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.

Filling the gap: Reflection on the Certificate course on Mobile Phones For Public Health organized by Techchange

by Marijs Carrin at Digital Campus

Recently, I was given the timely opportunity by Digital Campus to participate in a four-week online course on Mobile phones for Public Health, which examined the power of mobile technology and its revolutionary role in improving health outcomes worldwide.

The course focused on health education; service delivery and capacity building for health workers; patient care; diagnostics; as well as supply management and logistics. Throughout that month I gained new insight and reflected upon the benefits and remaining challenges of mobile health (mHealth), as we continuously try to adapt our Oppia mobile – health education and training- application to extend its use among health workers on a more global scale.

My preferred aspects of the course were:

  1. The vast amount of resources (videos, documents, presentations, exercises, links) available on mHealth;
  2. Learning about various mHealth tools and getting hands-on experience using them;
  3. The framework and taxonomy used in classifying mHealth projects (Dr. Alain Labrique, Founding director of the Johns Hopkins University Global mHealth Initiative);
  4. An outline of current evidence and projects.

The presentation by Dr. Labrique, one of the most respected professionals with years of experience in the field, was particularly useful and very inspirational to me. He shared a detailed synopsis of lessons learnt, opportunities and ideas around mHealth today, and allowed me to extend my knowledge regarding the definition, use and future of mHealth.

Dr. Labrique’s words have encouraged me to start thinking more outside the box. Innovation is critical in this field (also for development) and the examples of how it has changed the game are vast. Indeed, he emphasised that the success of mHealth interventions has to go beyond technology. The most important aspect, I learnt, is to create simple, sustainable and efficient solutions to health systems that are dynamic, crosscutting and moreover accessible to all. In a nutshell, mHealth is about people (or beneficiaries), not phones.

Finally, as we move forward in trying to develop, improve and adapt our app, I will keep Dr. Labrique’s words ingrained in my mind: not to ignore that mobile platforms need good design and functionality, but it needs to be equally fun and creative so that the end user (i.e. in our case health workers) “will want to continue to use the system beyond just being part of a routine job description.”

Filling the huge gap between technology and people is a challenge of the digital era. There is a lot of potential for great things to be achieved – and many have been already – but it is, in my opinion, essential that we don’t loose focus of the purpose and feasibility of the whole endeavor.

Thesis: The use of mHealth for Maternal Health Care in Ethiopia


Our colleague, Araya Abrha (now Dr Araya) has made available the summary of his doctoral thesis “The use of mHealth for Maternal Health Care in Ethiopia”.

Download the title and index
Download the thesis summary

Since one of the papers contained in his thesis is still pending publication, we’re unable to post the whole thesis here, however if you would like a copy then please contact Araya directly (at arayaabrha@yahoo.com)

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Patient visit records graph

Here’s a graph of the numbers of patient visit records the HEWs have been submitting over the last year or so (click to view a larger version):


The numbers of visit records submitted have been grouped by week, we’re not yet sure why there seem to be so many peaks & troughs in the numbers submitted each week, although the increase in the last couple of months will be attributable to us now having more HEWs and midwives working with us – in total we now have around 30 HEWs and midwives, it varies quite often as staff go away for further study, move on to other jobs, or go on maternity leave.

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Patient management tools – one year on

Our group of HEWs and midwives have now been using the ODK-based patient management tools for just over a year – that is using the tools with actual patients, they were using the tools for several months before this just for testing and for refining the patient visit forms.

Despite only working with a small group of HEWs and midwives (although recently approx 20 more joined the project), we now have over 1000 patients (pregnant mothers) registered who have attended ante-natal care or post-natal care visits. We also have nearly 300 deliveries recorded, although given we have 1000 pregnant mothers, we would expect this to increase substantially in the coming months.

Looking back over the patient visits forms submitted each day, we can see that the HEWs and midwives are making use of the tools more regularly, although we still see spikes in the number of forms submitted on some days – likely to coincide with ‘immunization days’ when more people attend the health centres/posts.

Now that we’re building up a lot of experience, data and knowledge in how the tools are being used, As I’ve already posted up (here and here) Araya has already had a couple of research papers published in this area, and we’re now working on completing the feasibility study and technical papers.

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New research paper: Knowledge and performance of the Ethiopian health extension workers

Araya has just had his second paper published: “Knowledge and performance of the Ethiopian health extension workers on antenatal and delivery care: a cross-sectional study”. The full paper is available from Human Resources for Health, provisional abstract:


In recognition of the critical shortage of human resources within health services, community health workers have been trained and deployed to provide primary health care in developing countries. However, very few studies have investigated whether these health workers can provide good quality of care. This study investigated the knowledge and performance of health extension workers (HEWs) on antenatal and delivery care. The study also explored the barriers and facilitators for HEWs in the provision of maternal health care.


