Embed Size (px)
Citation preview
www.jogh.org • doi: 10.7189/jogh.10.020438 1 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
Hana Mahmood1,2, Brian Mckinstry2, Saturnino Luz2, Karen Fairhurst2, Sumaira Nasim2, Tabish Hazir2; RESPIRE Collaboration
1 Maternal, Neonatal and Child Health Research Network (MNCHRN), Pakistan
2 NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, the University of Edinburgh, Edinburgh, UK
Correspondence to:Hana Mahmood BSc, MBBS, MS Health Informatics 402, 4th Floor, Islamabad Stock Exchange Building 55-B Jinnah Avenue Islamabad Pakistan [email protected]
Community health worker-based mobile health (mHealth) approaches for improving management and caregiver knowledge of common childhood infections: A systematic review
Electronic supplementary material: The online version of this article contains supplementary material.
© 2020 The Author(s)JoGH © 2020 ISGH
Background Children in lower middle-income countries (LMICs) are more at risk of dying, than those in High Income Countries (HICs), due to highly prevalent deadly yet preventable childhood infections. Alongside concerns about the inci-dence of these infections, there has been a renewed interest in involving communi-ty health workers (CHWs) in various public health programs. However, as CHWs are increasingly asked to take on different tasks there is a risk that their workload may become unmanageable. One solution to help reduce this burden is the use of mobile health (mHealth) technology in the community through behaviour change. Considering there are various CHWs based mHealth approaches on illness man-agement and education, therefore, we aimed to appraise the available literature on effectiveness of these mHealth approaches for caregivers to improve knowledge and management about common under-five childhood infections with respect to behaviour change.
Methods We searched six databases between October to December 2019 using subject heading (Mesh) and free text terms in title or abstract in US English. We included multiple study types of children under-five or their caregivers who have been counselled, educated, or provided any health care service by CHWs for any common paediatric infectious diseases using mHealth. We excluded articles pub-lished prior to 1990 and those including mHealth technology not coming under the WHO definition. A data extraction sheet was developed and titles, abstracts, and selected full text were reviewed by two reviewers. Quality assessment was done using JBI tools.
Results We included 23 articles involving around 300 000 individuals with eight types of study designs. 20 studies were conducted in Africa, two in Asia, and one in Latin America mainly on pneumonia or respiratory tract infections followed by malaria and diarrhoea in children. The most common types of Health approach-es were mobile applications for decision support, text message reminders and use of electronic health record systems. None of the studies employed the use of any behaviour change model or any theoretical framework for selection of models in their studies.
Conclusions Coupling mhealth with CHWs has the potential to benefit commu-nities in improving management of illnesses in children under-five. High quality evidence on impact of such interventions on behaviour is relatively sparse and fur-ther studies should be conducted using theoretically informed behaviour change frameworks/models.
Registration PROPSERO Registration number: CRD42018117679
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 2 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
Despite substantial progress made under the Millennium Development Goals and the transition to Sus-tainable Development Goals (SDGs), global inequalities are still evident in child health. Compared with high income countries(HICs), children of the low- and middle-income countries (LMICs) are more at risk of dying due to infections [1,2]. 1055 per 100 000 children and adolescents are dying in develop-ing countries with 6.89 million young children losing their lives of 7.7 million children and adolescents globally [3]. These deaths are attributed to several deadly yet preventable childhood infections [4]. The most noteworthy of these are pneumonia, diarrhoea, malaria, measles, typhoid, tuberculosis, hepatitis, and dengue [5,6]. Predisposing factors contributing to high incidence of these conditions include lack of education/health literacy or knowledge among caregivers, gender discrimination, religious factors, demo-graphic and economic barriers [7,8]. These result in delays in health care seeking which is compounded by limited public health care facilities particularly in remote areas [9].
Alongside concern about the incidence of childhood infectious diseases, there has been a renewed interest in involving community health workers (CHWs) in national community health programs [10]. CHW’s are literate individuals, usually women, residing within the local rural communities and fulfilling specified eligibility criteria (eg, at least eight years of education, possession of a middle school pass, local residen-cy, preferably married, and at least 18 years of age) hired as volunteers or against incentives (monetary or in-kind) to serve as the “focal point of care” for their communities [11,12]. According to the World Health Organization (WHO), they are trained for a shorter period of time (a few weeks to a few months) as compared to professional health care workers and although they are supported by the health system they are not a part of its organisations [13]. CHWs have been playing an important role in promoting healthy behaviours and extending the reach of the health system by acting as a bridge between the com-munity and the system [14] through provision of health education, family planning and basic curative care for childhood illnesses [15]. However, increasingly CHWs have been asked to broaden their remits such as their involvement in community based Integrated Management of Childhood illnesses (IMCI), supporting the expansion of their involvement in curative practices [16]. This has led to complaints of unmanageable workloads [17,18]. Therefore, there is a need to develop approaches that may facilitate a reduction of this workload whilst maintaining adequate health care services/education to the communi-ties and continuing to contribute towards reduction of infectious disease burden.
