention of CVD can be poor. Approximately 9% of CVD cases in the EU are attributed to poor adherence to vascular medications. Low-cost, scalable interventions to improve adherence to medications for the primary prevention of CVD have potential to reduce morbidity, mortality and healthcare costs associated with CVD.

OBJECTIVES

To establish the effectiveness of interventions delivered by mobile phone to improve adherence to medication prescribed for the primary prevention of CVD in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two other databases on 7 January 2020. We also searched two clinical trials registers on 5 February 2020. We searched reference lists of relevant papers. We applied no language or date restrictions.

SELECTION CRITERIA

We included randomised controlled trials investigating interventions delivered wholly or partly by mobile phones to improve adherence to cardiovascular medications prescribed for the primary prevention of CVD. We only included trials with a minimum of one-year follow-up in order that the outcome measures related to longer-term, sustained medication adherence behaviours and outcomes. Eligible comparators were usual care or control groups receiving no mobile phone-delivered component of the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The main outcomes of interest were objective measures of medication adherence (blood pressure (BP) and cholesterol), CVD events, and adverse events. We contacted study authors for further information when this was not reported.

MAIN RESULTS

We included 14 trials with 25,633 randomised participants. Participants were recruited from community-based primary and tertiary care or outpatient clinics. The interventions varied widely from those delivered solely through short messaging service (SMS) to those involving a combination of modes of delivery, such as SMS in addition to healthcare worker training, face-to-face counselling, electronic pillboxes, written materials, and home blood pressure monitors. Some interventions only targeted medication adherence, while others additionally targeted lifestyle changes such as diet and exercise. Due to heterogeneity in the nature and delivery of the interventions and study populations, we reported most results narratively, with the exception of two trials which were similar enough to meaningfully pool in meta-analyses. The body of evidence for the effect of mobile phone-based interventions on objective outcomes of adherence (BP and cholesterol) was of low certainty, due to most trials being at high risk of bias, and inconsistency in outcome effects. Two trials were at low risk of bias. Among five trials (total study enrolment: 5441 participants) recording low-density lipoprotein cholesterol (LDL-C), two studies found evidence for a small beneficial intervention effect on reducing LDL-C (-5.30 mg/dL, 95% confidence interval (CI) -8.30 to -2.30; and -9.20 mg/dL, 95% CI -17.70 to -0.70). The other three studies found results varying from a small reduction (-7.7 mg/dL) to a small increase in LDL-C (0.77 mg/dL). All of which had wide confidence intervals that included no effect. Across 13 studies (25,166 participants) measuring systolic blood pressure, effect estimates ranged from a large reduction (MD -12.45 mmHg, 95% CI -15.02 to -9.88) to a small increase (MD 2.80 mmHg, 95% CI 0.30 to 5.30). We found a similar range of effect estimates for diastolic BP, ranging from -12.23 mmHg (95% CI 14.03 to -10.43) to 1.64 mmHg (95% CI -0.55 to 3.83) (11 trials, 19,716 participants). Four trials showed intervention benefits for systolic and diastolic BP with confidence intervals excluding no effect, and among these were all three of the trials evaluating self-monitoring of blood pressure with mobile phone-based telemedicine. The fourth trial included SMS and provider support (with additional varied features). Seven studies (19,185 participants) reported 'controlled' BP as an outcome, and intervention effect estimates varied from negligible effects (odds ratio (OR) 1.01, 95% CI 0.76 to 1.34) to large improvements in BP control (OR 2.41, 95% CI: 1.57 to 3.68). The three trials of clinician training or decision support combined with SMS (with additional varied features) had confidence intervals encompassing benefits and harms, with point estimates close to zero. Pooled analyses of the two trials of interventions solely delivered through SMS were indicative of little or no beneficial intervention effect on systolic BP (MD -1.55 mmHg, 95% CI -3.36 to 0.25; I2 = 0%) and small increases in controlled BP (OR 1.32, 95% CI 1.06 to 1.65; I2 = 0%). Based on four studies (12,439 participants), there was very low-certainty evidence (downgraded twice for imprecision and once for risk of bias) relating to the intervention effect on combined (fatal and non-fatal) CVD events. Two studies (2535 participants) provided low-certainty evidence for the effect of the intervention on cognitive outcomes, with little or no difference between trial arms for perceived quality of care and satisfaction with treatment. There was moderate-certainty evidence (downgraded due to risk of bias) that the interventions did not cause harm, based on six studies (8285 participants). Three studies reported no adverse events attributable to the intervention. One study reported no difference between groups in experience of adverse effects of statins, and that no participants reported intervention-related adverse events. One study stated that potential side effects were similar between groups. One study reported a similar number of deaths in each arm, but did not provide further information relating to potential adverse events.

