Promoting Antenatal Care Attendance Through a Text Messaging Intervention in Samoa: Quasi-Experimental Study.

BACKGROUND: Antenatal care (ANC) has the potential to improve maternal health, but it remains underutilized and unevenly implemented in many low- and middle-income countries. Increasingly, text messaging programs for pregnant women show evidence that they can improve the utilization of ANC during pregnancy; however, gaps remain regarding how implementation affects outcomes. OBJECTIVE: This study aimed to assess facilitators and barriers to implementation of an SMS text messaging intervention for pregnant women in Samoa and to assess its impact on ANC attendance. METHODS: This study took place in Upolu, Samoa, from March to August 2014 and employed a quasi-experimental design. Half (n=3) of the public antenatal clinics on the island offered adult pregnant women the SMS text messaging intervention, with 552 women registering for the messages. At the comparison clinics (n=3), 255 women registered and received usual care. The intervention consisted of unidirectional text messages containing health tips and appointment reminders. The outcome of interest was the number of attended antenatal visits. Implementation data were also collected through a survey of the participating midwives (n=7) and implementation notes. Data analysis included a comparison of women's baseline characteristics between the two groups, followed by the use of negative binomial regressions to test for associations between participation in the intervention and increased ANC attendance, controlling for individual characteristics and accounting for the clustering of women within clinics. RESULTS: The comparison of ANC attendance rates found that women receiving the SMS text messaging intervention attended 15% fewer ANC visits than the comparison group (P=.004), controlling for individual characteristics and clustering. Data analysis of the implementation process suggests that barriers to successful implementation include women registering very late in pregnancy, sharing their phone with others, and inconsistent explanation of the intervention to women. CONCLUSIONS: These results suggest that unidirectional text messages do not encourage, and might even discourage, ANC attendance in Samoa. Interpreted with other evidence in the literature, these results suggest that SMS text messaging interventions are more effective when they facilitate better communication between patients and health workers. This study is an important contribution to our understanding of when SMS text messaging interventions are and are not effective in improving maternal health care utilization.

A systematic approach to equity assessment for digital health interventions: case example of mobile personal health records.

Despite the increasing number of digital health interventions in low- and middle-income countries and other low-resource settings, little attention has been paid to systematically evaluating impacts of these interventions on health equity. In this article, we present a systematic approach for assessing equity impacts of digital health interventions modeled after the Health Equity Impact Assessment of the Ontario Ministry of Health and Long-Term Care. The assessment approach has 4 steps that address (1) scope, (2) potential equity impacts, (3) mitigation, (4) monitoring, and (5) dissemination strategies. The approach examines impacts on vulnerable and marginalized populations and considers various social determinants of health. Equity principles outlined by Whitehead and Dahlgren are used to ensure systematic considerations of all potential equity impacts. The digital health evaluation approach that is presented is applied to a case example of mobile personal health record application in Kenya.

Do clinical decision-support reminders for medical providers improve isoniazid preventative therapy prescription rates among HIV-positive adults? Study protocol for a randomized controlled trial.

BACKGROUND: This document describes a research protocol for a study designed to estimate the impact of implementing a reminder system for medical providers on the use of isoniazid preventative therapy (IPT) for adults living with HIV in western Kenya. People living with HIV have a 5% to 10% annual risk of developing active tuberculosis (TB) once infected with TB bacilli, compared to a 5% lifetime risk in HIV-negative people with latent TB infection. Moreover, people living with HIV have a 20-fold higher risk of dying from TB. A growing body of literature suggests that IPT reduces overall TB incidence and is therefore of considerable benefit to patients and the larger community. However, in 2009, of the estimated 33 million people living with HIV, only 1.7 million (5%) were screened for TB, and about 85,000 (0.2%) were offered IPT. METHODS/DESIGN: This study will examine the use of clinical decision-support reminders to improve rates of initiation of preventative treatment in a TB/HIV co-morbid population living in a TB endemic area. This will be a pragmatic, parallel-group, cluster-randomized superiority trial with a 1:1 allocation to treatment ratio. For the trial, 20 public medical facilities that use clinical summary sheets generated from an electronic medical records system will participate as clusters. All HIV-positive adult patients who complete an initial encounter at a study cluster and at least one return encounter during the study period will be included in the study cohort. The primary endpoint will be IPT prescription at 3 months post the initial encounter. We will conduct both individual-level and cluster-level analyses. Due to the nature of the intervention, the trial will not be blinded. This study will contribute to the growing evidence base for the use of electronic health interventions in low-resource settings to promote high-quality clinical care, health system optimization and positive patient outcomes. Trial registration ClinicalTrials.gov NCT01934309, registered 29 August 2013.

