To improve the completeness of reporting of mobile health (mHealth) interventions, the WHO mHealth Technical Evidence Review Group developed the mHealth evidence reporting and assessment (mERA) ...checklist. The development process for mERA consisted of convening an expert group to recommend an appropriate approach, convening a global expert review panel for checklist development, and pilot testing the checklist. The guiding principle for the development of these criteria was to identify a minimum set of information needed to define what the mHealth intervention is (content), where it is being implemented (context), and how it was implemented (technical features), to support replication of the intervention. This paper presents the resulting 16 item checklist and a detailed explanation and elaboration for each item, with illustrative reporting examples. Through widespread adoption, we expect that the use of these guidelines will standardise the quality of mHealth evidence reporting, and indirectly improve the quality of mHealth evidence.
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The disruptive potential of mobile phones in catalyzing development is increasingly being recognized. However, numerous gaps remain in access to phones and their influence on health care utilization. ...In this cross-sectional study from India, we assess the gaps in women's access to phones, their influencing factors, and their influence on health care utilization.
Data drawn from the 2015 National Family Health Survey (NFHS) in India included a national sample of 45,231 women with data on phone access. Survey design weighted estimates of household phone ownership and women's access among different population sub-groups are presented. Multilevel logistic models explored the association of phone access with a wide range of maternal and child health indicators. Blinder-Oaxaca (BO) decomposition is used to decompose the gaps between women with and without phone access in health care utilization into components explained by background characteristics influencing phone access (endowments) and unexplained components (coefficients), potentially attributable to phone access itself.
Phone ownership at the household level was 92·8% (95% CI: 92·6-93·0%), with rural ownership at 91·1% (90·8-91·4%) and urban at 97.1% (96·7-97·3%). Women's access to phones was 47·8% (46·7-48·8%); 41·6% in rural areas (40·5-42·6%) and 62·7% (60·4-64·8%) in urban. Phone access in urban areas was positively associated with skilled birth attendance, postnatal care and use of modern contraceptives and negatively associated with early antenatal care. Phone access was not associated with improvements in utilization indicators in rural settings. Phone access (coefficient components) explained large gaps in the use of modern contraceptives, moderate gaps in postnatal care and early antenatal care, and smaller differences in the use of skilled birth attendance and immunization. For full antenatal car, phone access was associated with reducing gaps in utilization.
Women of reproductive age have significantly lower phone access use than the households they belong to and marginalized women have the least phone access. Existing phone access for rural women did not improve their health care utilization but was associated with greater utilization for urban women. Without addressing these biases, digital health programs may be at risk of worsening existing health inequities.
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The ‘continuum of care’ is proposed as a key framework for the delivery of maternal, neonatal and child health services. This study examined the extent of dropout as well as factors associated with ...retention across the MNCH continuum from antenatal care (ANC), through skilled birth attendance (SBA), to postnatal care (PNC).
We analyzed data from 1931 women who delivered in the preceding 2–14 months, from a twostage cluster sampling household survey in four districts of Tanzania’s Morogoro region. The survey was conducted in 2011 as a part of a baseline for an independent evaluation of a maternal health program. Using the Anderson model of health care seeking, we fitted logistic models for three transition stages in the continuum.
Only 10% of women received the ‘recommended’care package (4+ANC visits, SBA, and 1+PNC visit), while 1% reported not having care at any stage. Receipt of four ANC visits was positively associated with women being older in age (age 20–34 years—OR: 1.77, 95% CI: 1.22–2.56; age 35–49 years—2.03, 1.29–3.2), and knowledge of danger signs (1.75, 1.39–2.1). A pro-rich bias was observed in facility-based deliveries (proxy for SBA), with women from the fourth (1.66, 1.12–2.47) and highest quintiles of household wealth (3.4, 2.04–5.66) and the top tertile of communities by wealth (2.9, 1.14–7.4). Higher rates of facility deliveries were also reported with antenatal complications (1.37, 1.05–1.79), and 4+ANC visits (1.55, 1.14–2.09). Returning for PNC was highest among the wealthiest communities (2.25, 1.21–4.44); catchment areas of a new PNC program (1.89, 1.03–3.45); knowledge of danger signs (1.78, 1.13–2.83); community health worker counselling (4.22, 1.97–9.05); complicated delivery (3.25, 1.84–5.73); and previous health provider counselling on family planning (2.39, 1.71–3.35).