AUTHORS' CONCLUSIONS

There is low-certainty evidence on the effects of mobile phone-delivered interventions to increase adherence to medication prescribed for the primary prevention of CVD. Trials of BP self-monitoring with mobile-phone telemedicine support reported modest benefits. One trial at low risk of bias reported modest reductions in LDL cholesterol but no benefits for BP. There is moderate-certainty evidence that these interventions do not result in harm. Further trials of these interventions are warranted.

Mobile Apps for Dental Caries Prevention: Systematic Search and Quality Evaluation

Background

Dental caries is the most common multifactorial oral disease; it affects 60% to 90% of the global population. Dental caries is highly preventable through prevention behaviors aimed at improving oral hygiene, adequate fluoride usage, and dietary intake. Mobile apps have the potential to support patients with dental caries; however, little is known about the availability, target audience, quality, and features of these apps.

Objective

This review aims to systematically examine dental caries prevention apps; to describe their content, availability, target audience, and features; and to assess their quality.

Methods

We systematically identified and evaluated apps in a process paralleling a systematic review. This included a search strategy using search terms; an eligibility assessment using inclusion and exclusion criteria focused on accessibility and dental caries self-management behaviors, including oral hygiene, dietary intake, and fluoride usage; data extraction on app characteristics, including app store metrics; prevention behavior categorization; feature identification and description; a quality appraisal of all apps using the validated Mobile App Rating Scale (MARS) assessment tool; and data comparison and analysis.

Results

Using our search strategy, we retrieved 562 apps from the Google Play Store and iTunes available in Australia. Of these, 7.1% (40/562) of the apps fit our eligibility criteria, of which 55% (22/40) targeted adults, 93% (37/40) were free to download, and 65% (26/40) were recently updated. Oral hygiene was the most common dental caries prevention behavior domain, addressed in 93% (37/40) of the apps, while dietary intake was addressed in 45% (18/40) of the apps and fluoride usage was addressed in 42% (17/40) of the apps. Overall, 50% (20/40) of the apps addressed only 1 behavior, and 38% (15/40) of the apps addressed all 3 behaviors. The mean MARS score was 2.9 (SD 0.7; range 1.8-4.4), with 45% (18/40) of the apps categorized as high quality, with a rating above 3.0 out of 5.0. We identified 21 distinctive features across all dental caries prevention behaviors; however, the top 5 most common features focused on oral hygiene. The highest-ranking app was the Brush DJ app, with an overall MARS score of 4.4 and with the highest number of features (n=13). We did not find any apps that adequately addressed dental caries prevention behaviors in very young children.

Conclusions

Apps addressing dental caries prevention commonly focus on oral hygiene and target young adults; however, many are not of high quality. These apps use a range of features to support consumer engagement, and some of these features may be helpful for specific patient populations. However, it remains unclear how effective these apps are in improving dental caries outcomes, and further evaluation is required before they are widely recommended.

Telemedicine to deliver diabetes care in low- and middle-income countries: a systematic review and meta-analysis

Objective

To determine the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries.

Methods

We searched seven databases up to July 2020 for randomized controlled trials investigating the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries. We extracted data on the study characteristics, primary end-points and effect sizes of outcomes. Using random effects analyses, we ran a series of meta-analyses for both biochemical outcomes and related patient properties.

Findings

We included 31 interventions in our meta-analysis. We observed significant standardized mean differences of −0.38 for glycated haemoglobin (95% confidence interval, CI: −0.52 to −0.23; I² = 86.70%), −0.20 for fasting blood sugar (95% CI: −0.32 to −0.08; I² = 64.28%), 0.81 for adherence to treatment (95% CI: 0.19 to 1.42; I² = 93.75%), 0.55 for diabetes knowledge (95% CI: −0.10 to 1.20; I² = 92.65%) and 1.68 for self-efficacy (95% CI: 1.06 to 2.30; I² = 97.15%). We observed no significant treatment effects for other outcomes, with standardized mean differences of −0.04 for body mass index (95% CI: −0.13 to 0.05; I² = 35.94%), −0.06 for total cholesterol (95% CI: −0.16 to 0.04; I² = 59.93%) and −0.02 for triglycerides (95% CI: −0.12 to 0.09; I² = 0%). Interventions via telephone and short message service yielded the highest treatment effects compared with services based on telemetry and smartphone applications.