One such approach is the use of mobile technology-based health care solutions (mHealth)by CHWs. mHealth refers to the use of wireless, portable information and communication technologies (ICT) in-cluding the use of cellular phones, smart phones, personal digital assistants, tablets, or laptops to sup-port health and health care delivery [17-19]. Typically, text, voice or video messages or various applica-tions for public health interventions are used to increase access to care or provide information to induce health behaviour change.
With increasing penetration of mobile networks to the remotest of locations in low- and middle-income countries (LMICs), mHealth has opened new opportunities for accessible, affordable, and effective health care through CHWs [18] and is gaining momentum [12-21]. In Africa, for example, mHealth by CHWs has been used to report adverse events in intensive Multiple Drug Resistant-Tuberculosis (MDR-TB) therapy [19]. Similarly, CHWs in Uganda and Kenya have used mHealth in Acquired Immunodeficiency Syndrome (AIDS) care through text messaging [20-23]. Another study in Argentina showed the benefit of CHWs using a customised mHealth application to calculate patients’ cardiovascular risk [24]. Thus, mHealth has started to attract more attention in research with an increasing number of studies determin-ing appropriate design of mHealth based interventions for community and health care professionals, their impacts on the outcomes of care, and barriers and enablers to scaling up [25].
For interventions aimed at inducing behaviour change (specific behavioural patterns through a ‘coordi-nated set of activities’), a number of models have been used [26]. The Health Belief Model (HBP) focuses on the desire to prevent an illness and the belief that a specific health related action will prevent or cure the illness. The Theory of Planned Behaviour (TPB) predicts a person’s intention to engage in a behaviour at a specific place and time thus depending on both motivation and ability. Diffusion of Innovation (DOI) Theory explains how, over time, an idea gains momentum and spreads within a specific population or social system, the end result being the individuals or social system adopting that behaviour. The Social Cognitive Theory (SCT) considers an individual’s past experiences which shape whether a person will engage in a specific behaviour and what are the reasons why that person engages in that particular be-haviour. The Trans Theoretical Model (TTM)works on the assumption that behaviours are not changed quickly and decisively by people. Instead the behaviour change occurs continuously through a cyclical process. The Social Norms Theory (SNT) tries to understand influences such as the environment and in-terpersonal influences (peers) for behaviour change, which can be more effective than focusing on an in-
CHW-based mHealth approaches to common child infections
www.jogh.org • doi: 10.7189/jogh.10.020438 3 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
dividual to change behaviour [27]. For choosing the appropriate model, there are multiple frameworks which have been used one of which is the Behaviour Change Wheel (BCW) which recognises that the target behaviour can in arise from combinations of any of the components of the behaviour system (ca-pability, motivation and opportunity) [26].
There is limited evidence on review of available literature on various mobile health approaches used by CHWs to improve management of children under five by caregivers especially with respect to inducing behaviour change. There has been one systematic review which has focused on use of mHealth technol-ogy by CHWs to identify “opportunities and challenges for strengthening health systems in resource-con-strained settings”. However, it has not focused on management of under five children in particular [28]. We, therefore, appraised the available literature on the effectiveness of various CHW based mHealth ap-proaches for caregivers of children to improve knowledge and/or management of common childhood infections (under five children in particular) with respect to behaviour change.
METHODOLOGY
Registration
The protocol was registered to PROSPERO (Registration number CRD42018117679). Ethical approval was obtained from local ethical board of International Research Force, Pakistan.
Search strategy
Search databases and search terms
In order to finalize the search strategy and search terms a brief literature scoping activity in PubMed, Em-base and Medline was conducted initially to explore relevant keywords and common study types. There-after, we conducted a systematic literature search on six databases: MEDLINE(Ovid), EMBASE(Ovid), CINAHL, PsycINFO, AMED(Ovid) and Global Health from October to December 2019. Searches were conducted in each database using both subject heading (Mesh) where available and free text terms in-cluded in title or abstract. Appendix S1 in the Online Supplementary Document provides a complete list of all search terms and Appendix S2 in the Online Supplementary Document a sample of one elec-tronic search made in a database (Global Health). Once all the databases were searched and articles were extracted, duplicates were identified and removed using EndNote which was followed by a manual ex-ercise for verification which involved checking the excel sheet with any redundancy. If different data or information was presented in more than one publication describing the same study, all were included.
Eligibility criteria
There was no restriction on geographical location and study setting and the searches were run from 1990 onwards as the first mHealth technology interventions started in the early 1990s [29]. Studies were ex-cluded if the intervention did not fall under the WHO definition of mHealth [30], and if the study did not focus on use of mHealth by community health workers for childhood illnesses. Additionally, case studies, editorials, letter to editors, trial protocols, systematic reviews, opinion, or expert articles were also excluded. Conference abstracts were only considered if published in a peer-reviewed journal. We used the PICOS (Population, Intervention, Comparison, Outcome and Study Design) framework [31] to develop our eligibility criteria for the systematic review.
Population
Literature was considered for inclusion if the research included results pertaining to children under five or caregivers of children under five who have been counselled, educated, or provided with any health care service by CHWs for any common paediatric infectious disease. These paediatric infections includ-ed acute respiratory infections (pneumonia), diarrhoea, malaria, measles, typhoid, tuberculosis, hepati-tis, and dengue. This age group has been selected in particular as under five childhood mortality is more than any other age group [32].
