Impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here?

A narrative review of e-health systems' evolution - evidence from a regional study

PURPOSE

The growing implementation of electronic health (e-health) systems has raised the importance of analyzing how these systems have been implemented in diverse regions. By employing a contextual sensitive approach and social mechanism theory, this study aims to better understand the reasons for the success and failure of e-health initiatives in the ex-Yugoslav region and derive useful insights for policymakers.

DESIGN/METHODOLOGY/APPROACH

We employ a narrative review process grounded in the social mechanism theory, extended with field experts' review, to acquire state-of-the-art information.

FINDINGS

Findings indicate that different e-health systems coexist and evolve in different contexts in different countries, with varying levels of success. The contextual differences shape the broader environment, affecting the level of preparedness and capability for e-health implementation. Top-down approaches dominate e-health implementation in most countries when it comes to design process features, and more developed countries do not rely on strong social mechanisms for implementing e-health due to the openness of their culture towards e-health innovations.

PRACTICAL IMPLICATIONS

Analyzing the milestones, challenges and functionalities of e-health systems in the region of interest can assist policymakers, academics and practitioners in making informed decisions and recommendations to enhance future e-health implementation.

ORIGINALITY/VALUE

No known studies evaluated e-health initiatives in the former ex-Yugoslav countries holistically and evolutionarily in the form of a comprehensive regional study. Further, our research endeavor is contextually specific since the health systems of these countries in the past were tied together under the federative umbrella health system and then diverged in terms of e-health development.

Evaluating digital literacy of health professionals in Ethiopian health sectors: A systematic review and meta-analysis

BACKGROUND

Digital literacy refers to the capacity to critically assess digital content, use digital tools in professional settings, and operate digital devices with proficiency. The healthcare sector has rapidly digitized in the last few decades. This systematic review and meta-analysis aimed to assess the digital literacy level of health professionals in the Ethiopian health sector and identify associated factors. The study reviewed relevant literature and analyzed the data to provide a comprehensive understanding of the current state of digital literacy among health professionals in Ethiopia.

METHODS

The study was examined by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Evidence was gathered from the databases of Google Scholar, Pub Med, Cochrane Library, Hinari, CINAHL, and Global Health. Consequently, five articles met the eligible criteria for inclusion. The analysis was carried out using STATA version 11. The heterogeneity was evaluated using the I2 test, while the funnel plot and Egger's regression test statistic were used to examine for potential publication bias. The pooled effect size of each trial is evaluated using a random effect model meta-analysis, which provides a 95% confidence interval.

RESULT

A total of five articles were included in this meta-analysis and the overall pooled prevalence of this study was 49.85% (95% CI: 37.22-62.47). six variables, Monthly incomes AOR = 3.89 (95% CI: 1.03-14.66), computer literacy 2.93 (95% CI: 1.27-6.74), perceived usefulness 1.68 (95% CI: 1.59-4.52), educational status 2.56 (95% CI: 1.59-4.13), attitude 2.23 (95% CI: 1.49-3.35), perceived ease of use 2.22 (95% CI: 1.52-3.23) were significantly associated with the outcome variable.

CONCLUSION

The findings of the study revealed that the overall digital literacy level among health professionals in Ethiopia was relatively low. The study highlights the importance of addressing the digital literacy gap among health professionals in Ethiopia. It suggests the need for targeted interventions, such as increasing monthly incomes, giving computer training, creating a positive attitude, and educational initiatives, to enhance digital literacy skills among health professionals. By improving digital literacy, health professionals can effectively utilize digital technologies and contribute to the advancement of healthcare services in Ethiopia.

Digital health interventions for non-communicable disease management in primary health care in low-and middle-income countries

Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings. This scoping review evaluates the extent of use and effectiveness of digital health interventions for non-communicable disease (NCD) management in primary healthcare settings of low- and middle-income countries (LMICs) and identifies factors influencing digital health interventions' uptake. We use PubMed, Embase, and Web of Science search results from January 2010 to 2021. Of 8866 results, 52 met eligibility criteria (31 reviews, 21 trials). Benchmarked against World Health Organization's digital health classifications, only 14 out of 28 digital health intervention categories are found, suggesting critical under-use and lagging innovation. Digital health interventions' effectiveness vary across outcomes: clinical (mixed), behavioral (positively inclined), and service implementation outcomes (clear effectiveness). We further identify multiple factors influencing digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems, which points to future research and practices to invigorate digital health interventions for NCD management in primary health care of LMICs.

The effect of e-health interventions on meeting the needs of individuals with infertility: a narrative review

Background

The mental health and well-being of millions of people worldwide are negatively impacted by infertility. A promising solution to meet the needs of people suffering from infertility is e-health interventions, such as online counseling and support groups. This study aims to review the current literature on e-health interventions and how they impact people with infertility.

Main body of the abstract

Relevant studies were searched in PubMed, Web of Science, and Scopus databases. Articles were entered into the EndNote software and screened for duplicates and relevance. Two authors then reviewed full-text articles independently, with a third person resolving any disagreements. Thirteen studies conducted between 2007 and 2022 were identified. The interventions aimed to meet various needs, including training on drug use (n = 23), lifestyle modifications (n = 1), periconceptional behavior modifications (n = 1), drug management (n = 1), IVF training (n = 4), psychological support to reduce distress (n = 4), and promoting a positive sexual self-concept (n = 1).

Short conclusion

The limited number of e-health interventions for infertile patients, the heterogeneity of interventions, and the lack of long-term effectiveness data make it challenging to compare e-health interventions to nonelectronic alternatives. However, the increasing use of technology in healthcare, especially during and after the Covid-19 pandemic, suggests that e-health educational interventions such as those using the Internet, psychological support, and patient interaction will continue to play a crucial role in healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43043-023-00137-7.

Digital literacy level and associated factors among health professionals in a referral and teaching hospital: An implication for future digital health systems implementation

Background

In Ethiopia and other developing countries, electronic medical record systems and other health information technology are being introduced. However, a small proportion of low-income countries have successfully implemented national health information systems. One cause for this can be the lack of digital literacy among medical practitioners. As a result, this study aimed to assess health professionals' digital literacy level and associated factors in Northwest Ethiopia.

Method

A quantitative cross-sectional study was employed among 423 health professionals working in a teaching and referral hospital in Northwest Ethiopia. We modified and applied the European commission's framework for digital competency to assess the level of digital literacy among health professionals. We used stratified random sampling with proportional allocation to the size of the departments in the hospital to select study participants. Data were collected using a semi-structured, self-administered, and pretested questionnaire. Descriptive and binary logistic regression analysis techniques were used to describe respondents' digital literacy level and identify its associated factor, respectively. The odds ratio with 95% CI and value of p were used to assess the strength of the association and statistical significance, respectively.

Results

Out of 411 participants, 51.8% (95% CI, 46.9-56.6%) of health professionals had adequate digital literacy. Holding a master's degree (Adjusted OR = 2.13, 95% CI: 1.18-3.85), access to digital technology (AOR = 1.89, 95% CI: 1.12-3.17), having training in digital technology (AOR = 1.65, 95% CI: 1.05-2.59), and having a positive attitude towards digital health technology (AOR = 1.64, 95% CI: 1.02-2.68) were found to be significant factors associated with health professionals digital literacy level of health professionals.

Conclusion

Low level of digital literacy among health professionals was observed, with nearly half (48.2%) of them having poor digital literacy levels. Access to digital technology, training on digital technology, and attitude toward digital health technology were significant factors associated with digital literacy. It is suggested to increase computer accessibility, provide a training program on digital health technology, and promote a positive attitude toward this technology to improve the deployment of health information systems.

Strengthening urban primary healthcare service delivery using electronic health technologies: A qualitative study in urban Nepal

Background

Nepal is a South Asian country with a high burden of non-communicable diseases. Electronic health technologies are a promising strategy to mitigate the rising burden of non-communicable diseases by strengthening primary healthcare center service delivery. However, electronic health implementation in Nepal is limited. Furthermore, electronic health use at the primary healthcare center level is chronically understudied. This qualitative study seeks to understand the perceived awareness, benefits, and determinants of electronic health uptake in Nepal, focusing on primary healthcare center-level non-communicable disease management.

Methods

We conducted in-depth interviews with 27 participants including policymakers, health experts, facility administrators, providers, and non-communicable diseases patients in 2019. We selected six urban primary healthcare center facilities via cluster convenience sampling for recruiting facility administrators, providers, and patients, and used convenience sampling to recruit policymakers and experts. We conducted thematic data analysis inductively and deductively using the electronic health readiness assessment framework to understand perceived barriers and facilitators of electronic health implementation.

Results

While there was general awareness and acceptance of electronic health, multiple barriers impede readiness for implementation. These include policy making gaps, language barriers, low user technical literacy, concerns of overreliance on technology, and inadequate training for administrators and providers. Stakeholder suggestions include creating electronic health interfaces that meet the needs of end users (providers and patients), providing training to enable end users to effectively use electronic health technologies, and strong policy support at the national level.

