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Establishing a Global End to End Mobile Content Distribution Process for Health Workers

mPowering Frontline Health Workers, Johns Hopkins Center for Communication Program and Digital Campus have just published a report (funded by Qualcomm Wireless Reach) on an open collaborative model for how health worker training content can be delivered in a way that will help to reduce duplication of efforts and decrease the time and cost of deploying mobile learning for frontline health workers. The process described helps to tie up the work we are doing with OppiaMobile and the ORB platform.

Download the full report (pdf, 3.6Mb)

Executive Summary:

This report represents an initial “blueprint” to create a scalable, locally sustainable, ‘end-to-end’ content distribution process that uses mobile technology to provide frontline health workers (FLHWs) access to relevant health content.

The core of the proposed process aims to: (1) increase content contributions to a centralized content management platform; (2) reduce duplication through collaborative content production and adaptation; (3) shorten the time and reduce the cost required to implement solutions for specific contexts and geographies by making the design process more standardized and systematic; and (4) establish an open collaborative model for the ongoing refinement of the process that can evolve independent of specific technologies. Establishing this process is a first step towards creating a common delivery system that allows organizations to focus on content creation and adaptation in order to accelerate the development of knowledge and skills for FLHWs and the communities they serve.

Despite significant milestones in the use of mobile devices by FLHWs, the inability of mobile health (mHealth) programs to go to scale without an ongoing infusion of external resources continues to challenge the global health development sector. One factor is the lack of evidence of the effectiveness of mHealth, which for government and donors diminishes the value of the investment in mHealth:

The phenomenal growth in the number of new [over 1300 mHealth] services has not, unfortunately, seen a parallel growth in the evidence base of these services, particularly
economic (cost) proof points. 90% of services are reliant on donor funding and/or a consumer payment model, both of which we would argue are unsustainable, given the short term nature of funding and the inability of consumers at the bottom of the pyramid to contribute significantly to out of pocket health expenses.

With increasing affordability of smartphones and steady improvements in wireless telecommunications infrastructure, the failure to scale mHealth solutions will become increasingly hard to explain. If the existing technology already lends itself to scale what are the barriers to achieving that goal, and to do so in a way that is sustained beyond initial donor investment?

In proposing an end-to-end process for content distribution, this report directly addresses the challenges to sustainable scale of mHealth programs.

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Health Extension Workers mLearning training workshops

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During the last weeks we’ve been training a cohort of 160 HEWs and their tutors/ trainers in Tigray (Ethiopia) on how to use OppiaMobile. These first training workshops are simply to get the HEWs and Tutors used to the phones, find out what problems and issues they may have, navigating the courses and activities, recharging, completing quizzes etc.

The training is going quite well, and the HEWs (mostly women) seem very eager to learn how to use the phones and soon became quite comfortable using them. Over the coming weeks we’ll introduce more OppiaMobile functionalities  and we’ll find out what challenges may exist and the feasibility for using smartphones for training support in this environment.

We had a few of technical issues that we are looking at, but this is to be expected given that we’re still in the technical feasibility stage. One of the issues we’re still finding is the level of English of the HEWs, so we are working to provide a glossary of the most common medical terms and definitions in both English and Amharic / Tigrinyan.

 

Thesis: Intestinal parasitosis and under-nutrition in Ethiopia. Prevalence, risk factors and prevention

Mahmud thesis

Congratulations to our colleague, Mahmud Abdulkader, who has just completed his PhD in “Intestinal parasitosis and under-nutrition in Ethiopia. Prevalence, risk factors and prevention”. Digital Campus has been collaborating with Mahmud for the past years, so we’re really pleased he’s now completed and we look forward to continue to working and collaborating with him once he’s back in his full time role in the College of Health Sciences at Mekelle University (Ethiopia).

 

Could community health workers serve as mobile money agents?

Extract from posting in the Health Market Innovations blog:

A major barrier to mobile money uptake is the lack of a well-trained agent network to serve and address the financial needs of the community, with the greatest effects felt in remote areas. One way to address this challenge is to explore synergies between CHWs and mobile money agents, thereby leveraging the trust they have built in communities as frontline workers. Training CHWs to serve as “last mile” mobile money agents in hard-to-reach areas could extend the reach of both health services and mobile money.

The additional revenue potential could also be used to incentivize health workers to take up posts in remote areas. CHWs trained as mobile money agents would be well positioned to educate clients and communities about the benefits of expanded access to financial services, including paying for emergency transportation to health services or enrolling in insurance.


Read the full article.