Intervention
We included literature that focused on the use of mHealth by CHWs. We used the definition of mHealth as specified by Global Observatory for eHealth of WHO which is “medical and public health practice sup-
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 4 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
ported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices” [29]. This included mHealth interventions that involve a range of delivery modes such as voice calling and text messaging via Short Message Service (SMS). It also included applicationson public health messaging, behaviour change communications, and remote care provision. Also included were applications designed to enable health workers to provide better care to patients through decision support tools for informing screening or intervention decisions, workflow planning, and clinical docu-mentation. Additionally, global positioning system (GPS) tools for patient tracking and portable point-of-care testing devices able to transmit data via mobile phone were also included.
Outcome
Outcomes included any change in knowledge, perception, awareness, insight, behaviour, or familiarity among caregivers of children and/or community health workers about common childhood infections. Ad-ditionally, we sought any impact on hospitalisation eg, number of days in hospital, improved efficiency of the CHWs in managing workload, and improved clinical outcomes (childhood morbidity and mortality).
Study designs
The documents included were randomised controlled trials (RCTs), pilot/feasibility studies, quasi-exper-imental studies, cohort studies, qualitative studies, cross-sectional studies, and project evaluations which focused on assessing the impact of using mobile health technology by CHW for infectious diseases in children under five.
Quality assessment
The Joanna Briggs Institute (JBI) Critical appraisal tools were used to assess risk of bias. The JBI tools which were used for appraisal included those for RCTs, qualitative studies, quasi-experimental studies, cross-sectional studies, cohort studies and economic evaluations [33]. HM and SN conducted appraisal of all included studies and scored them independently. Results were presented as overall mean quality score, while we defined it as, summing mean score of both appraisers and dividing it by the number of appraisers. However, mean score was calculated by dividing sum of individual item score with total num-ber of quality items. Individual quality item was scored either as 1 (ie, present) or 0 (ie, absent)
Data synthesis and analysis
Titles, abstracts, and selected full text were reviewed by two reviewers (HM and SN). A data extraction sheet was used to extract all relevant information which included the title, author(s), year of publication, country, health care setting, aims and objectives, study design, sample size, target users, type of infection, type of mHealth approach, duration, key findings, strengths and limitations. Data extraction was done by one reviewer and reviewed by the other. We intended to conduct data synthesis if suitable comparable RCTs were found, however, due to heterogeneity in their intervention and outcomes, descriptive analy-sis of the attained data was conducted.
RESULTSA total of 736 articles were obtained from all the databases. 189 duplicates were removed leaving546 ar-ticles for title and abstracts review. A list of 49 articles were then extracted from these based-on inclusion criteria and then on full text assessment and consensus between the reviewers, 23 articles were selected for final stage. The PRISMA flow in Figure 1 indicates the process of selection.
Study types
The 23 articles reviewed described eight type of study designs; six RCTs [34-39], six quasi experimental studies [40-45], six qualitative studies [44,46-49], one case study [50], one cohort study [51], and one cost evaluation study [36] and one mixed method study [52].
Study settings
Most articles reported on projects in economically developing countries particularly Africa, with several focused-on Asia, and a few in Latin America as indicated in Table 1. Among the countries reported, most of the studies were conducted in Kenya (n = 5), followed by Uganda (n = 4), Malawi (n = 3) and Ghana (n = 2) with the rest of the studies in other countries.
CHW-based mHealth approaches to common child infections
www.jogh.org • doi: 10.7189/jogh.10.020438 5 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
Participants and illnesses
Among all the articles whereby an mHealth approach was used with/through CHWs, ten of those target-ed caregivers along with children with the rest focused on children alone. The target beneficiaries num-bered approximately 300 000 individuals.
Most of the articles (n = 11) focused on pneumonia or other respiratory tract infections. The next most common infections targeted were malaria (n = 10), diarrhoea (n = 5), two articles reported interventions addressing hepatitis, measles, and TB, and one each on rubella and typhoid fever. The majority of articles (n = 11) included various illnesses together.
Table 1 provides a summary of findings of the included studies.
Quality assessment
Table 2 shows the quality assessment of the studies using JBI tools. Overall, evidence was of moderate quality. Among the RCTS, three of the six covered all aspects of randomization, allocation concealment, blinding, follow up and reliable outcome measurement. Most of the quasi-experimental studies could not provide clear information on measurement of both outcome and exposure along with follow up. The in-cluded qualitative studies addressed all quality parameters except for ‘researcher influence on the research’. Two studies, the cross-sectional and the cohort, did not address the majority of the quality parameters.
Figure 1. PRISMA flow diagram.
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 6 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
Tabl
e 1.
Su
mm
ary
of fin
din
gs
Sr.
Auth
or, y
eAr,
coun
try,
tArg
et
grou
p, in
fect
ion,
And S
Ampl
e Si
ze
met
hodo
logy
Key f
indi
ngS
BehA
viou
r chA
nge
oBSe
rved
limit
Atio
nS
Ran
dom
ized
con
trol
tri
al1.