Conclusion

We identify several determinants for effectively promoting the use of electronic health for non-communicable diseases service delivery at the primary healthcare center level in Nepal.

A systematic review of healthcare provider-targeted mobile applications for non-communicable diseases in low- and middle-income countries

Mobile health (mHealth) interventions hold promise for addressing the epidemic of noncommunicable diseases (NCDs) in low- and middle-income countries (LMICs) by assisting healthcare providers managing these disorders in low-resource settings. We aimed to systematically identify and assess provider-facing mHealth applications used to screen for, diagnose, or monitor NCDs in LMICs. In this systematic review, we searched the indexing databases of PubMed, Web of Science, and Cochrane Central for studies published between January 2007 and October 2019. We included studies of technologies that were: (i) mobile phone- or tablet-based, (ii) able to screen for, diagnose, or monitor an NCD of public health importance in LMICs, and (iii) targeting health professionals as users. We extracted disease type, intervention purpose, target population, study population, sample size, study methodology, technology stage, country of development, operating system, and cost. Our initial search retrieved 13,262 studies, 315 of which met inclusion criteria and were analyzed. Cardiology was the most common clinical domain of the technologies evaluated, with 89 publications. mHealth innovations were predominantly developed using Apple's iOS operating system. Cost data were provided in only 50 studies, but most technologies for which this information was available cost less than 20 USD. Only 24 innovations targeted the ten NCDs responsible for the greatest number of disability-adjusted life years lost globally. Most publications evaluated products created in high-income countries. Reported mHealth technologies are well-developed, but their implementation in LMICs faces operating system incompatibility and a relative neglect of NCDs causing the greatest disease burden.

Did an Intervention Programme Aimed at Strengthening the Maternal and Child Health Services in Nigeria Improve the Completeness of Routine Health Data Within the Health Management Information System?

BACKGROUND

During 2012-2015, the Federal Government of Nigeria launched the Subsidy Reinvestment and Empowerment Programme, a health system strengthening (HSS) programme with a Maternal and Child Health component (Subsidy Reinvestment and Empowerment Programme [SURE-P]/MCH), which was monitored using the Health Management Information Systems (HMIS) data reporting tools. Good quality data is essential for health policy and planning decisions yet, little is known on whether and how broad health systems strengthening programmes affect quality of data. This paper explores the effects of the SURE-P/MCH on completeness of MCH data in the National HMIS.

METHODS

This mixed-methods study was undertaken in Anambra state, southeast Nigeria. A standardized proforma was used to collect facility-level data from the facility registers on MCH services to assess the completeness of data from 2 interventions and one control clusters. The facility data was collected to cover before, during, and after the SURE-P intervention activities. Qualitative in-depth interviews were conducted with purposefully-identified health facility workers to identify their views and experiences of changes in data quality throughout the above 3 periods.

RESULTS

Quantitative analysis of the facility data showed that data completeness improved substantially, starting before SURE-P and continuing during SURE-P but across all clusters (ie, including the control). Also health workers felt data completeness were improved during the SURE-P, but declined with the cessation of the programme. We also found that challenges to data completeness are dependent on many variables including a high burden on providers for data collection, many variables to be filled in the data collection tools, and lack of health worker incentives.

CONCLUSION

Quantitative analysis showed improved data completeness and health workers believed the SURE-P/MCH had contributed to the improvement. The functioning of national HMIS are inevitably linked with other health systems components. While health systems strengthening programmes have a great potential for improved overall systems performance, a more granular understanding of their implications on the specific components such as the resultant quality of HMIS data, is needed.

Therapeutic and technological advancements in haemophilia care: Quantum leaps forward

INTRODUCTION

Recent technological innovations in haemophilia have advanced at an astounding pace, including gene therapy programmes and bioengineered molecules for prophylaxis, products that reduce treatment burden through half-life extension, unique mechanisms of action, and subcutaneous administration. Additional technological advancements have emerged that are anticipated to further transform haemophilia care.

AIM

Review new and emerging haemophilia therapies, including replacement and bypassing products, digital applications, utilisation of big data, and personalised medicine.

METHODS

Data were obtained from peer-reviewed presentations/publications, and ongoing studies in haemophilia, ultrasonography, and artificial intelligence (AI).

RESULTS

Available treatments include new recombinant factors VIII (FVIII) and IX (FIX), extended half-life FVIII/IX products, a new FVIIa product for inhibitor patients, and a FVIIIa-mimetic. Several novel therapeutics are in clinical trials, including FVIIIa mimetics and inhibitors of naturally-occurring anticoagulants. Ongoing gene therapy trials suggest that a single vector infusion using an optimised construct can produce factor activity that reduces bleeding to near zero for years. Today, persons with haemophilia (PwH) approach a lifespan comparable to that of the general population, presenting treatment challenges for age-related co-morbidities. Technological innovations have broadened beyond therapeutics to include large database analyses utilising remote data collection with handheld devices, and to tailor AI applications. Current development efforts include patient-performed ultrasonography, algorithms for scan interpretation, and point-of-care haemostatic testing devices.

CONCLUSIONS

We have entered a golden age for haemophilia treatment and care with wide-ranging advancements targeting improved quality of life (QoL). Future-focused efforts by clinical and patient communities may provide equitable access and care for people impacted by haemophilia worldwide.

Regulatory standards and guidance for the use of health applications for self-management in Africa: scoping review protocol

INTRODUCTION

Despite health applications becoming ubiquitous and with enormous potential to facilitate self-management, regulatory challenges such as poor application quality, breach of data privacy and limited interoperability have impeded their full adoption. While many countries now have digital health-related policies/strategies, there is also a need for regulatory standards and guidance that address key regulatory challenges associated with the use of health applications. Currently, it is unclear the status of countries in Africa regarding regulatory standards and guidance that address the use of health applications.This protocol describes the process of conducting a scoping review which aims to investigate the extent to which regulatory standards and guidance address the use of health applications for self-management within the WHO African Region countries.

METHODS

The review will follow the methodological framework for conducting a scoping study by Arksey and O'Malley (2005), and the updated methodological guidance for conducting a Joanna Briggs Institute (JBI) scoping review. Given that regulatory standards and guidance are unlikely to be available in scientific databases, we will search Scopus, Google, OpenGrey, WHO Regional Office for Africa Library (AFROLIB), African Index Medicus (AIM), websites of WHO, ITU and Ministries of Health, repositories for digital health policies. We will also search the reference lists of included documents, and contact key stakeholders in the region. Results will be reported using descriptive qualitative content analysis based on the review objectives. The policy analysis framework by Walt and Gilson (1994) will be used to organise findings. A summary of the key findings will be presented using tables, charts and maps.

ETHICS AND DISSEMINATION

The collection of primary data is not anticipated in this study and hence ethical approval will not be required. The review will be published in a peer-reviewed journal while key findings will be shared with relevant organisations and/or presented at conferences.

An mHealth tool for community health workers to improve caregiver knowledge of child health in the Amazon: An effectiveness-implementation hybrid evaluation

When community health workers (CHWs) are effective, they can teach healthy child rearing practices in their communities and improve child health and development outcomes. An effective mHealth tool can improve the capacity of CHWs to transmit knowledge to caregivers. This article evaluates the implementation of an mHealth tool in a CHW program in the Amazon of Peru. The intervention was designed, implemented, and evaluated with the guidance of multiple implementation science tools. A Hybrid Type 3 evaluation design was used to test the effectiveness of the implementation strategies and appropriateness of the intervention. The implementation outcomes: acceptability, adoption, dosage, and fidelity were analyzed with mixed methods approach to determine if the intervention was successfully installed in the CHW program. The service outcome, knowledge scores, was analyzed with an independent samples t-test and one way ANOVA to determine the effect of the program. The implementation strategies resulted in high degrees of acceptability, adoption, and fidelity of the mHealth tool. The surveillance component of the mHealth tools was not adequately adopted. The group of caregivers that received home visits with the mHealth tool (N = 48) had significantly higher knowledge scores (+1.26 standard deviations) than those in the control group (N = 138) (t(184) = -4.39, p<0.001). The COVID-19 pandemic significantly decreased the dosage of the intervention received by the participants. The CHEST App intervention is a promising tool to improve the capacity of CHWs during their home visits. Trial registered with ISRCTN on 11/29/2018 at https://doi.org/10.1186/ISRCTN43591826.

An Innovative App (ExoDont) for Postoperative Care of Patients After Tooth Extraction: Prototype Development and Testing Study

BACKGROUND

The postoperative period is crucial for the initiation of healing and prevention of complications after any surgical procedure. Due to factors such as poor compliance, comprehension, and retention of instructions, and other unaccounted factors, the objectives of postoperative care are not always achieved. Therefore, an Android-based mobile health app (ExoDont) was developed to ensure a smooth postoperative period for patients after a dental extraction. The ExoDont app delivers reminders for postoperative instructions and drug intake at defined intervals, thus fostering self-reliance among patients in taking their prescribed dose of medication.