Dropout from maternal care continuum is high, especially for the poorest, in rural Tanzania. Interactions with formal health system and perceived need for future services appear to be important factors for retention.
”连续照护”是孕产妇、新生儿和儿童健康服务提供的关键框 架。MNCH 连续照护是从产前护理 （ANC） 、熟练助产护 理 （SBA） 到产后护理（PNC） 的连续过程, 本研究调查中途 退出 MNCH连续照护和继续使用的相关因素。
我们在坦桑尼亚莫罗戈罗省的四个区采用二阶段整群抽样住 户调查, 收集并分析了过去2-14个月分娩的 1931 位妇女的数 据并分析。该调查于 2011 年进行, 是一项孕产妇健康项目独 立评估基线调查的一部分。采用安德森模型分析求医行为, 建 立 Logistic 模型分析连续照护中的三个过渡阶段。
仅10%的妇女接受了推荐的整体护理 （4+ANC, SBA和1+PNC）, 1%的妇女未在任何阶段使用 MUCH 护理。接受四次 ANC 检查与年龄呈正相关（20–34 岁： OR=1.77, 95%CI 1.22–2.56； 35–49 岁： OR=2.03, 95%CI 1.29–3.2）, 与对危 险体征的了解也呈正相关 （1.75, 1.39–2.1） 。院内分娩 （SBA 的代理变量） 显示偏向富人的偏倚, 最富裕五分之一 和其次家庭的妇女院内分娩较高 （3.4, 2.04–5.66； 1.66, 1.12–2.47）, 最富裕的三分之一社区的妇女院内分娩也较高 （2.9, 1.14–7.4） 。 高院内分娩率还与产前并发症 （1.37, 1.05–1.79） 和接受4þ ANC 检查相关（1.55, 1.14–2.09） 。 与 返回医疗机构接受PNC 关联最强的是最富裕社区 （2.25, 1.21–4.44） ；新 PNC 项目服务地区 （1.89, 1.03–3.45） ； 了 解危险体征 （1.78, 1.13–2.83） ； 有社区卫生工作者咨询服务 （4.22, 1.97–9.05） ； 并发症分娩 （3.25, 1.84–5.73）； 和既 往计划生育咨询 （2.39, 1.71–3.35） 。
中途退出连续孕产妇保健的比例较高, 尤其是在坦桑尼亚贫困 人口和农村地区。与卫生体系的接触和对未来医疗服务需求 的预估可能是继续使用孕产妇保健的重要因素。
El ‘continuo de la atención’ se propone como un marco clave para la prestación de servicios de salud materna, neonatal e infantil (SMNI). Este estudio examinó el grado de deserción, así como los factores asociados con la retención a través del continuo de SMNI desde el cuidado prenatal (CPN), a través de la asistencia especializada en el parto (AEP), a la atención postnatal (APN).
Analizamos los datos de 1931 mujeres que dieron a luz entre los 2 y 14 meses anteriores, de una encuesta de hogares de muestreo por grupos de dos etapas en cuatro distritos de la región de Morogoro en Tanzania. La encuesta se llevó a cabo en 2011 como parte de una línea de base para una evaluación independiente de un programa de salud materna. Usando el modelo de Anderson de la búsqueda de atención de salud, ajustamos los modelos logísticos para tres etapas de transición en el continuo.