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Health workers’ experiences, barriers, preferences and motivating factors in using mHealth in Ethiopia

We have just published in Human Resources for Health  a new research paper, “Mobile health data collection at primary health care in  Ethiopia: a feasible challenge”. This article gives a detailed account of Community Health Workers’s experiences using mobile health data collection tools. Here is the abstract:

Background

Mobile health (mHealth) applications, such as innovative electronic forms on smartphones, could potentially improve the performance of health care workers and health systems in developing countries. However, contextual evidence on health workers’ barriers and motivating factors that may influence large-scale implementation of such interfaces for health care delivery is scarce.

Methods

A pretested semistructured questionnaire was used to assess health workers’ experiences, barriers, preferences, and motivating factors in using mobile health forms on smartphones in the context of maternal health care in Ethiopia. Twenty-five health extension workers (HEWs) and midwives, working in 13 primary health care facilities in Tigray region, Ethiopia, participated in this study.

Results

Over a 6-month period, a total of 2,893 electronic health records of 1,122 women were submitted to a central computer through the Internet. Sixteen (69.6%) workers believed the forms were good reminders on what to do and what questions needed to be asked. Twelve (52.2%) workers said electronic forms were comprehensive and 9 (39.1%) workers saw electronic forms as learning tools. All workers preferred unrestricted use of the smartphones and believed it helped them adapt to the smartphones and electronic forms for work purposes. With regards to language preference, 18 (78.3%) preferred using the local language (Tigrinya) version of the forms to English. Indentified barriers for not using electronic forms consistently include challenges related to electronic forms (for example, problem with username and password setting as reported by 5 (21.7%), smartphones (for example, smartphone froze or locked up as reported by 9 (39.1%) and health system (for example, frequent movement of health workers as reported by 19 (82.6%)).

Conclusions

Both HEWs and midwives found the electronic forms on smartphones useful for their day-to-day maternal health care services delivery. However, sustainable use and implementation of such work tools at scale would be daunting without providing technical support to health workers, securing mobile network airtime and improving key functions of the larger health system.

HIFA article on mHealth applications for provision of essential healthcare information

HIFA (Health Information for All) has recently published an article on the “application of mobile phones to enhance the provision of essential healthcare information for citizens in low resource settings … [segmented] by types of intended user, draws some conclusions about gaps in provision and makes some suggestions about ways forward.”

You can download the full article from the HIFA website at: http://www.hifa2015.org/wp-content/uploads/Ensuring-that-mHealth-applications-provide-essential-healthcare-information-for-citizens-in-low-resource-settings.pdf.

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Children Nutrition in Urban and Rural Areas of Ethiopia

We have recently had accepted and published a research paper entitled “The influence of father’s child feeding knowledge and practices on children’s dietary diversity: a study in urban and rural districts of Northern Ethiopia”  in Maternal & Child Nutrition.

Here is the abstract:

Infant and young child feeding has been recognized as an essential element to improve growth of children, especially in developing countries where malnutrition among children and its dire consequences are very prevalent. However, little attention has been paid on the influence of fathers on child feeding practices although fathers are very important in raising well-adjusted, happy and successful children. Therefore, this study aimed to assess the influence of fathers’ child feeding knowledge and practice on children’s dietary diversity.

A community based comparative cross sectional study was conducted among 850 eligible urban and rural households with children of 6 to 23 months. The father and mother of the child were interviewed on children’s dietary Diversity and fathers’ knowledge and practice of child feeding.

Nearly half (46%) of the children in the rural district did not meet the minimum dietary diversity, and in the urban district the rate was even worse (72%). Dairy products were the common food group given to the children in both districts, whereas vitamin A-rich food and other fruits and vegetables were the least commonly consumed food groups.

Almost all dimensions of fathers’ knowledge and practice were significantly related to children’s minimum dietary diversity; especially fathers’ knowledge of food groups was an important predictor (p value<0.001) in both districts. Interventions that focus on the fathers’ knowledge of child feeding, especially about food groups, is recommended to improbé children’s dietary diversity in the study communities.

 

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Research Paper on Sexual and Reproductive Health Services Utilization among Adolescents in Ethiopia

Our research paper entitled  “Utilization of Sexual and Reproductive Health Services  in Ethiopia- does it affect sexual activity among high school students?” has recently been accepted and published in Sexual and Reproductive Healthcare.