OBJECTIVE

The aim of this study is to design, develop, and validate ExoDont, an innovative app for improved adherence to postoperative instructions after tooth extraction.

METHODS

A postoperative treatment protocol was developed by a team of oral and maxillofacial surgeons and general dentists, following which the clinical and technological requirements of the app were determined along with the software engineers, graphic designers, and applications architect in the team. ExoDont was developed to provide timely reminders for medication and postoperative care. The app was field tested and validated using the User Version of the Mobile Application Rating Scale.

RESULTS

The ExoDont software design was divided into a 3-level architecture comprising a user interface application, logical layer, and database layer. The software architecture consists of an Android-based ExoDont app for patients and a web version of the admin panel. The testing and validation of the ExoDont app revealed that Perceived Impact received the highest mean score of all rated components (mean 4.6, SD 0.5), while Engagement received the lowest mean score (mean 3.5, SD 0.8).

CONCLUSIONS

The testing and validation of the app support its usability and functionality, as well as its impact on users. The ExoDont app has been designed, keeping the welfare of patients in view, in a user-friendly manner that will help patients adhere to the prescribed drug regimen and ensure easy and efficient dissemination of postoperative instructions. It could play an instrumental role in fostering compliance among patients and significantly decrease the complication rate following dental extractions.

A multivariate statistical evaluation of actual use of electronic health record systems implementations in Kenya

Background

Health facilities in developing countries are increasingly adopting Electronic Health Records systems (EHRs) to support healthcare processes. However, only limited studies are available that assess the actual use of the EHRs once adopted in these settings. We assessed the state of the 376 KenyaEMR system (national EHRs) implementations in healthcare facilities offering HIV services in Kenya.

Methods

The study focused on seven EHRs use indicators. Six of the seven indicators were programmed and packaged into a query script for execution within each KenyaEMR system (KeEMRs) implementation to collect monthly server-log data for each indicator for the period 2012–2019. The indicators included: Staff system use, observations (clinical data volume), data exchange, standardized terminologies, patient identification, and automatic reports. The seventh indicator (EHR variable Completeness) was derived from routine data quality report within the EHRs. Data were analysed using descriptive statistics, and multiple linear regression analysis was used to examine how individual facility characteristics affected the use of the system.

Results

213 facilities spanning 19 counties participated in the study. The mean number of authorized users who actively used the KeEMRs was 18.1% (SD = 13.1%, p<0.001) across the facilities. On average, the volume of clinical data (observations) captured in the EHRs was 3363 (SD = 4259). Only a few facilities(14.1%) had health data exchange capability. 97.6% of EHRs concept dictionary terms mapped to standardized terminologies such as CIEL. Within the facility EHRs, only 50.5% (SD = 35.4%, p< 0.001) of patients had the nationally-endorsed patient identifier number recorded. Multiple regression analysis indicated the need for improvement on the mode of EHRs use of implementation.

Conclusion

The standard EHRs use indicators can effectively measure EHRs use and consequently determine success of the EHRs implementations. The results suggest that most of the EHRs use areas assessed need improvement, especially in relation to active usage of the system and data exchange readiness.

Systematic review on the use of patient-held health records in low-income and middle-income countries

OBJECTIVE

To review the available evidence on the benefit of patient-held health records (PHRs), other than maternal and child health records, for improving the availability of medical information for handover communication between healthcare providers (HCPs) and/or between HCPs and patients in low-income and middle-income countries (LMICs).

METHODS

The literature searches were conducted in PubMed, EMBASE, CINAHL databases for manuscripts without any restrictions on dates/language. Additionally, articles were located through citation checking using previous systematic reviews and a grey literature search by contacting experts, searching of the WHO website and Google Scholar.

RESULTS

Six observational studies in four LMICs met the inclusion criteria. However, no studies reported on health outcomes after using PHRs. Studies in the review reported patients' experience of carrying the records to HCPs (n=3), quality of information available to HCPs (n=1) and the utility of these records to patients (n=6) and HCPs (n=4). Most patients carry PHRs to healthcare visits. One study assessed the completeness of clinical handover information and found that only 41% (161/395) of PHRs were complete with respect to key information on diagnosis, treatment and follow-up. No protocols or guidelines for HCPs were reported for use of PHRs. The HCPs perceived the use of PHRs improved medical information availability from other HCPs. From the patient perspective, PHRs functioned as documented source of information about their own condition.

CONCLUSION

Limited data on existing PHRs make their benefits for improving health outcomes in LMICs uncertain. This knowledge gap calls for research on understanding the dynamics and outcomes of PHR use by patients and HCPs and in health systems interventions.

PROSPERO REGISTRATION NUMBER

CRD42019139365.

Mapping the role of digital health technologies in the case detection, management, and treatment outcomes of neglected tropical diseases: a scoping review

BACKGROUND

Neglected tropical diseases (NTDs) are a diverse group of communicable diseases that principally impact the world's poorest people. The use of digital health technologies is an emerging and promising way to improve disease prevention, diagnosis, case detection, treatment delivery, and patient follow-up and facilitating health facility appointments thereby improving health outcomes. While the growing implementation of digital health technologies is evident, there is a lack of comprehensive evidence on the impact of digital health technologies in the control of NTDs. The main objective of this review was to map different pieces of evidence on the use of digital health technologies for case detection, management, and treatment outcome of the neglected tropical diseases.

METHODS

We conducted a scoping review guided by the Joanna Briggs Institute guidelines. The studies were searched using electronic databases like MEDLINE (PubMed), Science Direct, Cochrane Library, and manual searching engines. Two authors extracted the data and compared the results. Discrepancies were resolved by discussion or the third reviewer made the decision. We produced the distribution of geographical locations, residents (setting), types of publications, and digital health technologies used on neglected tropical diseases using tables and graphs.

FINDINGS

A total of 996 potentially relevant studies were generated from the initial search, and six studies were found to satisfy all the inclusion criteria and included in the final review. The review found that telehealth, eHealth, mHealth, telemedicine, and electronic health record were used digital health technologies to assess their impact on case detection, disease management, and treatment outcome of neglected tropical diseases. Mobile health was a feasible digital health technology for lymphatic filariasis patient identification and mHealth, eHealth, and electronic health records found to improve the service access, outcomes, and monitoring of visceral leishmaniasis at the community health system.

CONCLUSION

The scoping review identified that there were limited studies to see the impact of digital health technologies on case detection, management, and treatment outcomes for neglected tropical diseases. We also found that digital health technologies like ehealth, electronic medical linkage, telemed, and telehealth were practicable for patient identification, for treatment and diagnosis through contact with health professionals and teleconsultation, and support in improving health service delivery at the community-health system for managing the disease in both rural and urban settings.

Assessment of Psychological Distress in Adults With Type 2 Diabetes Mellitus Through Technologies: Literature Review

Background

The use of technological devices can support the self-management of individuals with type 2 diabetes mellitus (T2DM), particularly in addressing psychological distress. However, there is poor consistency in the literature regarding the use of psychological instruments for the web-based screening of patients’ psychological distress and subsequent monitoring of their psychological condition during digital interventions.

Objective

This study aims to review previous literature on the types of psychological instruments delivered in digital interventions for assessing depression, anxiety, and stress in patients with T2DM.

Methods

The literature review was conducted using the PsycINFO, CINAHL and PubMed databases, in which the following terms were considered: diabetes mellitus, measure, assessment, self-care, self-management, depression, anxiety, stress, technology, eHealth, mobile health, mobile phone, device, and smartphone.

Results

In most studies, psychological assessments were administered on paper. A few studies deployed self-reporting techniques employing automated telephonic assessment, a call system for screening and monitoring patients’ conditions and preferences, or through telephone interviews via interactive voice response calls, a self-management support program leveraging tailored messages and structured emails. Other studies used simple telephone interviews and included the use of apps for tablets and smartphones to assess the psychological well-being of patients. Finally, some studies deployed mood rating scales delivered through tailored text message–based support systems.

Conclusions

The deployment of appropriate psychological tools in digital interventions allows researchers and clinicians to make the screening of anxiety, stress, and depression symptoms faster and easier in patients with T2DM. Data from this literature review suggest that mobile health solutions may be preferred tools to use in such digital interventions.

e Health initiatives for screening and management of hypertension in Rural Rajasthan

Context:

Electronic health (e health) initiatives are being employed in various health programs for disease monitoring. Very few such studies have been conducted in India, so this study was planned.

Aims:

Assess feasibility and usefulness of e health interventions for health workers, ASHA (accredited social health activist) in screening and management of hypertension.

Setting and Design:

Prospective observational cohort study. ASHA's were recruited in two selected villages of Rajasthan and trained to use this technology.

Methods and Material:

A web-based application was developed for use on portable device (tablet) to screen and diagnose hypertension, provide health education focused on diet, physical exercise and promote adherence to therapies by repeated sessions of one-to-one health education. Statistical analysis was done by Excel.