Sólo el 10% de las mujeres recibieron el paquete de atención “recomendado” (4+ visitas de CPN, AEP y 1 visita APN), mientras que el 1% informó que no había recibido atención en ninguna etapa. Haber recibido cuatro visitas de CPN se asoció positivamente con mujeres mayores en edad (edad 20-34 años—RP: 1.77, IC 95%: 1.22-2.56, edad 35 a 49 años—2.03, 1.29-3.2) y conocimiento de las señales de peligro (1.75, 1.39 – 2.1). Se observó un sesgo favorable a los ricos en los partos basados en instalaciones (lo cual representa la AEP), con las mujeres del cuarto quintil (1.66, 1.12-2.47) y el quintil más altos de la riqueza de los hogares (3.4, 2.04-5.66) y el tercio superior de las comunidades por riqueza (2.9, 1.14-7.4). También se reportaron tasas más altas de partos en instalaciones con complicaciones prenatales (1.37, 1.05-1.79), y 4+ visitas de CPN (1.55, 1.14- 2.09). El regreso a la APN fue mayor entre las comunidades más ricas (2.25, 1.21-4.44); áreas de captación de un nuevo programa de APN (1.89, 1.03-3.45); conocimiento de señales de peligro (1.78, 1.13-2.83); asesoramiento de trabajadores comunitarios de salud (4.22, 1.97-9.05); parto complicado (3.25, 1.84 – 5.73); y asesoramiento previo de proveedores de salud sobre planeación familiar (2.39, 1.71-3.35).
La deserción del continuo de la atención materna es alta, especialmente para los más pobres, en las zonas rurales de Tanzania. Las interacciones con el sistema formal de la salud y la necesidad percibida de servicios futuros parecen ser factores importantes para la retención.
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We examined the incremental cost-effectiveness between two mHealth programs, implemented from 2011 to 2015 in rural Bangladesh: (1) Comprehensive mCARE package as an intervention group and (2) Basic ...mCARE package as a control group.
Both programs included a core package of census enumeration and pregnancy surveillance provided by an established cadre of digitally enabled community health workers (CHWs). In the comprehensive mCARE package, short message service (SMS) and home visit reminders were additionally sent to pregnant women (n = 610) and CHWs (n = 70) to promote the pregnant women's care-seeking of essential maternal and newborn care services. Economic costs were assessed from a program perspective inclusive of development, start-up, and implementation phases. Effects were calculated as disability adjusted life years (DALYs) and the number of newborn deaths averted. For comparative purposes, we normalized our evaluation to estimate total costs and total newborn deaths averted per 1 million people in a community for both groups. Uncertainty was assessed using probabilistic sensitivity analyses with Monte Carlo simulation.
The addition of SMS and home visit reminders based on a mobile phone-facilitated pregnancy surveillance system was highly cost effective at a cost per DALY averted of $31 (95% uncertainty range: $19-81). The comprehensive mCARE program had at least 88% probability of being highly cost-effective as compared to the basic mCARE program based on the threshold of Bangladesh's GDP per capita.
mHealth strategies such as SMS and home visit reminders on a well-established pregnancy surveillance system may improve service utilization and program cost-effectiveness in low-resource settings.
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In South Africa, breastfeeding promotion is a national health priority. Regular perinatal home visits by community health workers (CHWs) have helped promote exclusive breastfeeding (EBF) in ...underresourced settings. Innovative, digital approaches including mobile video content have also shown promise, especially as access to mobile technology increases among CHWs. We measured the effects of an animated, mobile video series, the Philani MObile Video Intervention for Exclusive breastfeeding (MOVIE), delivered by a cadre of CHWs ("mentor mothers"). We conducted a stratified, cluster-randomized controlled trial from November 2018 to March 2020 in Khayelitsha, South Africa. The trial was conducted in collaboration with the Philani Maternal Child Health and Nutrition Trust, a nongovernmental community health organization. We quantified the effect of the MOVIE intervention on EBF at 1 and 5 months (primary outcomes), and on other infant feeding practices and maternal knowledge (secondary outcomes). We randomized 1,502 pregnant women in 84 clusters 1:1 to 2 study arms. Participants' median age was 26 years, 36.9% had completed secondary school, and 18.3% were employed. Mentor mothers in the video intervention arm provided standard-of-care counseling plus the MOVIE intervention; mentor mothers in the control arm provided standard of care only. Within the causal impact evaluation, we nested a mixed-methods performance evaluation measuring mentor mothers' time use and eliciting their subjective experiences through in-depth interviews. This trial measured the effect of a video-based, mobile health (mHealth) intervention, delivered by CHWs during home visits in an underresourced setting. The videos replaced about two-fifths of CHWs' direct engagement time with participants in the intervention arm. The similar outcomes in the 2 study arms thus suggest that the videos were as effective as face-to-face counselling, when CHWs used them to replace a portion of that counselling. Where CHWs are scarce, mHealth video interventions could be a feasible and practical solution, supporting the delivery and scaling of community health promotion services.