Zu
rova
c 2011 [
36],
K
enya
, 119 h
ealt
h
wor
ker
s an
d 6
24
ch
ildre
n u
nd
er fi
ve,
Mal
aria
Tex
t m
essa
ge r
emin
der
s in
th
e fo
rm o
f te
n t
asks
abou
t p
aed
iatr
ic m
alar
ia c
ase
man
agem
ent
(tre
atm
ent,
dis
pen
sin
g an
d
cou
nse
llin
g) b
ased
on
Ken
yan
nat
ion
al
mal
aria
gu
idel
ines
wer
e se
nt
to h
ealt
h w
orker
s d
oin
g ou
tpat
ien
t co
nsu
ltat
ion
for
6 m
o.
Th
ree
hea
lth
fac
ility
su
rvey
s w
ere
con
du
cted
: bas
elin
e; o
ne
at 6
mon
ths
of in
terv
enti
on, a
nd
on
e 6 m
onth
s af
ter
the
inte
rven
tion
. Pri
mar
y ou
tcom
e w
as a
com
pos
ite
ind
icat
or for
cor
rect
ar
tem
eth
er-l
um
efan
trin
e m
anag
emen
t am
ong
recr
uit
ed c
hild
ren
bas
ed o
n a
ccom
plis
hm
ent
of t
he
10 s
pec
ified
tas
ks.
In t
he
inte
nti
on-t
o-tr
eat
anal
ysis
, cor
rect
art
emet
her
-lu
mef
antr
ine
man
agem
ent
was
imp
rove
d b
y 23 · 7
% (
95%
CI
9.0
-33.7
, P =
0.0
007)
imm
edia
tely
aft
er t
he
inte
rven
tion
an
d b
y 24 · 5
% (
11.6
-35.7
, P =
0.0
001)
6
mon
ths
afte
r th
e in
terv
enti
on. I
mp
rove
men
ts o
f si
mila
r ef
fect
siz
e w
ere
also
ob
serv
ed w
hen
th
e p
erfo
rman
ce in
dic
ator
was
all
fou
r tr
eatm
ent
task
s an
d
at le
ast
five
of si
x d
isp
ensi
ng
and
cou
nse
llin
g ta
sks;
21.4
% (
imp
rove
men
t so
on a
fter
th
e in
terv
enti
on 9
5%
CI
9.0
-33.7
, P =
0.0
007)
and
23.7
im
pro
vem
ent
6 m
onth
s p
ost
inte
rven
tion
% (
11.6
-35.7
, P =
0.0
001).
Eff
ect
size
s on
per
pro
toco
l an
alys
is w
ere
larg
er a
s co
rrec
t ar
tem
eth
er-l
um
efan
trin
e m
anag
emen
t im
pro
ved
by
31 · 7
% (
95%
CI
15.6
-47.8
) im
med
iate
ly a
fter
in
terv
enti
on a
nd
28.6
% (
12.7
-44.6
) 6 m
onth
s af
ter
the
inte
rven
tion
.
Imp
rove
d c
arer
p
erfo
rman
ce
on d
oin
g th
e te
n t
asks
by
10 · 3
%(4
.0-1
6 · 6
, P =
0 · 0
013)
imm
edia
tely
aft
er
the
inte
rven
tion
an
d 1
1 · 3
% (
5.1
-17.6
, P =
0 · 0
004)
6 m
onth
s af
ter
the
inte
rven
tion
en
ded
.
Mes
sage
s w
ere
not
sen
t in
nat
ive
or n
atio
nal
la
ngu
age
of K
enya
. In
terv
enti
on d
id n
ot
add
ress
nee
d t
o as
sess
ch
ildre
n w
ho
wou
ld t
est
neg
ativ
e fo
r m
alar
ia.
2.
Don
ovan
2018 [
35],
U
gan
da,
129 C
HW
s,
Pn
eum
onia
Mob
ile t
able
ts w
ere
up
load
ed w
ith
vid
eos
on p
neu
mon
ia, i
ts r
ecog
nit
ion
, its
tre
atm
ent
and
pre
ven
tion
for
inte
rven
tion
gro
up
wh
ich
re
ceiv
ed o
ne
and
hal
f d
ay t
rain
ing
on t
he
stan
dar
d iC
CM
gu
idel
ines
fol
low
ed b
y ta
ble
t-bas
ed v
ideo
tra
inin
g; p
re a
nd
pos
t tr
ain
ing
test
. Pri
mar
y ou
tcom
e w
as k
now
led
ge
acqu
isit
ion
an
d r
eten
tion
as
det
erm
ined
by
chan
ges
in M
CQ
sco
res.
Ind
epen
den
t sa
mp
les
t te
st s
how
ed m
ean
imp
rove
men
t in
MC
Q s
core
s to
2.6
(SD
± 3
.1)
in t
he
con
trol
gro
up
(10.8
%)
and
3.2
(SD
± 2
.3)
in t
he
inte
rven
tion
gro
up
(13.3
%),
bu
t th
e d
iffe
ren
ce b
etw
een
bot
h t
he
grou
ps
wit
h r
esp
ect
to im
pro
vem
ent
(mea
n 0
.6; 2
.5%
) w
as n
ot s
tati
stic
ally
si
gnifi
can
t (t
= 1
.15, P
= 0
.254).