Conclusion

Although we determined that telemedicine is effective in improving several diabetes-related outcomes, the certainty of evidence was very low due to substantial heterogeneity and risk of bias.

Protocol for a systematic review and meta-analysis of culturally adapted internet- and mobile-based health promotion interventions

INTRODUCTION

High rates of immigration pose challenges for the healthcare systems of many countries to offer high-quality care to diverse populations. Advancing health interventions with incorporating the cultural background of diverse populations can be helpful to overcome this challenge. First studies suggest that culturally diverse populations might benefit from culturally adapted internet-based and mobile-based interventions (IMI) to promote health behaviours. However, the effectiveness of culturally adapted IMIs for health promotion interventions has not been evaluated systematically. Therefore, the aim of this review is to assess the effectiveness of culturally adapted IMIs regarding health promotion. Additionally, the cultural adaptation features of these interventions will be outlined.

METHODS AND ANALYSIS

Randomised controlled trials (RCTs) investigating the effectiveness of culturally adapted IMIs to promote health behaviours in the field of healthy eating, smoking cessation, alcohol consumption, physical activity and sexual health behaviour will be identified via a systematic search of the databases MEDLINE, Embase, PsycINFO, CENTRAL. The preliminary search has been conducted on the 26 August 2019 and will be updated in the process. Data will be pooled meta-analytically in case of at least three included studies reporting on the same outcome. Moreover, a narrative synthesis of the included studies will be conducted. The risk of bias will be assessed using the Cochrane Collaboration's tool for the Quality Assessment of RCTs V. 2.0. Publication bias will be assessed using funnel plots.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. The results of this study will be published in a peer-reviewed international journal.

PROSPERO REGISTRATION NUMBER

PROSPERO; CRD42020152939.

Health system interventions for adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Effective health system interventions may help address the disproportionate burden of diabetes in low- and middle-income countries (LMICs). We assessed the impact of health system interventions to improve outcomes for adults with type 2 diabetes in LMICs.

METHODS AND FINDINGS

We searched Ovid MEDLINE, Cochrane Library, EMBASE, African Index Medicus, LILACS, and Global Index Medicus from inception of each database through February 24, 2020. We included randomized controlled trials (RCTs) of health system interventions targeting adults with type 2 diabetes in LMICs. Eligible studies reported at least 1 of the following outcomes: glycemic change, mortality, quality of life, or cost-effectiveness. We conducted a meta-analysis for the glycemic outcome of hemoglobin A1c (HbA1c). GRADE and Cochrane Effective Practice and Organisation of Care methods were used to assess risk of bias for the glycemic outcome and to prepare a summary of findings table. Of the 12,921 references identified in searches, we included 39 studies in the narrative review of which 19 were cluster RCTs and 20 were individual RCTs. The greatest number of studies were conducted in the East Asia and Pacific region (n = 20) followed by South Asia (n = 7). There were 21,080 total participants enrolled across included studies and 10,060 total participants in the meta-analysis of HbA1c when accounting for the design effect of cluster RCTs. Non-glycemic outcomes of mortality, health-related quality of life, and cost-effectiveness had sparse data availability that precluded quantitative pooling. In the meta-analysis of HbA1c from 35 of the included studies, the mean difference was -0.46% (95% CI -0.60% to -0.31%, I2 87.8%, p < 0.001) overall, -0.37% (95% CI -0.64% to -0.10%, I2 60.0%, n = 7, p = 0.020) in multicomponent clinic-based interventions, -0.87% (-1.20% to -0.53%, I2 91.0%, n = 13, p < 0.001) in pharmacist task-sharing studies, and -0.27% (-0.50% to -0.04%, I2 64.1%, n = 7, p = 0.010) in trials of diabetes education or support alone. Other types of interventions had few included studies. Eight studies were at low risk of bias for the summary assessment of glycemic control, 15 studies were at unclear risk, and 16 studies were at high risk. The certainty of evidence for glycemic control by subgroup was moderate for multicomponent clinic-based interventions but was low or very low for other intervention types. Limitations include the lack of consensus definitions for health system interventions, differences in the quality of underlying studies, and sparse data availability for non-glycemic outcomes.