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Despite the growing use of technology in the health sector, little evidence is available on the technological performance of mobile health programs nor on the willingness of target users to utilize ...these technologies as intended (behavioral performance). In this case study of the Mobile Technology for Health (MOTECH) program in Ghana, we assess the platform's effectiveness in delivering messages, along with user response across sites in five districts from 2011 to 2014.
MOTECH is comprised of "Client Data Application" (CDA) which allows providers to digitize and track service delivery information for women and infants and "Mobile Midwife" (MM) which sends automated educational voice messages to the mobile phones of pregnant and postpartum women. Using a naturalist study design, we draw upon system generated data to evaluate message delivery, client engagement, and provider responsiveness to MOTECH over time and by level of facility.
A total of 7,370 women were enrolled in MM during pregnancy and 14,867 women were enrolled postpa1rtum. While providers were able to register and upload patient-level health information using CDA, the majority of these uploads occurred in Community-based facilities versus Health Centers. For MM, 25% or less of expected messages were received by pregnant women, despite the majority (>77%) owning a private mobile phone. While over 80% of messages received by pregnant women were listened to, postpartum rates of listening declined over time. Only 25% of pregnant women received and listened to at least 1 first trimester message. By 6-12 months postpartum, less than 6% of enrolled women were exposed to at least one message.
Caution should be exercised in assuming that digital health programs perform as intended. Evaluations should measure the technological, behavioral, health systems, and/or community factors which may lead to breaks in the impact pathway and influence findings on effectiveness. The MOTECH platform's technological limitations in 'pushing' out voice messages highlights the need for more timely use of data to mitigate delivery challenges and improve exposure to health information. Alternative message delivery channels (USSD or SMS) could improve the platform's ability to deliver messages but may not be appropriate for illiterate users.
Not applicable.
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With the aim to support further understanding of scaling up and sustaining digital health, we explore digital health solutions that have or are anticipated to reach national scale in South Africa: ...the Perinatal Problem Identification Programme (PPIP) and Child Healthcare Problem Identification Programme (Child PIP) (mortality audit reporting and visualisation tools), MomConnect (a direct to consumer maternal messaging and feedback service) and CommCare (a community health worker data capture and decision-support application).
A framework integrating complexity and scaling up processes was used to conceptually orient the study. Findings are presented by case in four domains: value proposition, actors, technology and organisational context. The scale and use of PPIP and Child PIP were driven by 'champions'; clinicians who developed technically simple tools to digitise clinical audit data. Top-down political will at the national level drove the scaling of MomConnect, supported by ongoing financial and technical support from donors and technical partners. Donor preferences played a significant role in the selection of CommCare as the platform to digitise community health worker service information, with a focus on HIV and TB. A key driver of scale across cases is leadership that recognises and advocates for the value of the digital health solution. The technology need not be complex but must navigate the complexity of operating within an overburdened and fragmented South African health system. Inadequate and unsustained investment from donors and government, particularly in human resource capacity and robust monitioring and evaluation, continue to threaten the sustainability of digital health solutions.
There is no single pathway to achieving scale up or sustainability, and there will be successes and challenges regardless of the configuration of the domains of value proposition, technology, actors and organisational context. While scaling and sustaining digital solutions has its technological challenges, perhaps more complex are the idiosyncratic factors and nature of the relationships between actors involved. Scaling up and sustaining digital solutions need to account for the interplay of the various technical and social dimensions involved in supporting digital solutions to succeed, particularly in health systems that are themselves social and political dynamic systems.
