Michelle Helena van Velthoven

mHealth adoption in low-resource environments : a review of the use of mobile healthcare in developing countries

The acknowledged potential of using mobile phones for improving healthcare in low-resource environments of developing countries has yet to translate into significant mHealth policy investment. The low uptake of mHealth in policy agendas may stem from a lack of evidence of the scalable, sustainable impact on health indicators. The mHealth literature in low- and middle-income countries reveals a burgeoning body of knowledge; yet, existing reviews suggest that the projects yield mixed results. This article adopts a stage-based approach to understand the varied contributions to mHealth research. The heuristic of inputs-mechanism-outputs is proposed as a tool to categorize mHealth studies. This review (63 articles comprising 53 studies) reveals that mHealth studies in developing countries tend to concentrate on specific stages, principally on pilot projects that adopt a deterministic approach to technological inputs (n = 32), namely introduction and implementation. Somewhat less studied were research designs that demonstrate evidence of outputs (n = 15), such as improvements in healthcare processes and public health indicators. The review finds a lack of emphasis on studies that provide theoretical understanding (n = 6) of adoption and appropriation of technological introduction that produces measurable health outcomes. As a result, there is a lack of dominant theory, or measures of outputs relevant to making policy decisions. Future work needs to aim for establishing theoretical and measurement standards, particularly from social scientific perspectives, in collaboration with researchers from the domains of information technology and public health. Priorities should be set for investments and guidance in evaluation disseminated by the scientific community to practitioners and policymakers.

Integrating Prevention of Mother-to-Child HIV Transmission Programs to Improve Uptake: A Systematic Review

Background We performed a systematic review to assess the effect of integrated perinatal prevention of mother-to-child transmission of HIV interventions compared to non- or partially integrated services on the uptake in low- and middle-income countries. Methods We searched for experimental, quasi-experimental and controlled observational studies in any language from 21 databases and grey literature sources. Results Out of 28 654 citations retrieved, five studies met our inclusion criteria. A cluster randomized controlled trial reported higher probability of nevirapine uptake at the labor wards implementing HIV testing and structured nevirapine adherence assessment (RRR 1.37, bootstrapped 95% CI, 1.04–1.77). A stepped wedge design study showed marked improvement in antiretroviral therapy (ART) enrolment (44.4% versus 25.3%, p<0.001) and initiation (32.9% versus 14.4%, p<0.001) in integrated care, but the median gestational age of ART initiation (27.1 versus 27.7 weeks, p = 0.4), ART duration (10.8 versus 10.0 weeks, p = 0.3) or 90 days ART retention (87.8% versus 91.3%, p = 0.3) did not differ significantly. A cohort study reported no significant difference either in the ART coverage (55% versus 48% versus 47%, p = 0.29) or eight weeks of ART duration before the delivery (50% versus 42% versus 52%; p = 0.96) between integrated, proximal and distal partially integrated care. Two before and after studies assessed the impact of integration on HIV testing uptake in antenatal care. The first study reported that significantly more women received information on PMTCT (92% versus 77%, p<0.001), were tested (76% versus 62%, p<0.001) and learned their HIV status (66% versus 55%, p<0.001) after integration. The second study also reported significant increase in HIV testing uptake after integration (98.8% versus 52.6%, p<0.001). Conclusion Limited, non-generalizable evidence supports the effectiveness of integrated PMTCT programs. More research measuring coverage and other relevant outcomes is urgently needed to inform the design of services delivering PMTCT programs.

The Uptake of Integrated Perinatal Prevention of Mother-to-Child HIV Transmission Programs in Low- and Middle-Income Countries: A Systematic Review

Background The objective of this review was to assess the uptake of WHO recommended integrated perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions in low- and middle-income countries. Methods and Findings We searched 21 databases for observational studies presenting uptake of integrated PMTCT programs in low- and middle-income countries. Forty-one studies on programs implemented between 1997 and 2006, met inclusion criteria. The proportion of women attending antenatal care who were counseled and who were tested was high; 96% (range 30–100%) and 81% (range 26–100%), respectively. However, the overall median proportion of HIV positive women provided with antiretroviral prophylaxis in antenatal care and attending labor ward was 55% (range 22–99%) and 60% (range 19–100%), respectively. The proportion of women with unknown HIV status, tested for HIV at labor ward was 70%. Overall, 79% (range 44–100%) of infants were tested for HIV and 11% (range 3–18%) of them were HIV positive. We designed two PMTCT cascades using studies with outcomes for all perinatal PMTCT interventions which showed that an estimated 22% of all HIV positive women attending antenatal care and 11% of all HIV positive women delivering at labor ward were not notified about their HIV status and did not participate in PMTCT program. Only 17% of HIV positive antenatal care attendees and their infants are known to have taken antiretroviral prophylaxis. Conclusion The existing evidence provides information only about the initial PMTCT programs which were based on the old WHO PMTCT guidelines. The uptake of counseling and HIV testing among pregnant women attending antenatal care was high, but their retention in PMTCT programs was low. The majority of women in the included studies did not receive ARV prophylaxis in antenatal care; nor did they attend labor ward. More studies evaluating the uptake in current PMTCT programs are urgently needed.

