Mobile Technology for Community Health in Ghana: Is Maternal Messaging and Provider Use of Technology Cost-Effective in Improving Maternal and Child Health Outcomes at Scale?

BACKGROUND: Mobile technologies are emerging as tools to enhance health service delivery systems and empower clients to improve maternal, newborn, and child health. Limited evidence exists on the value for money of mobile health (mHealth) programs in low- and middle-income countries. OBJECTIVE: This study aims to forecast the incremental cost-effectiveness of the Mobile Technology for Community Health (MOTECH) initiative at scale across 170 districts in Ghana. METHODS: MOTECH's "Client Data Application" allows frontline health workers to digitize service delivery information and track the care of patients. MOTECH's other main component, the "Mobile Midwife," sends automated educational voice messages to mobile phones of pregnant and postpartum women. We measured program costs and consequences of scaling up MOTECH over a 10-year analytic time horizon. Economic costs were estimated from informant interviews and financial records. Health effects were modeled using the Lives Saved Tool with data from an independent evaluation of changes in key services coverage observed in Gomoa West District. Incremental cost-effectiveness ratios were presented overall and for each year of implementation. Uncertainty analyses assessed the robustness of results to changes in key parameters. RESULTS: MOTECH was scaled in clusters over a 3-year period to reach 78.7% (170/216) of Ghana's districts. Sustaining the program would cost US $17,618 on average annually per district. Over 10 years, MOTECH could potentially save an estimated 59,906 lives at a total cost of US $32 million. The incremental cost per disability-adjusted life year averted ranged from US $174 in the first year to US $6.54 in the tenth year of implementation and US $20.94 (95% CI US $20.34-$21.55) over 10 years. Uncertainty analyses suggested that the incremental cost-effectiveness ratio was most sensitive to changes in health effects, followed by personnel time. Probabilistic sensitivity analyses suggested that MOTECH had a 100% probability of being cost-effective above a willingness-to-pay threshold of US $50. CONCLUSIONS: This is the first study to estimate the value for money of the supply- and demand-side of an mHealth initiative. The adoption of MOTECH to improve MNCH service delivery and uptake represents good value for money in Ghana and should be considered for expansion. Integration with other mHealth solutions, including e-Tracker, may provide opportunities to continue or combine beneficial components of MOTECH to achieve a greater impact on health.

Caracterização físico-química e nutricional de variedades de tomate (Lycopersicum esculentum, Mill) orgânico / Physicochemical and nutritional characterization of organic tomato varieties (Lycopersicum esculentum, Mill)

provavelmente na Região Andina, parte ocidental da América do Sul. Seus frutos são bagas carnosas, suculentas, variando em aspecto, tamanho e peso, dependendo do cultivar e do manejo adotado. Este projeto procurou estudar a composição físico-química e nutricional de sete variedades de tomate obtidas sob cultivo orgânico de produção. Os resultados apresentaram os seguintes limites: massa variou entre 17 e 143g, o pH de 3,99 a 4,88, sólidos solúveis totais de 3,83 a 4,60 ºBrix, acidez total titulável de 0,28 a 0,36%, relação SST/ATT de 11,2 a 13,9, umidade de 88,8 a 96,2%, cinzas de 0,44 a 0,97%, proteínas de 0,25 a 0,94%, lipídeos de 0,12 a 0,90%, carboidratos de 2,02 a 8,70% e VET de 15,9 a 42,5 kcal. Cada amostra foi analisada em triplicata e apresentou entre baixa a média dispersão, mas com diferenças entre cultivares que podem ser atribuídas à genética e as condições edafoclimáticas. Com os resultados obtidos, concluiu-se que, além de terem sido obtidas sob cultivo orgânico, o que já confere vantagem por não possuírem resíduos químicos, os cultivares apresentaram alta qualidade do ponto de vista físico-químico e nutricional.(AU)