Results:

With the use of e health initiatives, among population above 18yrs, we found 19.1% hypertensives (464/2430) with 46.5% new cases of hypertension and 38.9 % (945/2430) prehypertensive. Mean age of hypertensives was 52.6 yrs. ± 15.2 and 36.8 yrs. ± 14.2 for prehypertensive and highly significant (p < 0.001). Mean systolic blood pressure level of hypertensives decreased from 147.14 Hg ±13.86 to 133.3 Hg ±13.07 and for prehypertensive from 123.18 mm Hg ± 4.5 to 117.55 mm Hg ± 6.9 after follow up, the difference in change was highly significant (P < 0.001). Also, could start 27.4% hypertensives on treatment, while 50.2% were already on treatment.

Conclusion:

Training ASHA worker in e health technology is feasible and can assist in screening and management of diseases.

Innovative and Assistive eHealth Technologies for Smart Therapeutic and Rehabilitation Outdoor Spaces for the Elderly Demographic

The use of technology for social connectivity and achieving engagement goals is increasingly essential to the overall well-being of our rapidly ageing population. While much of the extant literature has focused on home automation and indoor remote health monitoring; there is a growing literature that finds personal health and overall well-being improves when physical activities are conducted outdoors. This study presents a review of possible innovative and assistive eHealth technologies suitable for smart therapeutic and rehabilitation outdoor spaces for older persons. The article also presents key performance metrics required of eHealth technologies to ensure robust, timely and reliable biometric data transfer between patients in a therapeutic landscape environment and respective medical centres. A literature review of relevant publications with a primary focus of integrating sensors and eHealth technologies in outdoor spaces to collect and transfer data from the elderly demographic who engage such built landscapes to appropriate stakeholders was conducted. A content analysis was carried out to synthesize outcomes of the literature review. The study finds that research in assistive eHealth technologies and interfaces for outdoor therapeutic spaces is in its nascent stages and has limited generalisability. The level of technology uptake and readiness for smart outdoor spaces is still developing and is currently being outpaced by the growth of elderly fitness zones in public spaces. Further research is needed to explore those eHealth technologies with interactive feedback mechanisms that are suitable for outdoor therapeutic environments.

Perceptions and Attitudes Toward Mobile Health in Development of an Exclusive Breastfeeding Tool: Focus Group Study With Caregivers and Health Promoters in the Dominican Republic

BACKGROUND

Despite growing interest in the use of technology to improve health outcomes in low- and middle-income countries (LMICs), local attitudes toward mobile health (mHealth) use in these settings are minimally understood. This is especially true in the Dominican Republic, where mHealth interventions are starting to emerge. This information is critical for developing effective mHealth interventions to address public health issues, such as low exclusive breastfeeding (EBF) rates, which can lead to poor outcomes. With an EBF rate of 5% in the first 6 months of life, the Dominican Republic has one of the lowest EBF rates worldwide.

OBJECTIVE

This study aims to describe the current use of information and communication technology (ICT) and to analyze the attitudes and perceptions related to using mHealth interventions among caregivers of children aged ≤5 years and health promoters in the Dominican Republic. Findings can inform mHealth strategies aimed at improving EBF in this, and other, LMICs.

METHODS

Participants were recruited from 3 outpatient sites: the Niños Primeros en Salud program at Centro de Salud Divina Providencia in Consuelo (rural setting) and Clínica de Familia La Romana and its program Módulo de Adolescentes Materno Infantil in La Romana (urban setting). Focus groups were conducted with caregivers and community health promoters to identify the use, attitudes, perceptions, and acceptability of mHealth as well as barriers to EBF. Discussions were conducted in Spanish, guided by semistructured interview guides. All sessions were audio-recorded and later transcribed. Thematic content analysis was conducted in Spanish by two bilingual researchers and was structured around a hybrid behavioral theory framework to identify salient themes.

RESULTS

All participants (N=35) reported having a mobile phone, and 29 (83%) participants had a smartphone. Sources for obtaining health information included the internet, physicians and clinic, family and friends, health promoters, and television. Barriers to mHealth use included the cost of internet service, privacy concerns, and perceived credibility of information sources. Participants indicated the desire for, and willingness to use, an mHealth intervention to support breastfeeding. The desired features of a possible mHealth intervention included offering diverse methods of information delivery such as images and video content, text messages, and person-to-person interaction as well as notifications for appointments, vaccines, and feeding schedules. Other important considerations were internet-free access and content that included maternal and child health self-management topics beyond breastfeeding.

CONCLUSIONS

There is a high level of acceptance of ICT tools for breastfeeding promotion among caregivers in urban and rural areas of the Dominican Republic. As mHealth tools can contribute to increased breastfeeding self-efficacy, identifying desirable features of such a tool is necessary to create an effective intervention. Participants wanted to receive trusted and reliable information through various formats and were interested in information beyond breastfeeding.

Field testing of a digital health information system for primary health care: A quasi-experimental study from India

INTRODUCTION

Information and Communication Technologies (ICTs) are acknowledged as vital tools to strengthen Primary Health Care (PHC) in low- and middle-income countries (LMICs). However, these technologies have been used only for selected services. Moreover, there is limited evidence on how effective these interventions are in improving comprehensive primary health care in LMICs. Therefore, we developed an integrated digital solution and field-tested its impact on PHC services in an urban community of India.

METHODS

An integrated health information system for primary health care (IHIS4PHC) was designed on a free and open source digital platform which provided multiple features for registration of population and tracking for promotive, preventive, and curative health services (e.g. Antenatal Care, Immunization, TB, Malaria, and Hypertension Treatment etc.), and for generation of aggregate reports for real-time monitoring. The IHIS4PHC was implemented in an urban health centre of Chandigarh (India) which catered to about 25,000 population. A quasi-experimental study design was chosen for analysing the impact of IHIS4PHC on PHC services. Household sample surveys were conducted at baseline and endline in the intervention and comparison community to estimate the coverage of selected health indicators using standard questionnaires. Difference-in-difference method with adjusted generalised estimating equation was used for the assessment of the net impact of IHIS4PHC.

RESULTS

In relation to the comparison community, statistically significant (p < 0.05) increase was observed at the IHIS4PHC implementing centre in primary health care adequacy (7.2 %), and in the care-seeking behaviour for chronic illness (16.5 %). Improvements were also noticed in other health indicators such as mean blood pressure, adherence to antihypertensive medication, intake of dietary salt by hypertensives, intention to quit tobacco, and vitamin A supplementation.

CONCLUSIONS

The digital IHIS4PHC design was found to be effective in improving PHC-based health services. Therefore, IHIS4PHC like digital solutions should be considered for strengthening PHC services in LMICs.

The Present and Future of eHealth in Spain From a Health Management Perspective

eHealth has grown significantly over the last decade. The aim of this study was to determine the level of use of information and communication technologies for health care in Spain and identify the main barriers to development. We used a qualitative study based on data obtained from 8 Spanish autonomous communities through semi-structured, in-depth interviews with key informants in eHealth management and planning. Programs present varying degrees of implementation. Services such as electronic prescriptions, digital medical records, and appointment requests via the Internet are advanced and widespread; others, such as digital imaging, are advanced but not fully deployed; and some, such as telecare programs, are experimental. The study also revealed diverse levels of interoperability and barriers to the expansion of these technologies, which can be classified into 4 fields: technological, organizational, human, and economic. eHealth might evolve more slowly in the coming years. Unless the payoff is clearly seen, major budget cuts in the current economic climate will prevent the implementation of new projects. Programs that help reduce health spending are more likely to be implemented, to the detriment of projects involving simple techniques or even clear health care improvements.

Adherence to Electronic Health Tools Among Vulnerable Groups: Systematic Literature Review and Meta-Analysis

Background

Electronic health (eHealth) tools are increasingly being applied in health care. They are expected to improve access to health care, quality of health care, and health outcomes. Although the advantages of using these tools in health care are well described, it is unknown to what extent eHealth tools are effective when used by vulnerable population groups, such as the elderly, people with low socioeconomic status, single parents, minorities, or immigrants.

Objective

This study aimed to examine whether the design and implementation characteristics of eHealth tools contribute to better use of these tools among vulnerable groups.

Methods

In this systematic review, we assessed the design and implementation characteristics of eHealth tools that are used by vulnerable groups. In the meta-analysis, we used the adherence rate as an effect size measure. The adherence rate is defined as the number of people who are repetitive users (ie, use the eHealth tool more than once). We also performed a meta-regression analysis to examine how different design and implementation characteristics influenced the adherence rate.

Results

Currently, eHealth tools are continuously used by vulnerable groups but to a small extent. eHealth tools that use multimodal content (such as videos) and have the possibility for direct communication with providers show improved adherence among vulnerable groups.

Conclusions

eHealth tools that use multimodal content and provide the possibility for direct communication with providers have a higher adherence among vulnerable groups. However, most of the eHealth tools are not embedded within the health care system. They are usually focused on specific problems, such as diabetes or obesity. Hence, they do not provide comprehensive services for patients. This limits the use of eHealth tools as a replacement for existing health care services.