Text Messaging Data Collection for Monitoring an Infant Feeding Intervention Program in Rural China: Feasibility Study

Background An effective data collection method is crucial for high quality monitoring of health interventions. The traditional face-to-face data collection method is labor intensive, expensive, and time consuming. With the rapid increase of mobile phone subscribers, text messaging has the potential to be used for evaluation of population health interventions in rural China. Objective The objective of this study was to explore the feasibility of using text messaging as a data collection tool to monitor an infant feeding intervention program. Methods Participants were caregivers of children aged 0 to 23 months in rural China who participated in an infant feeding health education program. We used the test-retest method. First, we collected data with a text messaging survey and then with a face-to-face survey for 2 periods of 3 days. We compared the response rate, data agreement, costs, and participants’ acceptability of the two methods. Also, we interviewed participants to explore their reasons for not responding to the text messages and the reasons for disagreement in the two methods. In addition, we evaluated the most appropriate time during the day for sending text messages. Results We included 258 participants; 99 (38.4%) participated in the text messaging survey and 177 (68.6%) in the face-to-face survey. Compared with the face-to-face survey, the text messaging survey had much lower response rates to at least one question (38.4% vs 68.6%) and to all 7 questions (27.9% vs 67.4%) with moderate data agreement (most kappa values between .5 and .75, the intraclass correlation coefficients between .53 to .72). Participants who took part in both surveys gave the same acceptability rating for both methods (median 4.0 for both on a 5-point scale, 1=disliked very much and 5=liked very much). The costs per questionnaire for the text messaging method were much lower than the costs for the face-to-face method: ¥19.7 (US

mHealth series: New ideas for mHealth data collection implementation in low- and middle-income countries.

3.13) versus ¥33.9 (US

Poor infant and young child feeding practices and sources of caregivers’ feeding knowledge in rural Hebei Province, China: findings from a cross-sectional survey

5.39) for all questionnaires, and ¥27.1 (US

mHealth Series: mHealth project in Zhao County, rural China - Description of objectives, field site and methods.

4.31) versus ¥34.4 (US

mHealth Series: Measuring maternal newborn and child health coverage by text messaging - a county-level model for China.

5.47) for completed questionnaires. The main reasons for not replying were that participants did not receive text messages, they were too busy to reply, or they did not see text messages in time. The main reasons for disagreement in responses were that participants forgot their answers in the text messaging survey and that they changed their minds. We found that participants were more likely to reply to text messages immediately during 2 time periods: 8 AM to 3 PM and 8 PM to 9 PM. Conclusions The text messaging method had reasonable data agreement and low cost, but a low response rate. Further research is needed to evaluate effectiveness of measures that can increase the response rate, especially in collecting longitudinal data by text messaging.

Telephone consultation for improving health of people living with or at risk of HIV: a systematic review.

The use of mobile devices in healthcare, or mHealth, has the potential to play an important role in low– and middle–income countries in a wide range of areas. A particular area with great potential to improve global health is using mHealth for data collection. We propose three ideas: (i) to validate and conduct household surveys, (ii) to monitor large–scale programs, and (iii) to measure the global burden of disease. We need to know more about mHealth interventions and their validity to maximise their potential.

Feasibility of extracting data from electronic medical records for research: an international comparative study.

Objectives To obtain a general overview of infant and young child feeding practices in one rural county in China and identify current delivery channels and challenges. Design A cross-sectional study. Setting A rural county, Zhao County, in Hebei Province, China. Participants 10 clusters were first selected within each township (16 townships in total) with proportional to population size sampling. In each cluster, a name list was used to select 13 children aged 0–23 months. We interviewed caregivers of all the selected children. Primary and secondary outcomes measures Coverage of infant feeding practices, reasons for low coverage of infant feeding practices and current delivery channels of infant feeding practices. Results Findings from our survey indicated that infant feeding practices were poor. Early initiation of breastfeeding was only 22.4%, exclusive breastfeeding for 6 months was less than 10% and continued breastfeeding up to the age of two was just 38.2%. Only 32.5% of children were given iron-rich or iron-fortified foods. The leading sources of infant feeding information were family members, neighbours, friends and popular media. Only around 20% of the information came from health facilities and nearly none came from communities. Household property data showed that 99.9% of households owned televisions and 99.4% owned mobile phones. In addition, 61.2% of the households owned computers, with 54.8% having access to the internet. Conclusions Few caregivers of children in Zhao County received feeding information during pregnancy and after delivery. Moreover, their feeding knowledge and practices were poor. Multi-channel approaches, delivered through health facilities, community resources, popular media, the internet and mobile phones, hold potential to improve infant feeding practices and should be explored in future studies. Strengths and limitations Although this study took place only within one county, a full range of globally standard feeding indicators was used to assess the feeding practices of caregivers in our study. The name lists of children in some villages may not be complete, and therefore selection bias may have occurred. Some indicators may have recall bias due to long recall time. Trial registration number ChiCTR-PRC-11001446.