Yea
rs o
f ed
uca
tion
was
pos
itiv
ely
asso
ciat
ed
wit
h M
CQ
ch
ange
sco
res,
wit
h a
bet
a co
effi
cien
t of
0.3
3 (
P =
0.0
2)
thou
gh
mu
ltip
le r
egre
ssio
n. A
dd
itio
nal
ly, P
ears
on c
orre
lati
on c
oeffi
cien
t bet
wee
n
pre
-tra
inin
g sc
ores
an
d c
han
ge s
core
s of
MC
Qs
was
-46 (
P <
0.0
01).
-Sh
ort
du
rati
on o
f on
e m
onth
for
th
e p
ilot.
U
se o
f n
on-v
alid
ated
as
sess
men
t to
ol.
3.
Li C
hen
2016 [
39],
C
hin
a, v
illag
e d
octo
rs,
care
give
rs o
f ch
ildre
n; 7
p
arti
cip
ants
fro
m e
ach
cl
ust
er o
f 18 p
airs
of
clu
ster
s. H
epat
itis
B a
nd
M
easl
es
Inte
rven
tion
gro
up
vill
age
doc
tors
use
d
mob
ile p
hon
es w
ith
th
e E
PI
app
to
man
age
child
vac
cin
atio
n c
oup
led
wit
h t
ext
mes
sage
d
isse
min
atio
n t
o al
ert
care
give
rs a
bou
t u
pco
min
g va
ccin
atio
ns.
Tw
o cr
oss-
sect
ion
al
hou
seh
old
su
rvey
s w
ere
con
du
cted
at
bas
elin
e an
d e
nd
-lin
e. F
ace-
to-f
ace
in-d
epth
inte
rvie
ws
wit
h v
illag
e d
octo
rs w
ere
also
con
du
cted
at
the
end
of th
e st
ud
y.
Incr
ease
in fu
ll va
ccin
atio
n fro
m b
asel
ine
to e
nd
-lin
e in
bot
h t
he
inte
rven
tion
an
d c
ontr
ol g
rou
p ie
, fro
m 6
7%
(95%
CI:
58%
-75%
) to
84%
(95%
CI:
76%
-90%
), P
= 0
.028 in
inte
rven
tion
gro
up
an
d fro
m 7
1%
[95%
CI =
62%
-79%
] to
82%
[95%
CI:
74%
-88%
], P
= 0
.014 in
con
trol
gro
up
. Hig
her
incr
ease
was
ob
serv
ed in
inte
rven
tion
th
en in
con
trol
gro
up
fro
m b
asel
ine
to e
nd
-lin
e (1
7%
vs
10%
), b
ut
this
was
not
sta
tist
ical
ly s
ign
ifica
nt
(P =
0.1
64).
Vill
age
doc
tors
rep
orte
d t
hat
th
eir
man
agem
ent
of c
hild
vac
cin
atio
n s
aved
tim
e.
Th
e ed
uca
tion
mod
ule
in t
he
app
let
them
lear
n v
acci
nat
ion
rel
ated
key
kn
owle
dge
an
d s
kill
s co
nve
nie
ntl
y. H
owev
er, t
hey
did
ind
icat
e it
was
har
d
to m
anag
e m
igra
ted
ch
ildre
n.
Incr
ease
d fol
low
u
p b
y ca
regi
vers
fo
r ti
mel
y va
ccin
atio
n.
Shor
t p
roje
ct d
ura
tion
.
4.
Zak
us
2019 [
34],
So
uth
wes
t N
iger
, 31
C
HW
, 252 c
hild
ren
bet
wee
n 2
-59 m
o.
Dia
rrh
oea,
mal
aria
, an
d
pn
eum
onia
.
Bot
h c
ontr
ol a
nd
inte
rven
tion
gro
up
CH
Ws
(RC
oms)
, wer
e tr
ain
ed o
n iC
CM
; in
terv
enti
on
grou
p h
ad a
dd
itio
nal
tra
inin
g on
ap
ply
ing
iCC
M t
hro
ugh
a m
obile
ap
plic
atio
n w
hic
h
also
con
tain
ed m
odu
le o
n c
ontr
ol o
f d
rugs
an
d s
up
plie
s. E
ach
RC
om w
as v
isit
ed b
y a
trai
ned
clin
icia
n a
nd
an
ass
ista
nt
per
dis
tric
t to
ass
ess
QoC
an
d le
vels
of m
otiv
atio
n a
nd
re
ten
tion
.
A 3
.4%
hig
her
QoC
sco
re w
as s
how
n b
y m
Hea
lth
equ
ipp
ed R
Com
s w
ith
a m
ean
diffe
ren
ce o
f 0.8
3 p
oin
ts. T
hes
e R
Com
s w
ere
mor
e lik
ely
to
inqu
ire
abou
t d
ange
r si
gns
wit
h c
onvu
lsio
ns
at 6
9.7
% v
s 50.4
%, P
< 0
.001,
inca
pac
ity
to e
at o
r d
rin
k a
t 79.2
% v
s 59.4
%, P
< 0
.001, v
omit
ing
at 8
1.4
%
vs 6
9.9
%, P
< 0
.01),
an
d le
thar
gy o
r u
nco
nsc
iou
snes
s at
92.4
% v
s 84.8
%,
P <
0.0
1. A
QoC
sco
re o
f m
ore
than
80%
(25 o
ut
of 3
1)
was
obse
rved
am
ong
83%
RC
oms
of t
he
inte
rven
tion
gro
up
had
a a
s op
pos
ed t
o on
ly 6
7%
R
Com
s in
th
e co
ntr
ol g
rou
p. C
orre
ct r
efer
rals
wer
e 85%
in in
terv
enti
on
as c
omp
ared
to
29%
in c
ontr
ol. n
o st
atis
tica
lly s
ign
ifica
nt
diffe
ren
ces
in
mot
ivat
ion
, ret
enti
on, a
nd
su
per
visi
on.