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While the importance of mHealth scale-up has been broadly emphasized in the mHealth community, it is necessary to guide scale up efforts and investment in ways to help achieve the mortality reduction ...targets set by global calls to action such as the Millennium Development Goals, not merely to expand programs. We used the Lives Saved Tool (LiST)--an evidence-based modeling software--to identify priority areas for maternal and neonatal health services, by formulating six individual and combined interventions scenarios for two countries, Bangladesh and Uganda. Our findings show that skilled birth attendance and increased facility delivery as targets for mHealth strategies are likely to provide the biggest mortality impact relative to other intervention scenarios. Although further validation of this model is desirable, tools such as LiST can help us leverage the benefit of mHealth by articulating the most appropriate delivery points in the continuum of care to save lives.
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Mobile phones have the potential to increase access to health information, improve patient–provider communication, and influence the content and quality of health services received. Evidence on the ...gender gap in ownership of mobile phones is limited, and efforts to link phone ownership among women to care-seeking and practices for reproductive maternal newborn and child health (RMNCH) have yet to be made. This analysis aims to assess household and women’s access to phones and its effects on RMNCH health outcomes in 15 countries for which Demographic and Health Surveys data on phone ownership are available. Multilevel logistic regression models were used to explore factors associated with women’s phone ownership, along with the association of phone ownership to a wide range of RMNCH indicators. Study findings suggest that (1) gender gaps in mobile phone ownership vary, but they can be substantial, with less than half of women owning mobile phones in several countries; (2) the gender gap in phone ownership is larger for rural and poorer women; (3) women’s phone ownership is generally associated with better RMNCH indicators; (4) among women phone owners, utilisation of RMNCH care-seeking and practices differs based on their income status; and (5) more could be done to unleash the potential of mobile phones on women’s health if data gaps and varied metrics are addressed. Findings reinforce the notion that without addressing the gender gap in phone ownership, digital health programmes may be at risk of worsening existing health inequities.
In South Africa, rates of exclusive breastfeeding remain low and breastfeeding promotion is a national health priority. Mobile health and narrative entertainment-education are recognized strategies ...for health promotion. In-home counseling by community health workers (CHWs) is a proven breastfeeding promotion strategy. This protocol outlines a cluster-randomized controlled trial with a nested mixed-methods evaluation of the MObile Video Intervention for Exclusive breastfeeding (MOVIE) program. The evaluation will quantify the causal effect of the MOVIE program and generate a detailed understanding of the context in which the intervention took place and the mechanisms through which it enacted change. Findings from the study will inform the anticipated scale-up of mobile video health interventions in South Africa and the wider sub-Saharan region.
We will conduct a stratified cluster-randomized controlled trial in urban communities of the Western Cape, to measure the effect of the MOVIE intervention on exclusive breastfeeding and other infant feeding practices. Eighty-four mentor-mothers (CHWs employed by the Philani Maternal Child Health and Nutrition Trust) will be randomized 1:1 into intervention and control arms, stratified by neighborhood type. Mentor-mothers in the control arm will provide standard of care (SoC) perinatal in-home counseling. Mentor-mothers in the intervention arm will provide SoC plus the MOVIE intervention. At least 1008 pregnant participants will be enrolled in the study and mother-child pairs will be followed until 5 months post-delivery. The primary outcomes of the study are exclusive breastfeeding at 1 and 5 months of age. Secondary outcomes are other infant feeding practices and maternal knowledge. In order to capture human-centered underpinnings of the intervention, we will conduct interviews with stakeholders engaged in the intervention design. To contextualize quantitative findings and understand the mechanisms through which the intervention enacted change, end-line focus groups with mentor-mothers will be conducted.
This trial will be among the first to explore a video-based, entertainment-education intervention delivered by CHWs and created using a community-based, human-centered design approach. As such, it could inform health policy, with regards to both the routine adoption of this intervention and, more broadly, the development of other entertainment-education interventions for health promotion in under-resourced settings.
The study and its outcomes were registered at clinicaltrials.gov ( #NCT03688217 ) on September 27th, 2018.
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