CONCLUSIONS

In this meta-analysis, we found that health system interventions for type 2 diabetes may be effective in improving glycemic control in LMICs, but few studies are available from rural areas or low- or lower-middle-income countries. Multicomponent clinic-based interventions had the strongest evidence for glycemic benefit among intervention types. Further research is needed to assess non-glycemic outcomes and to study implementation in rural and low-income settings.

Expanded genome-wide comparisons give novel insights into population structure and genetic heterogeneity of Leishmania tropica complex

Leishmania tropica is one of the main causative agents of cutaneous leishmaniasis (CL). Population structures of L. tropica appear to be genetically highly diverse. However, the relationship between L. tropica strains genomic diversity, protein coding gene evolution and biogeography are still poorly understood. In this study, we sequenced the genomes of three new clinical L. tropica isolates, two derived from a recent outbreak of CL in camps hosting Syrian refugees in Lebanon and one historical isolate from Azerbaijan to further refine comparative genome analyses. In silico multilocus microsatellite typing (MLMT) was performed to integrate the current diversity of genome sequence data in the wider available MLMT genetic population framework. Single nucleotide polymorphism (SNPs), gene copy number variations (CNVs) and chromosome ploidy were investigated across the available 18 L. tropica genomes with a main focus on protein coding genes. MLMT divided the strains in three populations that broadly correlated with their geographical distribution but not populations defined by SNPs. Unique SNPs profiles divided the 18 strains into five populations based on principal component analysis. Gene ontology enrichment analysis of the protein coding genes with population specific SNPs profiles revealed various biological processes, including iron acquisition, sterols synthesis and drug resistance. This study further highlights the complex links between L. tropica important genomic heterogeneity and the parasite broad geographic distribution. Unique sequence features in protein coding genes identified in distinct populations reveal potential novel markers that could be exploited for the development of more accurate typing schemes to further improve our knowledge of the evolution and epidemiology of the parasite as well as highlighting protein variants of potential functional importance underlying L. tropica specific biology.

Effectiveness of ICT-based intimate partner violence interventions: a systematic review

BACKGROUND

Intimate Partner Violence is a "global pandemic". Meanwhile, information and communication technologies (ICT), such as the internet, mobile phones, and smartphones, are spreading worldwide, including in low- and middle-income countries. We reviewed the available evidence on the use of ICT-based interventions to address intimate partner violence (IPV), evaluating the effectiveness, acceptability, and suitability of ICT for addressing different aspects of the problem (e.g., awareness, screening, prevention, treatment, mental health).

METHODS

We conducted a systematic review, following PRISMA guidelines, using the following databases: PubMed, PsycINFO, and Web of Science. Key search terms included women, violence, domestic violence, intimate partner violence, information, communication technology, ICT, technology, email, mobile, phone, digital, ehealth, web, computer, online, and computerized. Only articles written in English were included.

RESULTS

Twenty-five studies addressing screening and disclosure, IPV prevention, ICT suitability, support and women's mental health were identified. The evidence reviewed suggests that ICT-based interventions were effective mainly in screening, disclosure, and prevention. However, there is a lack of homogeneity among the studies' outcome measurements and the sample sizes, the control groups used (if any), the type of interventions, and the study recruitment space. Questions addressing safety, equity, and the unintended consequences of the use of ICT in IPV programming are virtually non-existent.

CONCLUSIONS

There is a clear need to develop women-centered ICT design when programming for IPV. Our study showed only one study that formally addressed software usability. The need for more research to address safety, equity, and the unintended consequences of the use of ICT in IPV programming is paramount. Studies addressing long term effects are also needed.

Recruiting Student Health Coaches to Improve Digital Blood Pressure Management: Randomized Controlled Pilot Study

BACKGROUND

Hypertension is a significant problem in the United States, affecting 1 in 3 adults aged above 18 years and is associated with a higher risk for cardiovascular disease and stroke. The prevalence of hypertension has increased in medically underserved areas (MUAs). Mobile health technologies, such as digital self-monitoring devices, have been shown to improve the management of chronic health conditions. However, patients from MUAs have reduced access to these devices because of limited resources and low health literacy. Health coaches and peer training programs are a potentially cost-effective solution for the shortage of physicians available to manage hypertension in MUAs. Activating young people as student health coaches (SHCs) is a promising strategy to improve community health.