A clinical decision support system for integrating tuberculosis and HIV care in Kenya: a human-centered design approach.

With the aim of integrating HIV and tuberculosis care in rural Kenya, a team of researchers, clinicians, and technologists used the human-centered design approach to facilitate design, development, and deployment processes of new patient-specific TB clinical decision support system for medical providers. In Kenya, approximately 1.6 million people are living with HIV and have a 20-times higher risk of dying of tuberculosis. Although tuberculosis prevention and treatment medication is widely available, proven to save lives, and prioritized by the World Health Organization, ensuring that it reaches the most vulnerable communities remains challenging. Human-centered design, used in the fields of industrial design and information technology for decades, is an approach to improving the effectiveness and impact of innovations that has been scarcely used in the health field. Using this approach, our team followed a 3-step process, involving mixed methods assessment to (1) understand the situation through the collection and analysis of site observation sessions and key informant interviews; (2) develop a new clinical decision support system through iterative prototyping, end-user engagement, and usability testing; and, (3) implement and evaluate the system across 24 clinics in rural West Kenya. Through the application of this approach, we found that human-centered design facilitated the process of digital innovation in a complex and resource-constrained context.

Development and Assessment of Traditional and Innovative Media to Reduce Individual HIV/AIDS-Related Stigma Attitudes and Beliefs in India.

Although stigma is considered a major barrier to effective response to the HIV/AIDS epidemic, there is a lack of evidence on effective interventions. This media intervention took place among key HIV-vulnerable communities in Southern India. Two HIV stigma videos were created using techniques from traditional film production and new media digital storytelling. A series of 16 focus group discussions were held in 4 rural and 4 urban sites in South India, with specific groups for sex workers, men who have sex with men, young married women, and others. Focus groups with viewers of the traditional film (8 focus groups, 80 participants) and viewers of the new media production (8 focus groups, 69 participants) revealed the mechanisms through which storyline, characters, and esthetics influence viewers' attitudes and beliefs about stigma. A comparative pre-/post-survey showed that audiences of both videos significantly improved their stigma scores. We found that a simple illustrated video, produced on a limited budget by amateurs, and a feature film, produced with an ample budget by professionals, elicited similar responses from audiences and similar positive short-term outcomes on stigma.

mHealth for HIV Treatment & Prevention: A Systematic Review of the Literature.

This systematic review assesses the published literature to describe the landscape of mobile health technology (mHealth) for HIV/AIDS and the evidence supporting the use of these tools to address the HIV prevention, care, and treatment cascade. The speed of innovation, broad range of initiatives and tools, and heterogeneity in reporting have made it difficult to uncover and synthesize knowledge on how mHealth tools might be effective in addressing the HIV pandemic. To do address this gap, a team of reviewers collected literature on the use of mobile technology for HIV/AIDS among health, engineering, and social science literature databases and analyzed a final set of 62 articles. Articles were systematically coded, assessed for scientific rigor, and sorted for HIV programmatic relevance. The review revealed evidence that mHealth tools support HIV programmatic priorities, including: linkage to care, retention in care, and adherence to antiretroviral treatment. In terms of technical features, mHealth tools facilitate alerts and reminders, data collection, direct voice communication, educational messaging, information on demand, and more. Studies were mostly descriptive with a growing number of quasi-experimental and experimental designs. There was a lack of evidence around the use of mHealth tools to address the needs of key populations, including pregnant mothers, sex workers, users of injection drugs, and men who have sex with men. The science and practice of mHealth for HIV are evolving rapidly, but still in their early stages. Small-scale efforts, pilot projects, and preliminary descriptive studies are advancing and there is a promising trend toward implementing mHealth innovation that is feasible and acceptable within low-resource settings, positive program outcomes, operational improvements, and rigorous study design.

Community health workers and mobile technology: a systematic review of the literature.