The tomatoes probably have their origin in the Andean Region, western part of South America. Its berries are fleshy, succulent, varying in appearance, size and weight, depending on the cultivar and management adopted. This project sought to study the physical and chemical composition and nutritional seven tomato varieties produced under organic crop production. The results showed the following limits: mass ranged between 17 and 143g, the pH from 3.99 to 4.88, soluble solids from 3.83 to 4.60 ºBrix, titratable acidity from 0.28 to 0.36%, TSS / TTA ratio from 11.2 to 13.9 ºBrix/%, 88.8 to 96.2 moisture%, ash 0.44 to 0.97%, protein 0.25 to 0.94%, lipid 0, 12 to 0.90%, carbohydrates from 2.02 to 8.70% and from 15.9 to 42.5 VET kcal. Each sample was analyzed in triplicate and showed low and medium dispersion, but with differences between cultivars that can be attributed to genetics and the soil and climatic conditions. With these results, it was concluded that in addition to having been obtained under organic cultivation, which already gives advantage by not having chemical residues, the cultivars showed high quality in terms of physical-chemical and nutritional.

Mobile Technology for Community Health in Ghana: what happens when technical functionality threatens the effectiveness of digital health programs?

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. TRIAL REGISTRATION: Not applicable.

Qualitative Assessment of the Feasibility, Usability, and Acceptability of a Mobile Client Data App for Community-Based Maternal, Neonatal, and Child Care in Rural Ghana.

Mobile phone applications may enhance the delivery of critical health services and the accuracy of health service data. Yet, the opinions and experiences of frontline health workers on using mobile apps to track pregnant and recently delivered women are underreported. This evaluation qualitatively assessed the feasibility, usability, and acceptability of a mobile Client Data App for maternal, neonatal, and child client data management by community health nurses (CHNs) in rural Ghana. The mobile app enabled CHNs to enter, summarize, and query client data. It also sent visit reminders for clients and provided a mechanism to report level of care to district officers. Fourteen interviews and two focus groups with CHNs, midwives, and district health officers were conducted, coded, and thematically analyzed. Results indicated that the app was easily integrated into care, improved CHN productivity, and was acceptable due to its capacity to facilitate client follow-up, data reporting, and decision-making. However, the feasibility and usability of the app were hindered by high client volumes, staff shortages, and software and device challenges. Successful integration of mobile client data apps for frontline health workers in rural and resource-poor settings requires real-time monitoring, program investments, and targeted changes in human resources.

Willingness to pay more for value-added pomegranate juice (Punica granatum L.): An open-ended contingent valuation.

This study aimed at estimating the consumer's willingness to pay (WTP) more for value-added pomegranate juice using the contingent valuation method (CVM). The WTP was estimated applying the open-ended elicitation technique with 454 consumers in two supermarkets located in Rio de Janeiro, Brazil. The average consumer's WTP more for pomegranate juice was estimated in R$2.04 (Brazilian currency) and the income elasticity coefficient at the midpoint was 0.19, i.e., a 10% increase in consumer income will increase, on average, 1.9% the WTP of pomegranate juice (ceteris paribus). Therefore, the income elasticity coefficient was considered inelastic, once an increase in income would have low effect on the WTP for these consumers. The results indicated that the consumers were interested in acquiring a non-traditional juice processed using a technology that preserves vitamins and antioxidants, maintains the flavor of "fresh juice" without colorants and preservatives, despite the pomegranate is not part of the Brazilian diet.

How do Brazilian consumers perceive a non-traditional and innovative fruit juice? An approach looking at the packaging.