OBJECTIVE

This pilot study aims to assess (1) the feasibility of training high school students as health technology coaches in MUAs and (2) whether the addition of SHCs to digital home monitoring improves the frequency of self-monitoring and overall blood pressure (BP) control.

METHODS

In total, 15 high school students completed 3-day health coach training. Patients who had a documented diagnosis of hypertension were randomly assigned to 1 of the 3 intervention arms. The QardioArm alone (Q) group was provided a QardioArm cuff only for convenience. The SHC alone (S) group was instructed to meet with a health coach for 30 min once a week for 5 weeks to create action plans for reducing BP. The student+QardioArm (S+Q) group received both interventions.

RESULTS

Participants (n=27) were randomly assigned to 3 groups in a ratio of 9:9:9. All 15 students completed training, of which 40% (6/15) of students completed all the 5 meetings with their assigned patient. Barriers to feasibility included transportation and patient response drop-off at the end of the study. Overall, 92% (11/12) of the students rated their experience as very good or higher and 69% (9/13) reported that this experience made them more likely to go into the medical field. There was a statistically significant difference in the frequency of cuff use (S+Q vs Q groups: 37 vs 17; P<.001). Participants in the S+Q group reported better BP control after the intervention compared with the other groups. The average BP at the end of the intervention was 145/84 (SD 9/18) mm Hg, 150/85 (SD 18/12) mm Hg, and 128/69 (SD 20/14) mm Hg in the Q, S, and S+Q groups, respectively.

CONCLUSIONS

This pilot study demonstrates the feasibility of pairing technology with young student coaches, although challenges existed. The S+Q group used their cuff more than the Q group. Patients were more engaged in the S+Q group, reporting higher satisfaction with their SHC and better control of their BP.

Integrating Health Technologies in Health Services for Syrian Refugees in Lebanon: Qualitative Study

Background

Lebanon currently hosts around one million Syrian refugees. There has been an increasing interest in integrating eHealth and mHealth technologies into the provision of primary health care to refugees and Lebanese citizens.

Objective

We aimed to gain a deeper understanding of the potential for technology integration in primary health care provision in the context of the protracted Syrian refugee crisis in Lebanon.

Methods

A total of 17 face-to-face semistructured interviews were conducted with key informants (n=8) and health care providers (n=9) involved in the provision of health care to the Syrian refugee population in Lebanon. Interviews were audio recorded and directly translated and transcribed from Arabic to English. Thematic analysis was conducted.

Results

Study participants indicated that varying resources, primarily time and the availability of technologies at primary health care centers, were the main challenges for integrating technologies for the provision of health care services for refugees. This challenge is compounded by refugees being viewed by participants as a mobile population thus making primary health care centers less willing to invest in refugee health technologies. Lastly, participant views regarding the health and technology literacies of refugees varied and that was considered to be a challenge that needs to be addressed for the successful integration of refugee health technologies.

Conclusions

Our findings indicate that in the context of integrating technology into the provision of health care for refugees in a low or middle income country such as Lebanon, some barriers for technology integration related to the availability of resources are similar to those found elsewhere. However, we identified participant views of refugees’ health and technology literacies to be a challenge specific to the context of this refugee crisis. These challenges need to be addressed when considering refugee health technologies. This could be done by increasing the visibility of refugee capabilities and configuring refugee health technologies so that they may create spaces in which refugees are empowered within the health care system and can work toward debunking the views discovered in this study.

Utilising digital health to improve medication-related quality of care for hypertensive patients: An integrative literature review

BACKGROUND

Hypertension or high blood pressure is considered as a significant contributor and risk factor to many serious conditions, approximately 1.13 billion people have hypertension globally. However, the integrated technologies can upscale health provisions and improve the effectiveness of the healthcare system. WHO has recommended that the digital health interventions (DHIs) and the Health System Challenges should be used in tandem in addressing health.

AIM

To summarise the outcomes from a range of research which investigated the use of DHI to improve the medication-related quality of care (MRQOC) for hypertensive patients.

METHODS

An integrative literature review was undertaken in October 2019 using the Medline, Cumulative Index of Nursing and Allied Health Literature, and Scopus databases for publications in English with no date limit.