The use of eHealth to design a regional health promotion program in the workplace: Institute of Costa Rican Electricity case series

The development of sustainable health promotion programs in the workplace requires a coordinated systematic approach. Costs and resources often cause barriers to implement workplace programs in low-and middle-income countries. The objective of the case series is to evaluate the feasibility of health informatics to evaluate and monitor the physical activity and dietary habits of individuals in the workplace on a small scale as a preparation to implement the health promotion program across a company in Costa Rica. Participants were 25 employees where 17 participants had a body mass index (BMI) of 25.0 km/m² or more. This case series assesses and evaluates patient data during an 8-week period using multiple tools of eHealth technologies such as an Electronic Health Record (EHR), a Personal Health Record (PHR), electronic surveys and fitness trackers with compatible mobile applications. Adherence to wearing Fitbit was high and stable with a mean of 97.5% over 30 days (n=16). The participants in the first week walked on average 8,239 steps but, at the end of the fourth week, the average steps decreased to 7,798. The dietary electronic survey was answered satisfactorily by 86.6% of the employees (n=25). The employees scored on average 35 out of 100 on a diet quality scale. The consumption of vegetables, beans, whole grains, nuts and seeds is lower than the recommended dietary guidelines of 60. The integration of eHealth technologies can provide a clearer understanding of the employees' health situation to more appropriately allocate efforts to promote behavior change where needed most.

Patient and healthcare provider knowledge, attitudes and barriers to handover and healthcare communication during chronic disease inpatient care in India: a qualitative exploratory study

OBJECTIVES

1) To investigate patient and healthcare provider (HCP) knowledge, attitudes and barriers to handover and healthcare communication during inpatient care. 2) To explore potential interventions for improving the storage and transfer of healthcare information.

DESIGN

Qualitative study comprising 41 semi-structured, individual interviews and a thematic analysis using the Framework Method with analyst triangulation.

SETTING

Three public hospitals in Himachal Pradesh and Kerala, India.

PARTICIPANTS

Participants included 20 male (n=10) and female (n=10) patients with chronic non-communicable disease (NCD) and 21 male (n=15) and female (n=6) HCPs. Purposive sampling was used to identify patients with chronic NCDs (cardiovascular disease, chronic respiratory disease, diabetes or hypertension) and HCPs.

RESULTS

Patient themes were (1) public healthcare service characteristics, (2) HCP to patient communication and (3) attitudes regarding medical information. HCP themes were (1) system factors, (2) information exchange practices and (3) quality improvement strategies. Both patients and HCPs recognised public healthcare constraints that increased pressure on hospitals and subsequently limited consultation times. Systemic issues reported by HCPs were a lack of formal handover systems, training and accessible hospital-based records. Healthcare management communication during admission was inconsistent and lacked patient-centredness, evidenced by varying reports of patient information received and some dissatisfaction with lifestyle advice. HCPs reported that the duty of writing discharge notes was passed from senior doctors to interns or nurses during busy periods. A nurse reported providing predominantly verbal discharge instructions to patients. Patient-held medical documents facilitated information exchange between HCPs, but doctors reported that they were not always transported. HCPs and patients expressed positive views towards the idea of introducing patient-held booklets to improve the organisation and transfer of medical documents.

CONCLUSIONS

Handover and healthcare communication during chronic NCD inpatient care is currently suboptimal. Structured information exchange systems and HCP training are required to improve continuity and safety of care during critical transitions such as referral and discharge. Our findings suggest that patient-held booklets may also assist in enhancing handover and patient-centred practices.

SERIES: eHealth in primary care. Part 1: Concepts, conditions and challenges

Primary care is challenged to provide high quality, accessible and affordable care for an increasingly ageing, complex, and multimorbid population. To counter these challenges, primary care professionals need to take up new and innovative practices, including eHealth. eHealth applications hold the promise to overcome some difficulties encountered in the care of people with complex medical and social needs in primary care. However, many unanswered questions regarding (cost) effectiveness, integration with healthcare, and acceptability to patients, caregivers, and professionals remain to be elucidated. What conditions need to be met? What challenges need to be overcome? What downsides must be dealt with? This first paper in a series on eHealth in primary care introduces basic concepts and examines opportunities for the uptake of eHealth in primary care. We illustrate that although the potential of eHealth in primary care is high, several conditions need to be met to ensure that safe and high-quality eHealth is developed for and implemented in primary care. eHealth research needs to be optimized; ensuring evidence-based eHealth is available. Blended care, i.e. combining face-to-face care with remote options, personalized to the individual patient should be considered. Stakeholders need to be involved in the development and implementation of eHealth via co-creation processes, and design should be mindful of vulnerable groups and eHealth illiteracy. Furthermore, a global perspective on eHealth should be adopted, and eHealth ethics, patients’ safety and privacy considered.

Investigating the Use of Mobile Health Interventions in Vulnerable Populations for Cardiovascular Disease Management: Scoping Review

Background

Cardiovascular disease (CVD) has grown to become one of the leading causes of mortality worldwide. The advancements of CVD-related treatments have led to a decline in CVD prevalence among individuals in high-income countries (HICs). However, these improvements do not reflect the state of individuals in low- and middle-income countries (LMICs) and vulnerable subgroup populations in HICs, such as the Indigenous. To help minimize the health disparities in these populations, technology-based interventions have been offered as a potential solution, but there is concern regarding if they will be effective, or even needed, as these tools have been designed for use in HICs.

Objective

The objective of this study was to explore how mobile health (mHealth) interventions currently assist individuals in Indigenous communities and LMICs with CVD management.

Methods

A scoping review guided by the methods outlined by Arksey and O’Malley was conducted. A comprehensive search was completed by 2 reviewers in 5 electronic databases using keywords related to mobile health, cardiovascular disease, self-care, Indigenous communities, and LMICs. Studies were screened over 2 rounds and critically reviewed using a descriptive-analytical narrative method. Descriptive data were categorized into thematic groups reflecting the major findings related to the study objective.

Results

We identified a total of 11 original articles and 11 review papers that met the criteria for this scoping review. The majority of the studies included a telemonitoring- and text messaging (short message service, SMS)–related feature associated with the intervention. The use of SMS was the most common approach to effectively promote disease management among individuals in both LMICs and Indigenous communities. However, customizing for cultural considerations within the design of the intervention was highlighted as a pivotal component to encourage CVD management. Specifically, individuals emphasized that the inclusion of collaborative partnerships with community members would strengthen the effectiveness of the intervention by ensuring it was designed with the appropriate context.

Conclusions

Technology-based interventions used within Indigenous communities and LMICs have shown their potential to assist individuals with managing their condition. Although the literature available regarding this topic is limited, this review outlines key components to promote the effective use of these tools in the context of these vulnerable populations.

The Elusive Path Toward Measuring Health Outcomes: Lessons Learned From a Pseudo-Randomized Controlled Trial of a Large-Scale Mobile Health Initiative

Mobile health (mHealth) offers new opportunities to improve access to health services and health information. It also presents new challenges in evaluating its impact, particularly in linking the use of a technology intervention that aims to improve health behaviors with the health outcomes that are impacted by changed behaviors. The availability of data from a multitude of sources (paper-based and electronic) provides the conditions to facilitate making stronger connections between self-reported data and clinical outcomes. This commentary shares lessons and important considerations based on the experience of applying new research frameworks and incorporating maternal and child health records data into a pseudo-randomized controlled trial to evaluate the impact of mMitra, a stage-based voice messaging program to improve maternal, newborn, and child health outcomes in urban slums in India.

Ear biometrics for patient identification in global health: a field study to test the effectiveness of an image stabilization device in improving identification accuracy

Background

In many low and middle-income countries (LMICs), difficulties in patient identification are a major obstacle to the delivery of longitudinal care. In absence of unique identifiers, biometrics have emerged as an attractive solution to the identification problem. We developed an mHealth App for subject identification using pattern recognition around ear morphology (Project SEARCH (Scanning EARS for Child Health). Early field work with the SEARCH App revealed that image stabilization would be required for optimum performance.

Methods

To improve image capture, we designed and tested a device (the ‘Donut’), which standardizes distance, angle, rotation and lighting. We then ran an experimental trial with 194 participants to measure the impact of the Donut on identification rates. Images of the participant’s left ear were taken both with and without use of the Donut, then processed by the SEARCH algorithm, measuring the top one and top ten most likely matches.

Results

With the Donut, the top one identification rate and top ten identification rates were 99.5 and 99.5%, respectively, vs. 38.4 and 24.1%, respectively, without the Donut (P < 0.0001 for each comparison). In sensitivity analyses, crop technique during pre-processing of images had a powerful impact on identification rates, but this too was facilitated through the Donut.

Conclusions

By standardizing lighting, angle and spatial location of the ear, the Donut achieved near perfect identification rates on a cohort of 194 participants, proving the feasibility and effectiveness of using the ear as a biometric identifier.