Here is the abstract:

Objective

Universal access to Sexual and Reproductive Health (SRH) services for adolescents was added as a target to the revised Millennium Development Goals framework in 2005. However, the utilization of SRH services among adolescents and their sexual activity is not well explored in Ethiopia, with the result that there is no well-designed and sustainable school based intervention for high school students. We aimed to investigate the utilization of sexual and reproductive health services and sexual activity and, to provide evidence based information and recommendations for possible interventions.

Study design

A cross-sectional survey was conducted among 1031 female and male high school students aged 14–19 years in Mekelle town, Tigray Region, North Ethiopia. A total of 1031 students participated. Self-administered questionnaire was used.

Main outcome measures

Utilization of sexual and reproductive health services and sexual activity were investigated using a self-administered questionnaire.

Results

One out of five students had used the SRH services in the past year. The primary reason for visiting the SRH services was to receive information. The mean age for the first sexual intercourse was 15.7 and one-quarter of the students had multiple sexual partners. Unwanted pregnancies and abortions were reported by female students.

Conclusion

SRH services are known and used by students. However, sexual activity at an early age among high school students and unwanted pregnancies and abortions among female students still call for attention. Therefore, providing accurate SRH information on safe sex and enhancing family–student discussion could be a good approach to reach SRH of adolescents.

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New Research Paper on Mobile Health Data Collection for Primary Health Workers

We have just had a research paper entitled “Mobile health data collection at primary health care in  Ethiopia: a feasible challenge” accepted and published in The Journal of Clinical Epidemiology. The paper describes our experience working with community health workers in Ethiopia using mobile health data collection tools for recording and managing maternal care visits.

Here is the abstract:

Objectives: Feasibility assessment of mobile health (mHealth) data collection at primary health care in Ethiopia.

Study Design and Setting: A total of 14 health workers were recruited from 12 primary health care facilities to use smartphones,installed with customized data collection application and electronic maternal health care forms for assessing pregnant women’s health for 6 months. Qualitative approaches comprising in-depth interviews and field notes were used to document the users’ perception and experience in using the application and forms.

Results: All health workers had never had previous exposure to smartphones and electronic forms, but they got used to them easily. Over 6 months, all health workers completed a total of 952 patient records using the forms on smartphones. Health workers’ acceptability and demand for the application and forms were high. In introducing the application, nontechnical challenges were more difficult to solve than technical challenges.

Conclusion: Introducing an mHealth application at primary health care for routine collection of health data relevant to maternal health at a small scale was feasible. Nonetheless, implementing a system of assigning unique and consistent patient identifier, standardization of health services, and improving mobile network coverage would be prerequisites for scaled-up usage of such an application.

 

 

 

GETHealth Conference in Dublin

At the end of last week, Roman and I were at the GETHealth Summit in Dublin. Roman had a poster presentation accepted (get it here) and I was on the mPowering sponsored breakout session on content adaptation.

I was great to get to meet many people who I’ve only ever spoken to on skype, and with the size of the conference (~200 attendees) it was small enough to get chance to make new contacts with some new faces too.

There was plenty of lively discussion during all the sessions, however now I’ve had a bit of time to reflect on it all there are a few comments and queries that are still outstanding in my mind:

  • Much of the training appears still to be NGO driven, so although this training may well fit with countries health ministries priorities, until this training becomes a core part of health workers career progression and “professionalisation”, the incentives to attend training may still be limited to per-diems.
  • There was little discussion about the quality of the teachers/trainers – for me, the teachers (whether it be via face to face or blended learning) are critical to truly engaging their students in the subject matter, whether or not they have quality content/resources to use. Perhaps this could be a good topic for next years discussions?
  • The dreaded ‘pilotitis’ word appeared a few times, with a suggestion to reterm this as ‘phase 1’. I would prefer to use the word ‘research’. Unfortunately, although there was talk of the number of pilots (30,000 – although no idea how this figure was arrived at, it’s certainly a lot), the systematic review of published research presented by Travis Porter (from Tulane Uni) cited a very limited number of published research articles (~55). So there’s a huge mismatch here between the work that’s being done and what has been properly studied and published. Until more results (good or poor) from these projects are published, we could keep repeating the same mistakes.

One of the highlights for me was to see the “CHN On the Go” mobile app being presented (more info on this project). This is work being done in Ghana, with Concern Worldwide and Grameen Foundation and was presented by Jahera Otieno. What’s great for us is that the app is based on OppiaMobile and has been developed/extended in-country with no support from Digital Campus apart from a short skype call over a year ago. This, to me demonstrates that we have taken the right approach in making the OppiaMobile platform open source, and that it’s in a state where others can expand and adapt to fit their needs.

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