RESULTS

In total, 18433 participants were included in this review from 28 studies meeting the eligibility criteria. There were 19 DHI identified within eight countries: Australia, Canada, India, South Korea, Lebanon, Pakistan, the United Kingdom, and the United States of America. The DHI were provided as community-based, clinical-based and home-based program through mobile phone, mobile health system, short message service, and telehealth, digital medicine, and online healthcare (web-based). The mean age of participants was 59 ranging from 42 to 81 years with an average mean systolic blood pressure of 143.3 mmHg at baseline, ranging from 129.0 mmHg to 159.0 mmHg. The proportion of male participants ranged from 13.9% to 92.0%. Eighteen interventions showed evidence of reduction in blood pressure and improvement of self-management in relation to medication adherence and blood pressure control. The reduction of systolic blood pressure ranged between 1.9 mmHg and 26.0 mmHg, with a mean of 10.8 mmHg. The digital health was found positively associated with the MRQOC for hypertensive patients such as improvement in medication adherence and medication management; better blood pressure control; maintaining follow-ups appointment and self-management; increasing access to healthcare particularly among patients living in rural area; and reducing adverse events. However, some interventions found no significant effect on hypertensive care. The follow up duration varied between 2 mo and 18 mo with an average attrition rate of 10.1%, ranging from 0.0% to 17.4%.

CONCLUSION

Utilising digital health innovation for hypertensive care in different settings with tailored interventions positively impacted on MRQOC leading to an improvement of patient outcomes and their quality of life. Nevertheless, inconclusive findings were found in some interventions, and inconsistent outcomes between DHI were noted. A future research and evidence-based DHI for hypertension or chronic diseases should be developed through the evidence-to-decision framework and guidelines.

Development of Health-RESPECT: An Integrated Service Model for Older Long-Term Care Hospital/Nursing Home Patients Using Information and Communication Technology

BACKGROUND

Korea, as one of the fastest-aging countries worldwide, requires an improved healthcare service model for older adults. We evaluated the current healthcare system and developed a service model based on information and communication technologies (ICT) for use in older patients in long-term care facilities (LTCF).

METHODS

We conducted a qualitative literature review, focus group interviews (FGIs), and structured survey to identify the current technology use and status of healthcare systems. We then developed a web-based platform with necessary, high-priority, and usable content for the care of older patients in LTCF.

RESULTS

We reviewed 60 (23 hypertension, 18 diabetes, and 19 heart failure) articles on information and communication technologies (ICT)-based disease management for clinical effectiveness and improved patient satisfaction. FGIs and structured surveys were used to evaluate the inconvenience in patient and medical information transfer between hospitals and cost and time required for its process. Accordingly, we confirmed the unmet need for an ICT-based service model for management, monitoring, and consultation among older patients and developed the Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT), a service platform for older patients residing in LTCF. The medical information exchange system was used to transfer medical information. Health-RESPECT includes an established algorithm for evidence-based comprehensive geriatric assessment and customized management; chronic disease management; management of potentially inappropriate medications; rehabilitation; and consultation and videoconferencing.

CONCLUSION

This study identified the current status and unmet needs of healthcare systems for older adults. We developed an ICT-based system to manage older institutionalized patients. However, the Health-RESPECT service model requires further validation.

Equity in Health Care: A Qualitative Study with Refugees, Health Care Professionals, and Administrators in One Region in Germany

Introduction. Equity in health is an essential issue and it would appear that it is not guaranteed for all human beings, especially refugee groups. The aim of this qualitative descriptive study was to explore the experiences of refugees, health care professionals, and administrators of refugee health care in a host country.

Methods

The study used qualitative methods which consisted of a convenience sample of stakeholders directly and indirectly involved in care for refugees and refugees themselves. The study participants were located in a rural area in the federal state of Schleswig-Holstein, Germany. Focus groups and interviews were conducted with 25 participants. A semistructured interview guideline was used for the focus groups and interviews. The data were evaluated using qualitative content analysis.

Results

Four main categories were identified which are important for equity in health care: legal aspects, sociocultural aspects, environmental aspects, and communication aspects. Legal frameworks and language barriers were perceived as strong barriers for accessing health care.

Conclusions

The findings suggest that the host countries should address the specific needs of this population group at a systemic and individual level. Based on the views of the participants interviewed it can be concluded that the refugee population group is particularly affected by limited access to health care services. Bureaucratic barriers, unfamiliarity with a new health system, and language issues all contribute to limiting access to health care services.