Trial registration

This study did not include a medical intervention or assess a medical outcome, and therefore did not meet the definition of a human subjects research study as defined by FDAAA. We did not register our study under clinicaltrials.gov.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0833-9) contains supplementary material, which is available to authorized users.

Artificial Intelligence vs. Natural Stupidity: Evaluating AI readiness for the Vietnamese Medical Information System

This review paper presents a framework to evaluate the artificial intelligence (AI) readiness for the healthcare sector in developing countries: a combination of adequate technical or technological expertise, financial sustainability, and socio-political commitment embedded in a healthy psycho-cultural context could bring about the smooth transitioning toward an AI-powered healthcare sector. Taking the Vietnamese healthcare sector as a case study, this paper attempts to clarify the negative and positive influencers. With only about 1500 publications about AI from 1998 to 2017 according to the latest Elsevier AI report, Vietnamese physicians are still capable of applying the state-of-the-art AI techniques in their research. However, a deeper look at the funding sources suggests a lack of socio-political commitment, hence the financial sustainability, to advance the field. The AI readiness in Vietnam's healthcare also suffers from the unprepared information infrastructure-using text mining for the official annual reports from 2012 to 2016 of the Ministry of Health, the paper found that the frequency of the word "database" actually decreases from 2012 to 2016, and the word has a high probability to accompany words such as "lacking", "standardizing", "inefficient", and "inaccurate." Finally, manifestations of psycho-cultural elements such as the public's mistaken views on AI or the non-transparent, inflexible and redundant of Vietnamese organizational structures can impede the transition to an AI-powered healthcare sector.

Assessment of mobile health technology for maternal and child health services in rural Upper West Region of Ghana

OBJECTIVES

This study assessed the perspectives of women and health workers on the feasibility of using mobile health technology (mHealth) for the provision of maternal and child health services in rural settings of the Upper West Region of Ghana.

STUDY DESIGN

The study used a mixed-design approach of quantitative and qualitative methods.

METHODS

Interviewer-administered questionnaires, focus group discussions (FGDs), and key informant interviews (KIIs) were employed. Participants included pregnant women, lactating mothers, and health workers from three rural districts.

RESULTS

A total of 489 interviews were conducted, consisting of 290 pregnant women and 199 lactating mothers, with an average age of 26.9 years. Some level of formal education had been received by 67.1% of participants. The mHealth intervention was implemented in the study districts via mobile phones in the form of SMS voice messages, text messages, and phone call reminders. Our results show that participants who received follow-up call reminders and messages (10.2%) from health providers about their health expressed general satisfaction and high optimism toward receiving future follow-ups via their mobile phones. The high acceptability level was also demonstrated in the FGDs and KIIs. Overall, our findings showed that this mHealth intervention was an acceptable and feasible solution to the challenges of access to healthcare services seen in rural areas. Despite the high acceptability level, participants also highlighted barriers, such as limited or erratic power supply and poor mobile network connectivity, which need to be addressed.

CONCLUSIONS

mHealth interventions targeting health providers and rural women have the potential to reduce barriers to equitable access to maternal and child healthcare services in these settings. These findings are of clear public health importance and are relevant to policy-makers in this area of service delivery and use; however, policy-makers and program implementers should be cautious of the challenges involved in the scale-up of such an intervention.

Investigating clinical handover and healthcare communication for outpatients with chronic disease in India: A mixed-methods study

OBJECTIVES

Research concentrating on continuity of care for chronic, non-communicable disease (NCD) patients in resource-constrained settings is currently limited and focusses on inpatients. Outpatient care requires attention as this is where NCD patients often seek treatment and optimal handover of information is essential. We investigated handover, healthcare communication and barriers to continuity of care for chronic NCD outpatients in India. We also explored potential interventions for improving storage and exchange of healthcare information.

METHODS

A mixed-methods design was used across five healthcare facilities in Kerala and Himachal Pradesh states. Questionnaires from 513 outpatients with cardiovascular disease, chronic respiratory disease, or diabetes covered the form and comprehensiveness of information exchange between healthcare professionals (HCPs) and between HCPs and patients. Semi-structured interviews with outpatients and HCPs explored handover, healthcare communication and intervention ideas. Barriers to continuity of care were identified through triangulation of all data sources.

RESULTS

Almost half (46%) of patients self-referred to hospital outpatient clinics (OPCs). Patient-held healthcare information was often poorly recorded on unstructured sheets of paper; 24% of OPC documents contained the following: diagnosis, medication, long-term care and follow-up information. Just 55% of patients recalled receiving verbal follow-up and medication instructions during OPC appointments. Qualitative themes included patient preference for hospital visits, system factors, inconsistent doctor-patient communication and attitudes towards medical documents. Barriers were hospital time constraints, inconsistent referral practices and absences of OPC medical record-keeping, structured patient-held medical documents and clinical handover training. Patients and HCPs were in favour of the introduction of patient-held booklets for storing and transporting medical documents.

CONCLUSIONS

Deficiencies in communicative practices are compromising the continuity of chronic NCD outpatient care. Targeted systems-based interventions are urgently required to improve information provision and exchange. Our findings indicate that well-designed patient-held booklets are likely to be an acceptable, affordable and effective part of the solution.

Assessing Ghana's eHealth workforce: implications for planning and training

BACKGROUND

eHealth-the proficient application of information and communication technology to support healthcare delivery-has been touted as one of the best solutions to address quality and accessibility challenges in healthcare. Although eHealth could be of more value to health systems in low- and middle-income countries (LMICs) where resources are limited, identification of a competent workforce which can develop and maintain eHealth systems is a key barrier to adoption. Very little is known about the actual or optimal states of the eHealth workforce needs of LMICs. The objective of this study was to develop a framework to characterize and assess the eHealth workforce of hospitals in LMICs.

METHODS

To characterize and assess the sufficiency of the workforce, we designed this study in twofold. First, we developed a general framework to categorize the eHealth workforce at any LMIC setting. Second, we combined qualitative data, using semi-structured interviews and the Workload Indicator of Staffing Needs (WISN) to assess the sufficiency of the eHealth workforce in selected hospitals in a LMIC setting like Ghana.

RESULTS

We surveyed 76 (60%) of the eHealth staff from three hospitals in Ghana-La General Hospital, University of Ghana Hospital, and Greater Accra Regional Hospital. We identified two main eHealth cadres, technical support/information technology (IT) and health information management (HIM). While the HIM cadre presented diversity in expertise, the IT group was dominated by training in Science (42%) and Engineering (55%), and the majority (87%) had at least a bachelor's degree. Health information clerk (32%), health information officer (25%), help desk specialist (20%), and network administrator (11%) were the most dominant roles. Based on the WISN assessment, the eHealth workforce at all the surveyed sites was insufficient. La General and University of Ghana were operating at 10% of required IT staff capacity, while Ridge was short by 42%.

CONCLUSIONS

We have developed a framework to characterize and assess the eHealth workforce in LMICs. Applying it to a case study in Ghana has given us a better understanding of potential eHealth staffing needs in LMICs, while providing the quantitative basis for building the requisite human capital to drive eHealth initiatives. Educators can also use our results to explore competency gaps and refine curricula for burgeoning training programs. The findings of this study can serve as a springboard for other LMICs to assess the effects of a well-trained eHealth workforce on the return on eHealth investments.

Energy poverty in healthcare facilities: a "silent barrier" to improved healthcare in sub-Saharan Africa

This paper addresses an important topic, energy poverty in healthcare facilities. We try to provide an interesting perspective on bringing together two SDGs. The SDG 7, which seeks to ensure access to affordable, sustainable, and modern energy for all, is interlinked with Goal 3 on Health. The literature studies as well as data on the subject are sparse. Nevertheless, a systematic documentation of the levels and variation in access to energy at the health-facility level is important for designing effective policies to improve the quality of healthcare and the ultimate health of the population. Using the 2012-2013 Senegal Service Provision Assessment (SCSPA), we assessed energy access in health facilities and health systems' performance. Data were also geocoded using ArcGIS 10.3 to give a snapshot of the situation.

eHealth for people with multimorbidity: Results from the ICARE4EU project and insights from the "10 e's" by Gunther Eysenbach

Background

People with multimorbidity, especially older people, have complex health and social needs, and require an integrated care approach. In this respect, eHealth could be of support. This paper aims to describe the implementation of eHealth technologies in integrated care programs for people with multimorbidity in Europe, and to analyse related benefits and barriers according to outcomes from ICARE4EU study and within the more general conceptual framework of the “10 e's” in eHealth by Gunther Eysenbach.

Methods

In 2014, ICARE4EU project identified 101 integrated care programs in 24 European countries. Expert organizations and managers of the programs completed an on-line questionnaire addressing several aspects including the adoption of eHealth. Findings from this questionnaire were analyzed, by linking in particular benefits and barriers of eHealth with the “10 e's” by Eysenbach (Efficiency, Enhancing, Evidence-based, Empowerment, Encouragement, Education, Enabling, Extending, Ethics, and Equity).