INTRODUCTION: In low-resource settings, community health workers are frontline providers who shoulder the health service delivery burden. Increasingly, mobile technologies are developed, tested, and deployed with community health workers to facilitate tasks and improve outcomes. We reviewed the evidence for the use of mobile technology by community health workers to identify opportunities and challenges for strengthening health systems in resource-constrained settings. METHODS: We conducted a systematic review of peer-reviewed literature from health, medical, social science, and engineering databases, using PRISMA guidelines. We identified a total of 25 unique full-text research articles on community health workers and their use of mobile technology for the delivery of health services. RESULTS: Community health workers have used mobile tools to advance a broad range of health aims throughout the globe, particularly maternal and child health, HIV/AIDS, and sexual and reproductive health. Most commonly, community health workers use mobile technology to collect field-based health data, receive alerts and reminders, facilitate health education sessions, and conduct person-to-person communication. Programmatic efforts to strengthen health service delivery focus on improving adherence to standards and guidelines, community education and training, and programmatic leadership and management practices. Those studies that evaluated program outcomes provided some evidence that mobile tools help community health workers to improve the quality of care provided, efficiency of services, and capacity for program monitoring. DISCUSSION: Evidence suggests mobile technology presents promising opportunities to improve the range and quality of services provided by community health workers. Small-scale efforts, pilot projects, and preliminary descriptive studies are increasing, and there is a trend toward using feasible and acceptable interventions that lead to positive program outcomes through operational improvements and rigorous study designs. Programmatic and scientific gaps will need to be addressed by global leaders as they advance the use and assessment of mobile technology tools for community health workers.

Videovoice: community assessment in post-Katrina New Orleans.

This study describes a videovoice project implemented in post-Katrina New Orleans during a pivotal time in city rebuilding and revitalization. Videovoice is a health advocacy, promotion, and research method through which people get behind video cameras to research issues of concern, communicate their knowledge, and advocate for change. Using videovoice method, a community-academic-filmmaker partnership engaged 10 Central City neighbors, who took part in an 18-week training and community assessment. The resulting 22-min film premiered before more than 200 city leaders and residents, reached more than 4,000 YouTube viewers during its first 2 months online, and was shared through the distribution of 1,000 DVDs. Viewing further helped mobilize the community for action on three priority issues: affordable housing, education, and economic development. Challenges in using videovoice, including privacy issues and cost considerations in a resource-poor community, are discussed. Despite such challenges, this method may provide community-academic partnerships with the opportunity to equitably engage in research, produce independent media, and mobilize for action.

Photovoice: a review of the literature in health and public health.

Although a growing number of projects have been implemented using the community-based participatory research method known as photovoice, no known systematic review of the literature on this approach has been conducted to date. This review draws on the peer-reviewed literature on photovoice in public health and related disciplines conducted before January 2008 to determine (a) what defines the photovoice process, (b) the outcomes associated with photovoice, and (c) how the level of community participation is related to photovoice processes and outcomes. In all, 37 unduplicated articles were identified and reviewed using a descriptive coding scheme and Viswanathan et al.'s quality of participation tool. Findings reveal no relationship between group size and quality of participation but a direct relationship between the latter and project duration as well as with getting to action. More participatory projects also were associated with long-standing relationships between the community and outside researcher partners and an intensive training component. Although vague descriptions of project evaluation practices and a lack of consistent reporting precluded hard conclusions, 60% of projects reported an action component. Particularly among highly participatory projects, photovoice appears to contribute to an enhanced understanding of community assets and needs and to empowerment.

Community health worker insights on their training and certification.

BACKGROUND: In recent years, the community health worker (CHW) field has grown significantly in the United States, with increasing numbers, roles, and visibility of CHWs. State health department regulators, health program administrators, and community health advocates have observed this growth with uncertainty about the definition of a CHW, how CHW roles differ from those of other health professionals, CHW training needs, and the potential impact of the growing certification and accreditation regulations. OBJECTIVE: Despite the proliferation of regulatory policies, few studies have examined how regulation can most effectively support CHWs in the field. Our objective is to define CHW, identify training needs, and examine possibilities for credentialing from the perspective of CHWs in New York City. METHODS: Community-based participatory research (CBPR) was used to engage CHW leadership and gather input from CHWs in the design and conduct of the study. The academic-community-state partnership designed focus group topic guides, and conducted fifteen focus groups with CHWs in New York City. The focus group responses were analyzed using HyperResearch and formed the basis for policy recommendations to the participating partners. RESULTS: We developed a consensus definition of CHW and its fundamental qualities. We identified unmet training needs in the area of core competencies. We outlined the characteristics of a credentialing process that would support and advance the work of CHWs. CONCLUSIONS: CBPR enabled CHWs to have a direct voice in defining their description, roles, training, and certification preferences. This informed policy recommendations to the state, university, and CHWs through a collaborative process.