Utilization of Mobile Mental Health Services among Syrian Refugees and Other Vulnerable Arab Populations-A Systematic Review

The global refugee crisis is at its most critical state in history; Syria alone has produced 12 million internally displaced persons, with another 5 million refugees seeking protection across the globe. Faced with the heavy burden of mental distress carried by a massive refugee influx, many host nations lack the service capacity to respond adequately. While mobile mental health (mMHealth) applications and platforms have the potential to augment screenings and interventions for vulnerable populations, an insufficient gender and cultural adaptation of technology may drastically hamper its uptake in Arab refugees. Reporting only papers originating from Middle Eastern and/or Arab nations or refugee host nations, this systematic review evaluates the available literature published between 2000 and 2019 on the usage acceptability of mMHealth in Syrian refugees and other vulnerable Arab populations. We conducted a systematic review in PubMed, PsychInfo, Association of Computing Machinery (ACM) and the Directory of Open Access Journals (DOAJ) using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies that addressed mMHealth implementation in these populations; of a total of 607 articles identified, only 10 (1.6%) available, unique articles met our search criteria. These studies discussed the feasibility and efficacy of mMHealth applications and the barriers to their uptake. The few existing studies show positive impacts of mMHealth on the access to services and on treatment outcomes but also reveal a paucity of literature on mMHealth for vulnerable Arab populations. These findings indicate a critical need for research on the barriers to mMHealth uptake, to bolster service capacity in the Arab Region and in the refugee diaspora of other, non-Arab host countries.

Lessons from humanitarian clusters to strengthen health system responses to mass displacement in low and middle-income countries: A scoping review

•

Potential scope for health-system learning from cluster responses to mass displacement.

•

Non-health clusters can contribute to health improvements during mass displacement.

•

Cluster approaches are often siloed with insufficient cross-cluster learning.

•

Equitable power dynamics between displaced people, humanitarian actors, and governments are still needed.

The humanitarian cluster approach was established in 2005 but clarity on how lessons from humanitarian clusters can inform and strengthen health system responses to mass displacement in low and middle-income countries (LMIC) is lacking. We conducted a scoping review to examine the extent and nature of existing research and identify relevant lessons.

We used Arksey and O'Malley's scoping framework with Levac's 2010 revisions and Khalil's 2016 refinements, focussing on identifying lessons from discrete humanitarian clusters that could strengthen health system responses to mass population displacement. We summarised thematically by cluster.

Of 186 sources included, 56% were peer-reviewed research articles. Most related to health (37%), protection (18%), or nutrition (13%) clusters. Key lessons for health system responses included the necessity of empowering women; ensuring communities are engaged in decision-making processes (e.g. planning and construction of camps and housing) to strengthen trust and bonds between and within communities; and involving potential end-users in technological innovations development (e.g. geographical information systems) to ensure relevance and applicability.

Our review provided evidence that non-health clusters can contribute to improving health outcomes using focussed interventions for implementation by government or humanitarian partners to inform LMIC health system responses to mass displacement.

mHealth use for non-communicable diseases care in primary health: patients' perspective from rural settings and refugee camps

Background

Non-communicable diseases (NCDs) account for 85% of deaths in Lebanon and contribute to remarkable morbidity and mortality among refugees and underserved populations. This study assesses the perspectives of individuals with hypertension and/or diabetes in rural areas and Palestinian refugee camps towards a population based mHealth intervention called 'eSahha'.

Methods

The study employs a mixed-methods design to evaluate the effectiveness of SMSs on self-reported perceptions of lifestyle modifications. Quantitative data was collected through phone surveys, and qualitative data through focus group discussions. Descriptive statistics and bivariate analysis were performed.

Results

About 93.9% (n = 1000) of respondents perceived the SMSs as useful and easy to read and understand. About 76.9% reported compliance with SMSs through daily behavioral modifications. Women (P = 0.007), people aged ≥76 years (P < 0.001), unemployed individuals (P < 0.001), individuals who only read and write (P < 0.001) or those who are illiterate (P < 0.001) were significantly more likely to receive and not read the SMSs. Behavior change across settings was statistically significant (P < 0.001).

Conclusion

While SMS-based interventions targeting individuals with hypertension and/or diabetes were generally satisfactory among those living in rural areas and Palestinian refugee camps in Lebanon, a more tailored approach for older, illiterate and unemployed individuals is needed.

Keywords

e-health, refugees.