Results

Out of 101 programs, 85 adopted eHealth tools, of which 42 focused explicitly on older people. eHealth could improve care integration/management, quality of care/life and cost-efficiency, whereas inadequate funding represents a major barrier. The “10 e's” by Eysenbach seem to show contact points with ICARE4EU findings, in particular when referring to positive aspects of eHealth such as Efficiency and Enhancing quality of care/life, although Empowerment/Education of patients, care Equity and Ethics issues seem crucial in this respect. Encouragement of a new relationship patient-health professional, and Enabling standardized exchange of electronic information, represent further aspects impacting integration/management of care.

Conclusions

Aspects of eHealth, which emerged as benefits and barriers impacting integration/management of care, as well as cost-efficiency and quality of care/life, can be identified on the basis of both ICARE4EU findings and the “10 e's” in eHealth by Eysenbach. They could represent objectives of new policies for supporting the deployment of eHealth technologies within integrated care across Europe.

Designing mHealth for maternity services in primary health facilities in a low-income setting - lessons from a partially successful implementation

BACKGROUND

Increasing mobile phone ownership, functionality and access to mobile-broad band internet services has triggered growing interest to harness the potential of mobile phone technology to improve health services in low-income settings. The present project aimed at designing an mHealth system that assists midlevel health workers to provide better maternal health care services by automating the data collection and decision-making process. This paper describes the development process and technical aspects of the system considered critical for possible replication. It also highlights key lessons learned and challenges during implementation.

METHODS

The mHealth system had front-end and back-end components. The front-end component was implemented as a mobile based application while the back-end component was implemented as a web-based application that ran on a central server for data aggregation and report generation. The current mHealth system had four applications; namely, data collection/reporting, electronic health records, decision support, and provider education along the continuum of care including antenatal, delivery and postnatal care. The system was pilot-tested and deployed in selected health centers of North Shewa Zone, Amhara region, Ethiopia.

RESULTS

The system was used in 5 health centers since Jan 2014 and later expanded to additional 10 health centers in June 2016 with a total of 5927 electronic forms submitted to the back-end system. The submissions through the mHealth system were slightly lower compared to the actual number of clients who visited those facilities as verified by record reviews. Regarding timeliness, only 11% of the electronic forms were submitted on the day of the client visit, while an additional 17% of the forms were submitted within 10 days of clients' visit. On average forms were submitted 39 days after the day of clients visit with a range of 0 to 150 days.

CONCLUSIONS

In conclusion, the study illustrated that an effective mHealth intervention can be developed using an open source platform and local resources. The system impacted key health outcomes and contributed to timely and complete data submission. Lessons learned through the process including success factors and challenges are discussed.

Cost Effectiveness of Mobile Health for Antenatal Care and Facility Births in Nigeria

Background:

The use of mobile technology in the health sector, often referred to as mHealth, is an innovation that is being used in countries to improve health outcomes and increase and improve both the demand and supply of health care services. This study assesses the actual cost-effectiveness of initiating and implementing the use of the mHealth as a supply side job aid for antenatal care. The study also estimates the cost-effectiveness ratio if mHealth was also used to encourage and track women through facility delivery.

Methods:

The methodology utilized a retrospective, micro-costing technique to extract costing data from health facilities and administrative offices to estimate the costs of implementing the mHealth antenatal care program and estimate the cost of facility delivery for those that used the antenatal care services in the year 2014. Five different costing tools were developed to assist in the costing analysis.

Findings:

The results show that the provision of tetanus toxoid vaccination and malaria prophylaxis during pregnancy and improved labor and delivery during facility delivery contributed the most to mortality reductions for women, neonates and stillbirths in mHealth facilities versus non-mHealth facilities. The cost-effectiveness ratio of this program for antenatal care and no demand-side generation for facility delivery is US$13,739 per life saved. The cost-effectiveness ratio adding in an additional demand-side generation for facility births reduces to US$9,806 per life saved.

Conclusion:

These results show that mHealth programs are inexpensive and save a number of lives for the dollar investment and could save additional lives and funds if women were also encouraged to seek facility delivery.

Cost Effectiveness of Mobile Health for Antenatal Care and Facility Births in Nigeria

BACKGROUND

The use of mobile technology in the health sector, often referred to as mHealth, is an innovation that is being used in countries to improve health outcomes and increase and improve both the demand and supply of health care services. This study assesses the actual cost-effectiveness of initiating and implementing the use of the mHealth as a supply side job aid for antenatal care. The study also estimates the cost-effectiveness ratio if mHealth was also used to encourage and track women through facility delivery.

METHODS

The methodology utilized a retrospective, micro-costing technique to extract costing data from health facilities and administrative offices to estimate the costs of implementing the mHealth antenatal care program and estimate the cost of facility delivery for those that used the antenatal care services in the year 2014. Five different costing tools were developed to assist in the costing analysis.

FINDINGS

The results show that the provision of tetanus toxoid vaccination and malaria prophylaxis during pregnancy and improved labor and delivery during facility delivery contributed the most to mortality reductions for women, neonates and stillbirths in mHealth facilities versus non-mHealth facilities. The cost-effectiveness ratio of this program for antenatal care and no demand-side generation for facility delivery is US$13,739 per life saved. The cost-effectiveness ratio adding in an additional demand-side generation for facility births reduces to US$9,806 per life saved.

CONCLUSION

These results show that mHealth programs are inexpensive and save a number of lives for the dollar investment and could save additional lives and funds if women were also encouraged to seek facility delivery.

A comparison between paper-based and m-Health tools for collating and reporting clinical cases of lymphatic filariasis and podoconiosis in Ethiopia

BACKGROUND

Lymphatic filariasis (LF) and podoconiosis are disabling diseases, endemic in Ethiopia. The main clinical manifestations include lymphoedema from LF and podoconiosis, and hydrocoele from LF. To ensure access to morbidity management and disability prevention (MMDP) services, data on patient numbers in each implementation unit (IU) is required. House-to-house census is considered the gold standard for determining patient numbers, and data are usually collated and reported using paper-based methods. However, often there are delays in data reaching the regional and central level, which leads to subsequent delays in rolling out and prioritising MMDP services. The increase in mobile phone mHealth tools offers an alternative, potentially more rapid and cost-effective approach.

METHODS

As part of an LF and podoconiosis burden assessment conducted in Hawella Tula and Bensa districts in Ethiopia, this study compared the standard paper-based methods with the new MeasureSMS-Morbidity tool for clinical cases data collation and reporting. Health extension workers (HEWs) were trained on both methods. Comparisons were made on patient information; age, gender, location (i.e., kebele), condition, severity of condition and acute attacks. Data were analysed for trends, including the differences in ranking the villages in each district based on the highest to lowest number of cases. In addition, financial and human resource requirements were compared.

RESULTS

In total, 59 HEWs (19 from Hawella Tula; 40 from Bensa) collated and reported a similar number of cases by paper-based (n=2,377) and SMS (n=2,372) methods. Significant correlations were found between the two methods for all cases and lymphoedema cases in both districts, and for hydrocoele cases in Bensa district only. The total cost of paper-based reporting was 13.7% more expensive than SMS reporting due to costs associated with data collection and entry.

CONCLUSIONS

The rank correlation showed the same villages would be prioritised for delivery of MMDP services, with time and cost-savings observed using SMS reporting, suggesting it is an effective and efficient alternative tool to help facilitate care to those who need it most.

Impact of using eHealth tools to extend health services to rural areas of Nigeria: protocol for a mixed-method, non-randomised cluster trial

INTRODUCTION

eHealth solutions that use internet and related technologies to deliver and enhance health services and information are emerging as novel approaches to support healthcare delivery in sub-Saharan Africa. Using digital technology in this way can support cost-effectiveness of care delivery and extend the reach of services to remote locations. Despite the burgeoning literature on eHealth approaches, little is known about the effectiveness of eHealth tools for improving the quality and efficiency of health systems functions or client outcomes in resource-limited countries. eHealth tools including satellite communications are currently being implemented at scale, to extend health services to rural areas of Nigeria, in Ondo and Kano States and the Federal Capital Territory. This paper shares the protocol for a 2-year project ('EXTEND') that aims to evaluate the impact of eHealth tools on health system functions and health outcomes.

METHODOLOGY AND ANALYSIS

This multisite, mixed-method evaluation includes a non-randomised, cluster trial design. The study comprises three phases-baseline, midline and endline evaluations-that involve: (1) process evaluation of video training and digitisation of health data interventions; (2) evaluation of contextual influences on the implementation of interventions; and (3) impact evaluation of results of the project. A convergent mixed-method model will be adopted to allow integration of quantitative and qualitative findings to achieve study objectives. Multiple quantitative and qualitative datasets will be repeatedly analysed and triangulated to facilitate better understanding of impact of eHealth tools on health worker knowledge, quality and efficiency of health systems and client outcomes.