Consumer interest in nutritious and innovative foods encourages the development of products based on raw materials with nutraceutical potential. The health benefits provided by pomegranate have been recognized; therefore, the development of pomegranate juice may match consumer expectations regarding this goal. However, the concept has to first be accepted by the consumer. The aim of the study was to utilize a rating based conjoint analysis to investigate how Brazilian consumers perceive pomegranate juice by identifying the role of packaging attributes relevant to the consumer's intention to purchase. Five factors were considered in the study: technology used in the juice production (high hydrostatic pressure - HHP - a technology that preserves nutritional and sensory properties), antioxidants, price, preservatives, and colorant. Eight hypothetical pomegranate juice packages were created following an incomplete block design and evaluated by 150 fruit juice consumers. Three clusters were identified. The average results revealed that antioxidants were the attribute of greatest relative importance to cluster 1 (RI: 36%), followed by HHP (RI: 25%) and colorants (14%). Consumers in cluster 2 considered price as the most important attribute (RI: 41%), followed by antioxidants (RI: 21%) and HHP (RI: 18%). Cluster 3, as well as cluster 2, considered price the most important attribute (RI: 28%), followed by antioxidants (RI: 26%) and HHP (RI: 22%). The results showed that consumers valued information on the health benefits of antioxidants as well as on the technology, suggesting that both types of information may be relevant tools to increase the intention to purchase the product. The application of HHP for pomegranate juice processing was positively perceived by consumers, suggesting a potential commercial application in the Brazilian industry.

A phase II study of high-dose cetuximab plus irinotecan in colorectal cancer patients with KRAS wild-type tumors who progressed after standard dose of cetuximab plus irinotecan.

OBJECTIVES: We conducted a phase II clinical trial of high-dose cetuximab plus irinotecan in KRAS wild-type patients who progressed on standard-dose cetuximab plus irinotecan. METHODS: Patients who progressed within 4 weeks from receiving a minimum of 6 weeks of standard-dose cetuximab plus irinotecan were included in this study. Cetuximab was administered at 500 mg/m(2)/week and irinotecan was administered at the same dose/schedule on which each individual patient had previously progressed. The study was closed early after having met its primary end point. RESULTS: Twenty patients were treated. The regimen was found to be efficacious, with 9 patients achieving disease control lasting more than 12 weeks. The median progression-free survival and overall survival were 2.8 and 6.6 months, respectively. The toxicity profile was favorable, with the exception of grade 3-4 hypomagnesemia which was noted in 25% of patients. CONCLUSIONS: High-dose cetuximab plus irinotecan rechallenge can re-elicit clinical benefits in patients who have previously failed cetuximab plus irinotecan treatment. The clinical benefits are modest and may be related to cetuximab rechallenge rather than cetuximab dose escalation.

Healthcare technician delivered screening of adults with diabetes to improve primary care provider recognition of depression.

PURPOSE: The purpose of this study was to implement a continuous quality improvement project aimed at improving primary care provider recognition of depression. MATERIALS AND METHODS: A randomized, blinded, pre- and post-test design was implemented with 92 adults attending an academic internal medicine clinic. Subjects were assigned to an intervention where healthcare technicians (HCT) trained in the fundamentals of diabetes education delivered brief probing questions about self-care behavior and tailored talking points to encourage patients to talk to their primary care physician about their emotional health. The control group received a sham intervention that included only information on standards of diabetes care. Measures included both a paper-and-pencil screening of depression and the Primary Healthcare Questionnaire-8 (PHQ-8). Outcomes were evaluated for antidepressant and/or counseling treatment modalities once the possibility of depression was identified. RESULTS: Both the control and intervention groups improved from pre-test to 3-month post-test scores on the PHQ-8 in clinically significant ways, but continued to have moderate to severe depression symptoms. There was a significant likelihood of receiving antidepressant therapy and/or counseling in those who scored high on the PHQ-8. CONCLUSION: HCT can be trained to talk to patients about emotional health issues during routine primary care visits. Depression screening measures can be administered as part of the triage routine at the start of a primary care visit, along with tasks such as vital signs. Answering a screening measure can help create awareness of symptoms and feelings that can prompt discussion during the patient-provider encounter that can result in the diagnosis and treatment of depression.

Methyl selenocysteine: single-dose pharmacokinetics in men.