-In
itia
l an
d s
ubse
qu
ent
trai
nin
g on
usi
ng
the
smar
tph
one
cou
ld h
ave
bee
n b
ette
r, a
lon
g w
ith
cl
oser
an
d m
ore
spec
ific
sup
ervi
sion
to
use
th
e te
chn
olog
y to
max
imu
m
effe
ct t
o le
vera
ge
effe
ctiv
enes
s of
th
e iC
CM
p
rogr
am.
CHW-based mHealth approaches to common child infections
www.jogh.org • doi: 10.7189/jogh.10.020438 7 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
Sr.
Auth
or, y
eAr,
coun
try,
tArg
et
grou
p, in
fect
ion,
And S
Ampl
e Si
ze
met
hodo
logy
Key f
indi
ngS
BehA
viou
r chA
nge
oBSe
rved
limit
Atio
nS
5.
Dav
is 2
019 [
37],
U
gan
da,
387 h
ouse
hol
d
con
tact
s; c
hild
ren
fro
m
<5 y
to
14 y
, >15 y
w
ith
out
HIV
, PLH
W.
Tu
ber
culo
sis
CH
Ws
for
bot
h in
terv
enti
on a
nd
sta
nd
ard
ca
re a
rms
wer
e tr
ain
ed t
o p
rovi
de
hom
e sp
utu
m c
olle
ctio
n a
nd
HIV
cou
nse
llin
g an
d
test
ing
serv
ices
acc
ord
ing
to U
gan
da
Nat
ion
al
Gu
idel
ines
. In
terv
enti
on g
rou
p C
HW
s en
tere
d
all i
nfo
rmat
ion
in a
su
rvey
ap
plic
atio
n, w
hic
h
app
lied
an
alg
orit
hm
to
char
acte
rise
eac
h
con
tact
’s n
eed
for
fu
rth
er e
valu
atio
n. S
pu
tum
te
stin
g re
sult
s an
d/o
r fo
llow
-up
inst
ruct
ion
s w
ere
retu
rned
by
auto
mat
ed S
MS
text
s.
Pri
mar
y ou
tcom
e: C
omp
leti
on o
f a
full
TB
ev
alu
atio
n w
ith
in 1
4 d
of tr
eatm
ent.
CH
Ws
iden
tifi
ed 1
90/4
71 (
40%
) in
terv
enti
on a
nd
213/4
48 (
48%
) st
and
ard
ca
re c
onta
cts
requ
irin
g T
B e
valu
atio
n. C
HW
s ob
tain
ed s
pu
tum
fro
m 3
5/9
1
(39%
) of
sp
utu
m-e
ligib
le c
onta
cts
and
tex
t m
essa
ges
wer
e se
nt
to 9
5/1
90
(5
0%
) of
con
tact
s in
th
e in
terv
enti
on a
rm. I
n b
oth
th
e in
terv
enti
on a
nd
st
and
ard
car
e ar
ms,
com
ple
tion
of T
B e
valu
atio
n a
t 14 d
was
14%
an
d
15%
res
pec
tive
ly w
ith
a d
iffe
ren
ce o
f -1
% a
t 95%
CI
(-9%
to
7%
, P =
0.8
1).
H
owev
er, y
ield
s of
con
firm
ed T
B d
iagn
osis
(1.5
% in
inte
rven
tion
an
d 1
.1%
in
sta
nd
ard
car
e, P
= 0
.62)
and
new
HIV
dia
gnos
is (
2.0
% in
inte
rven
tion
vs
1.8
% in
sta
nd
ard
car
e, P
= 0
.90)
wer
e si
mila
r.
-N
on r
evie
w o
f cl
inic
re
gist
ers.
In
com
ple
te
del
iver
y of
inte
rven
tion
, d
iffi
cult
ies
in c
olle
ctin
g sp
utu
m.
6.
Tal
isu
na
2017 [
38],
U
gan
da,
1677 c
hild
ren
<5ye
ars
and
th
eir
care
give
rs. M
alar
ia
It w
as a
n o
pen
-lab
el, r
and
omiz
ed, c
ontr
olle
d
tria
l ass
essi
ng
effe
cts
of S
MS
rem
ind
ers
on p
atie
nts
’ ad
her
ence
to
AL. P
arti
cip
ants
in
inte
rven
tion
an
d c
ontr
ol g
rou
p w
ere
ran
dom
ized
into
3 c
ateg
orie
s: c
ateg
ory
1:
care
give
rs w
ere
visi
ted
at
hom
e on
day
1
to m
easu
re a
dh
eren
ce o
f th
e se
con
d a
nd
th
e th
ird
dos
e of
AL; c
ateg
ory
2: c
areg
iver
s w
ere
visi
ted
at
hom
e on
day
2 t
o m
easu
re
adh
eren
ce o
f fo
urt
h a
nd
fift
h A
L d
oses
an
d,
cate
gory
3: c
areg
iver
s w
ere
visi
ted
at
hom
e on
d
ay 3
to
mea
sure
ad
her
ence
to
full
trea
tmen
t.