In conducting this research, a cross-sectional study was performed. A total of 50 HEWs working in 39 health posts, covering a population of approximately 195,000 people, were interviewed. Descriptive statistics was used and a composite score of knowledge of HEWs was made and interpreted based on the Ethiopian education scoring system.


Almost half of the respondents had at least 5 years of work experience as a HEW. More than half (27 (54%)) of the HEWs had poor knowledge on contents of antenatal care counseling, and the majority (44 (88%)) had poor knowledge on danger symptoms, danger signs, and complications in pregnancy. Health posts, which are the operational units for HEWs, did not have basic infrastructures like water supply, electricity, and waiting rooms for women in labor. On average within 6 months, a HEW assisted in 5.8 births. Only a few births (10%) were assisted at the health posts, the majority (82%) were assisted at home and only 20% of HEWs received professional assistance from midwives.


Considering the poor knowledge of HEWs, poorly equipped health posts, and poor referral systems, it is difficult for HEWs to play a key role in improving health facility deliveries, skilled birth attendance, and on-time referral through early identification of danger signs. Hence, there is an urgent need to design appropriate strategies to improve the performance of HEWs by enhancing their knowledge and competencies, while creating appropriate working conditions.

Demo site for patient management tools

We’ve just set up a demonstration site of our analytics and mobile site for the patient management tools. Previously if someone wanted to test out the tool for themselves, we could really only give them the mobile application and the protocols to look at, but we didn’t have a demo area for the server side. The only demo was on my laptop, and we can’t give access to the live site as it has real patient cases. I took this opportunity to look at using Amazon Web Services (EC2) for setting up the demo server – it all worked out really well and very easy to use.

You can log into the analytics/scorecard site at:

http://odk-demo.digital-campus.org/scorecard/ (username/password is demo/demo)

and the mobile version is at:

http://odk-demo.digital-campus.org/scorecard/mobile (same username/password)

The demo user has supervisor privileges, so is able to see all the data entered, usually health workers logging in would only get to see the data directly related to their patients.

If you would like to see the whole process, from entering the protocols on the smartphone, all the way through to seeing the cases on the analytics scorecard and mobile site, I also set up a demo ODK Aggregate server for submitting protocols. To set this up:

  1. Download and install on your phone our version of ODK
  2. start the app and enter the following settings (go to menu > change settings):
    • Server: http://odk-demo.digital-campus.org/ODKAggregate (note that this is case sensitive)
    • Username: demo
    • Password: demo
  3. Go to ‘get blank form’ – this should connect to the server and show all the available protocol forms – select and download the ones you would like to try out
  4. Enter and submit a few protocols from your phone
  5. You will then be able to see the forms you have entered on the analytics scorecard, and the mobile version – note that the forms don’t appear instantly on the scorecard or mobile site, it may take a couple of hours, as we have some caching running, to make the site run more quickly

Please let us know how you get on – especially if I need to add some more info to the instructions above.

Research article published on role of HEWs

Araya, one of the PhD students from Ethiopia we have been working with for the last few years, has just this week had his first journal article published: “The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study”. More details on BioMed Central or PubMed. Abstract:


Community health workers are widely used to provide care for a broad range of health issues. Since 2003 the government of Ethiopia has been deploying specially trained new cadres of community based health workers named health extension workers (HEWs). This initiative has been called the health extension program. Very few studies have investigated the role of these community health workers in improving utilization of maternal health services.


A cross sectional survey of 725 randomly selected women with under-five children from three districts in Northern Ethiopia. We investigated women’s utilization of family planning, antenatal care, birth assistance, postnatal care, HIV testing and use of iodized salt and compared our results to findings of a previous national survey from 2005. In addition, we investigated the association between several variables and utilization of maternal health services using logistic regression analysis.


HEWs have contributed substantially to the improvement in women’s utilization of family planning, antenatal care and HIV testing. However, their contribution to the improvement in health facility delivery, postnatal check up and use of iodized salt seem insignificant. Women who were literate (OR, 1.85), listened to the radio (OR, 1.45), had income generating activities (OR, 1.43) and had been working towards graduation or graduated as model family (OR, 2.13) were more likely to demonstrate good utilization of maternal health services. A model family is by definition a family which has fulfilled all the packages of the HEP.


The HEWs seem to have substantial contribution in several aspects of utilization of maternal health services but their insignificant contribution in improving health facility delivery and skilled birth attendance remains an important problem. More effort is needed to improve the effectiveness of HEWs in these regards. For example, strengthening HEWs’ support for pregnant women for birth planning and preparedness and referral from HEWs to midwives at health centers should be strengthened. In addition, women’s participation in income generating activities, access to radio and education could be targets for future interventions.

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