The recently published report of the SELECT evaluation of selenium and vitamin E provided strong evidence that selenium 200 µg per day in the form of selenomethionine does not protect selenium-replete men against prostate or any other cancer. This seems to refute the result of the much smaller Nutritional Prevention of Cancer (NPC) trial of selenium. Because SELECT did not test the NPC agent, it is possible that the difference between the two trials stems partly from the use of different agents: selenomethionine in SELECT, and selenized yeast in the NPC trial. One of the organic selenium forms suspected of having strong chemopreventive effects, and which may have been present in the NPC agent, is methyl selenocysteine. This study characterizes the single-dose pharmacokinetics of methyl selenocysteine.

Serological immune responses to influenza vaccine in patients with colorectal cancer.

BACKGROUND: The immune responses to influenza vaccination in patients with colorectal cancer on surveillance or active chemotherapy have not been previously reported. We conducted a prospective influenza vaccination study to determine the serological immune response rate in patients with colorectal cancer. METHODS: During the 2006-2007 influenza season, patients with colorectal cancer treated at Roswell Park Cancer Institute were offered vaccination with the trivalent influenza vaccine (Fluzone, 2006-2007). Blood samples for hemagglutination inhibition (HI) assay titers were collected before and 3 months after vaccination. Response to vaccination was determined using an endpoint of ≥ 1:40 HI titer ratio or a fourfold HI increase at 3 months from vaccination. A response in HI to at least one of the 3 strains was considered an immune response. RESULTS: Eighty-five patients with colorectal cancer participated in the study. The immune response in the overall population was 70.6%. No differences in response were noted between the 58 patients on active chemotherapy and the 27 patients on surveillance [Odds Ratio (OR) = 0.78; P = 0.8]. The odds of response did not vary by chemotherapy regimen or by chemotherapy-vaccination timing. HI response in all 3 titers concurrently were low in both the chemotherapy (12.1%) and surveillance groups (11.1%) (OR = 1.10; P = 1). CONCLUSIONS: Patients with colorectal cancer mount an immune response to influenza vaccination irrespective of their chemotherapy regimen or timing. However, concurrent responses to all three strains in the individual patient with colorectal cancer are uncommon. The investigation of a booster vaccine in this population is warranted.

A phase II study of first-line biweekly capecitabine and bevacizumab in elderly patients with metastatic colorectal cancer.

PURPOSE: This phase II study was conducted to determine the efficacy and safety of capecitabine and bevacizumab in untreated elderly metastatic colorectal cancer patients. METHODS: Patients received 1500 mg/m(2)/dose of capecitabine twice daily x 7 days and bevacizumab at 5mg/kg on day 1, in 2 week-cycles. RESULTS: The study was closed early, due to poor accrual, after a total of 16 patients enrolled. Four patients had an objective response and 11 patients had stable disease. The median time to progression and overall survival were 9.5 and 21.2 months, respectively. The most common grade >or= 3 toxicities included diarrhea (13%) and hand and foot syndrome (25%). Three patients had an arterial thrombotic event and one patient developed a bowel perforation. CONCLUSIONS: In this underpowered phase II study in elderly patients with metastatic colorectal cancer, capecitabine plus bevacizumab was associated with considerable clinical activity but at an increased risk of hand and foot syndrome and arterial thrombotic events.

Length of hospital stay after percutaneous coronary interventions.

INTRODUCTION AND AIM: Post-percutaneous coronary intervention (PCI) length of hospital stay (LOHS) is one of the key modifiers of hospital cost and quality assessment. Commencing 2000, the cardiovascular services at our institution engaged in a continuous quality improvement program to reduce post-PCI LOHS. METHODS: All PCI patients were screened for potential early discharge. An expedited discharge protocol was applied to all suitable patients. Length of hospital stay and other outcomes were monitored daily. Data were compiled and reported monthly and quarterly by an independent chart review and data analysis team. RESULTS: Over the study period, PCI volume increased 4-fold. Annually, 61.8% to 78.4% of the patients were rendered suitable for abbreviated LOHS. Timely discharge of suitable candidates gradually improved from 77.6% (n = 116) discharged within 48 hours in 2000 to 95% (n = 480) discharged within 30 hours in 2006. CONCLUSION: With the appropriate continuous quality improvement program, 30-hour post-PCI discharge is feasible in more than 95% of suitable cases.