Car
egiv
ers
in t
he
inte
rven
tion
arm
wer
e al
so
sen
t au
tom
ated
SM
S re
min
der
s on
tre
atm
ent
adh
eren
ce. P
rim
ary
outc
omes
wer
e: (
a) t
he
pro
por
tion
of p
atie
nts
ad
her
ing
to c
omp
lete
A
L c
ours
e an
d, (
b)
the
pro
por
tion
of p
atie
nts
’ re
turn
ing
to t
he
faci
lity
on d
ay 3
.
Ran
dom
izat
ion
of al
l en
rolle
d c
hild
ren
: 849 (
50.6
%)
into
con
trol
gro
up
an
d 8
29 (
49.4
%)
into
inte
rven
tion
gro
up
. Of th
e 562 c
hild
ren
vis
ited
at
hom
e on
day
3 t
o m
easu
re fu
ll tr
eatm
ent
adh
eren
ce, a
ll d
oses
wer
e gi
ven
to
97.6
% (
282/2
89)
of c
hild
ren
in t
he
con
trol
an
d 9
7.8
% (
267/2
73)
in
the
inte
rven
tion
gro
up
(O
R =
1.1
0; 9
5%
CI =
0.3
7-3
.33; P
= 0
.860).
On
as
sess
men
t of
cor
rect
tim
ing
of t
akin
g ea
ch d
ose,
72.3
% (
209/2
89)
wer
e ad
her
ent
in t
he
con
trol
an
d 6
9.2
% (
189/2
73)
in t
he
inte
rven
tion
gro
up
(O
R =
0.8
2; 9
5%
CI =
0.5
6-1
.19; P
= 0
.302).
Th
e od
ds
of c
hild
ren
ret
urn
ing
to t
he
faci
litie
s on
day
3 a
nd
28 w
ith
in t
he
inte
rven
tion
gro
up
wer
e al
so
incr
ease
d b
y se
nd
ing
SMS
rem
ind
ers;
day
3 (
81.4
in v
s 74.0
%; O
R =
1.5
5;
95%
CI =
1.1
5-2
.08; P
= 0
.004),
28 (
63.4
vs
52.5
%; O
R =
1.5
8; 9
5%
C
I = 1
.30-1
.92; P
< 0
.001).
Imp
rove
d
adh
eren
ce t
o tr
eatm
ent
by
care
give
rs a
nd
im
pro
ved
fol
low
u
p v
isit
in h
ealt
h
care
fac
ility
-
Qu
asi-
exp
erim
enta
l:7.
Xeu
atvo
ngs
a 2016 [
45],
Lao
Peo
ple
Dem
ocra
tic
Rep
ublic
, hea
lth
car
e w
orker
s, h
ealt
h c
are
volu
nte
ers,
9319
ch
ildre
n u
p t
o ag
e of
on
e ye
ar. H
epat
itis
B
6-m
o In
terv
enti
on; d
istr
ict-
leve
l non
-ran
dom
as
sign
men
t. I
nte
rven
tion
hea
lth
wor
ker
s re
ceiv
ed a
on
e-d
ay t
rain
ing
on u
sin
g p
hon
es
in c
ase
of im
min
ent
del
iver
y, m
oth
er/b
aby
wit
h d
ange
r si
gns,
bir
th n
otifi
cati
on, P
NC
se
rvic
es H
CW
s p
rovi
sion
, an
d a
dm
inis
trat
ion
of
Hep
B v
acci
ne.
Com
par
ison
dis
tric
t w
orker
s d
id n
ot h
ave
ph
one
rela
ted
tra
inin
g.
Stu
dy
also
incl
ud
ed a
hou
seh
old
eva
luat
ion
su
rvey
on
diffe
ren
ce in
th
e ch
ange
of H
epB
-B
D c
over
age
bet
wee
n in
terv
enti
on a
nd
co
mp
aris
on d
istr
icts
.
Th
e m
edia
n d
iffe
ren
ce in
vill
age
leve
l Hep
-B v
acci
nat
ion
cov
erag
e w
as 5
7%
(i
nte
rqu
arti
le r
ange
[IQ
R]
32%
-88%
, P <
0.0
001)
in in
terv
enti
on d
istr
icts
, co
mp
ared
wit
h 2
0%
(IQ
R 0
%-5
0%
, P <
0.0
001)
in c
omp
aris
on d
istr
icts
. In
terv
enti
on d
istr
icts
sh
owed
mor
e im
pro
vem
ent
than
in c
ontr
ol d
istr
icts
(P
= 0
.0009).
Car
egiv
ers
resp
ond
ed t
o re
ferr
als
by
hea
lth
w
orker
s fo
r H
ep
B v
acci
nat
ion
in
crea
sin
g co
vera
ge fro
m
20%
to
57%
.