ETHICS AND DISSEMINATION

Ethics approvals were obtained from the University of Leeds and three States' Ministries of Health in Nigeria. All data collected for this study will be anonymised and reports will not contain information that could identify respondents. Study findings will be presented to Ministries of Health at scientific conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN32105372; Pre-results.

Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus

OBJECTIVE

To identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes.

DESIGN

Systematic review and Delphi study.

METHODS

We searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists.

RESULTS

We included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators.

CONCLUSIONS

The proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable.

PROSPERO REGISTRATION NUMBER

CRD42015027351.

Data-informed decision-making for life-saving commodities investments in Malawi: A qualitative case study

Background

During the last 15 years, Malawi has made remarkable progress in reducing child mortality. However, maternal and newborn mortality remains persistently high. To help address these entrenched challenges, the Reproductive, Maternal, Newborn and Child Health (RMNCH) Trust Fund provided short-term catalytic financing of $11.5 million (2013-2016) to support country plans to advance the RMNCH and commodity agenda.

Objectives

(1) To document how Malawi (ministries, partners, working groups) used evidence to inform decision-making and RMNCH investments, (2) To identify barriers to utilizing information and evidence in the planning and prioritization process at national and sub-national levels, and (3) To assess the utility of the RMNCH Landscape Synthesis, which uses existing information to review life-saving RMNCH commodities and services.

Methods

This was a qualitative case study utilizing a Rapid Appraisal (RA) approach, where semi-structured interviews were conducted with staff members from UN agencies, development partners and the Ministry of Health (MoH) at national and district level. The analysis enlists a framework approach for manual qualitative content analysis.

Results

Led by the MoH, the RMNCH Trust Fund grant proposal utilized an evidence-based and equity-focused process for prioritization of investments. Data-informed decision-making permeates similar commodity-focused working groups. However, common health information system (HIS) weaknesses, such as data quality and collection burden, persist and are more prevalent at district-level. The collation of evidence in the RMNCH Landscape Synthesis was a useful and sustainable tool to support planning.

Conclusions

The evidence-based, equity-focused decision-making process for the RMNCH Trust Fund proposal provides an effective model for inter-agency investment prioritization. Strengthening data-informed decision-making will require financial and political commitments to HIS and capacity building for data use, particularly at the district-level. New initiatives (e.g. Health Data Collaborative and QED Network to Improve Quality of Care) provide opportunities to further improve evidence-informed decision-making.

Overcoming the Maternal Care Crisis: How Can Lessons Learnt in Global Health Informatics Address US Maternal Health Outcomes?

Despite unprecedented spending, US maternal outcomes have worsened drastically over the past decade. In comparison, maternal outcomes of many Low and Middle-Income Countries (LMIC) have improved. Lessons learnt by their success may be applicable to the US. We performed a literature review to identify innovations that had met with success across LMIC, and should be considered for adoption in the US. mHealth and patient facing alerts, Telehealth, patient controlled health records, inclusion of patient relationship data in health information systems and positioning empowered community health workers as catalysts of maternal care delivery were identified as innovations worthy of further evaluation. These innovations were categorized into several themes; knowledge, technology, patient/community empowerment, coordination and process change. Tools that place informed and empowered patients and community members at the center of maternal care has greatly improved maternal outcomes, and are suitable to be considered for the US healthcare system.

Addressing gaps in international blood availability and transfusion safety in low- and middle-income countries: a NHLBI workshop

In April 2017, a workshop sponsored by the National Heart, Lung, and Blood Institute, Division of Blood Diseases and Resources, and the Center for Translation Research and Implementation Science was held to discuss blood availability and transfusion safety in low- and middle-income countries (LMICs). The purpose of the workshop was to identify research opportunities for implementation science (IS) to improve the availability of safe blood and blood components and transfusion practices in LMICs. IS describes the late stages of the translational research spectrum and studies optimal and sustainable strategies to deliver proven-effective interventions. Regional working groups were formed to focus on opportunities and challenges in East Africa, Central/West Africa, Middle East and North Africa, Latin America and the Caribbean, Southeast Asia, Western Pacific Asia, Eastern Europe, and Central Asia. The need for an "adequate supply of safe blood" emerged as the major overriding theme. Among the regional working groups, common cross-cutting themes were evident. The majority of research questions, priorities, and strategies fell into the categories of blood availability, blood transfusion safety, appropriate use of blood, quality systems, health economics and budgeting, and training and education in IS. The workshop also brought into focus inadequate country-level data that can be used as the basis for IS initiatives. A mixed approach of needs assessment and targeted interventions with sufficient evidence base to move toward sustainment is an appropriate next step for blood availability and transfusion safety research in LMICs.

Using eHealth to engage and retain priority populations in the HIV treatment and care cascade in the Asia-Pacific region: a systematic review of literature

BACKGROUND

The exponential growth in the reach and development of new technologies over the past decade means that mobile technologies and social media play an increasingly important role in service delivery models to maximise HIV testing and access to treatment and care. This systematic review examines the impact of electronic and mobile technologies in medical care (eHealth) in the linkage to and retention of priority populations in the HIV treatment and care cascade, focussing on the Asia-Pacific region.

METHODS

The review was informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement from the Cochrane Collaboration guidelines. Both grey and published scientific literature from five different databases were searched for all original articles in English published from 2010 to 2017. Studies conducted outside the Asia-Pacific region or not including HIV priority populations were excluded. The methodological quality of studies included in the review was assessed using the Quality Assessment Tool for Quantitative Studies.

RESULTS

The database search identified 7309 records. Of the 224 peer-reviewed articles identified for full text review, 16 studies from seven countries met inclusion criteria. Six cross sectional studies found evidence to support the use of eHealth, via text messages, instant messaging, social media and health promotion websites, to increase rates of HIV testing and re-testing among men who have sex with men (MSM). Evidence regarding the efficacy of eHealth interventions to improve antiretroviral treatment (ART) adherence was mixed, where one randomised controlled trial (RCT) showed significant benefit of weekly phone call reminders on improving ART adherence. Three further RCTs found that biofeedback eHealth interventions that provided estimated ART plasma concentration levels, showed promising results for ART adherence.

CONCLUSIONS

This review found encouraging evidence about how eHealth can be used across the HIV treatment and care cascade in the Asia-Pacific region, including increasing HIV testing and re-testing in priority populations as well as ART adherence. eHealth interventions have an important role to play in the movement towards the end of AIDS, particularly to target harder-to-reach HIV priority populations, such as MSM.

eRegQual-an electronic health registry with interactive checklists and clinical decision support for improving quality of antenatal care: study protocol for a cluster randomized trial

Background

Health worker compliance with established best-practice clinical and public health guidelines may be enhanced by customized checklists of care and clinical decision support driven by point-of-care data entry into an electronic health registry. The public health system of Palestine is currently implementing a national electronic registry (eRegistry) for maternal and child health. This trial is embedded in the national implementation and aims to assess the effectiveness of the eRegistry’s interactive checklists and clinical decision support, compared with the existing paper based records, on improving the quality of care for pregnant women.

Methods

This two-arm cluster randomized controlled trial is conducted in the West Bank, Palestine, and includes 120 clusters (primary healthcare clinics) with an average annual enrollment of 60 pregnancies. The intervention tool is the eRegistry’s interactive checklists and clinical decision support implemented within the District Health Information System 2 (DHIS2) Tracker software, developed and customized for the Palestinian context. The primary outcomes reflect the processes of essential interventions, namely timely and appropriate screening and management of: 1) anemia in pregnancy; 2) hypertension in pregnancy; 3) abnormal fetal growth; 4) and diabetes mellitus in pregnancy. The composite primary health outcome encompasses five conditions representing risk for the mother or baby that could have been detected or prevented by high-quality antenatal care: moderate or severe anemia at admission for labor; severe hypertension at admission for labor; malpresentation at delivery undetected during pregnancy; small for gestational age baby at delivery undetected during pregnancy; and large for gestational age baby at delivery. Primary analysis at the individual level taking the design effect of the clustering into account will be performed as intention-to-treat.

Discussion

This trial, embedded in the national implementation of the eRegistry in Palestine, allows the assessment of process and health outcomes in a large-scale pragmatic setting. Findings will inform the use of interactive checklists and clinical decision support driven by point-of-care data entry into an eRegistry as a health systems-strengthening approach.

Trial registration

ISRCTN trial registration number, ISRCTN18008445. Registered on 6 April 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2386-5) contains supplementary material, which is available to authorized users.

Discussion of “Evidence-based Health Informatics: How Do We Know What We Know?”

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper “Evidence-based Health Informatics: How Do We Know What We Know?” written by Elske Ammenwerth [1]. It is introduced by an editorial. This article contains the combined commentaries invited to independently comment on the Ammenwerth paper. In subsequent issues the discussion can continue through letters to the editor.

With these comments on the paper “Evidence-based Health Informatics: How do we know what we know?”, written by Elske Ammenwerth [1], the journal seeks to stimulate a broad discussion on the challenges of evaluating information processing and information technology in health care. An international group of experts has been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.