Res
ult
s n
ot g
ener
aliz
able
, se
vera
l sel
ecte
d v
illag
es
only
had
ch
ildre
n fro
m
one
age
grou
p, m
akin
g co
mp
aris
on im
pos
sible
, so
me
villa
ges
had
100%
co
vera
ge a
t bas
elin
e an
d t
her
efor
e n
o fu
rth
er
imp
rove
men
t co
uld
be
exp
ecte
d.
Tabl
e 1.
Con
tin
ued
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 8 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
Sr.
Auth
or, y
eAr,
coun
try,
tArg
et
grou
p, in
fect
ion,
And S
Ampl
e Si
ze
met
hodo
logy
Key f
indi
ngS
BehA
viou
r chA
nge
oBSe
rved
limit
Atio
nS
8.
Tu
mu
siim
e 2014
[4
3], U
gan
da,
CH
Ws,
ch
ildre
n u
nd
er a
ge
of fi
ve, c
areg
iver
s of
ch
ildre
n, l
ocal
lead
ers
& g
over
nm
ent
hea
lth
of
fici
als.
Dia
rrh
oea,
ac
ute
res
pir
ator
y in
fect
ion
(A
RI)
, p
neu
mon
ia
9-m
o st
ud
y on
dev
elop
men
t of
a m
obile
ap
plic
atio
n for
tim
ely
dia
gnos
es, r
ecog
nit
ion
of
dan
ger
sign
s, c
omm
un
icat
ion
abou
t re
ferr
als
and
init
iati
on t
reat
men
t th
rou
gh a
sp
ecia
lly d
esig
ned
mob
ile a
pp
licat
ion
use
d b
y C
HW
s. T
he
enti
re im
ple
men
tati
on p
roce
ss
wit
h d
evel
opm
ent
of m
obile
alg
orit
hm
s,
com
ple
tion
of an
en
viro
nm
enta
l sca
n w
ith
tr
ain
ing
of 9
6 C
HW
s, t
ook p
lace
bet
wee
n J
uly
2011 a
nd
Mar
ch 2
012
Th
e p
roje
ct w
as c
omp
lete
d in
7 p
has
es. P
has
e 1 in
clu
ded
dev
elop
men
t of
in
terf
ace
and
its
test
ing,
Ph
ase
2 u
sabili
ty t
esti
ng
was
acc
omp
lish
ed, P
has
e 3 in
clu
ded
th
e en
viro
nm
enta
l sca
n, P
has
e 4 r
epor
ted
on
ph
ase
3, P
has
e 5
in
clu
ded
th
e p
rocu
rem
ent
pro
cess
, Ph
ase
6 in
clu
ded
up
load
ing
the
ph
ones
w
ith
ap
plic
atio
n a
nd
ph
ase
7 w
as d
evel
opm
ent
of t
rain
ing
man
ual
. Up
on
trai
nin
g C
HW
s d
emon
stra
ted
th
e ca
pac
ity
to c
ontr
ibu
te s
ign
ifica
ntl
y to
th
e ti
mel
y ga
ther
ing
of d
ata
on in
cid
ence
, ref
erra
l, an
d t
reat
men
t of
ch
ildh
ood
ill
nes
s. T
he
qu
alit
y of
th
e in
form
atio
n o
bta
ined
usi
ng
the
mob
ile p
hon
es
surp
asse
d t
hat
obta
ined
fro
m c
onve
nti
onal
pap
er r
ecor
ds.
Ad
dit
ion
ally
, re
trie
val o
f d
ata
alon
g w
ith
an
alys
is fro
m m
obile
ph
one
reco
rds
was
gre
atly
fa
cilit
ated
.
Imp
rove
d
care
see
kin
g by
care
give
rs
up
on r
efer
rals
th
rou
gh C
HW
s u
sin
g th
e m
obile
ap
plic
atio
n.
Rec
ruit
men
t of
CH
Ws
and
th
e d
emon
stra
tion
of
th
e co
ntr
olle
d
inte
rven
tion
tri
al la
cked
d
etai
l. T
he
stu
dy
was
not
ab
le t
o p
rove
lon
g te
rm
ben
efits
of u
sin
g m
obile
p
hon
es in
ru
ral U
gan
da
and
sim
ilar
sett
ings
.
9.
Kab
akye
nga
2016
[4
4], S
outh
Wes
tern
U
gan
da,
196 C
HW
s,
1529 c
hild
ren
un
der
ag
e of
five
, car
egiv
ers
of c
hild
ren
. Mal
aria
, p
neu
mon
ia &
dia
rrh
oea.
An
obse
rvat
ion
al s
tud
y in
five
par
ish
es (
47
vi
llage
s) s
erve
d b
y C
HW
s w
ell v
erse
d in
iCC
M
wit
h s
up
ple
men
tal t
rain
ing
in m
obile
ph
one
use
. Im
pac
t w
as a
sses
sed
by
qu
anti
tati
ve
mea
sure
s an
d q
ual
itat
ive
eval
uat
ion
th
rou
gh
hou
seh
old
su
rvey
s, k
ey in
form
ant
inte
rvie
ws
and
foc
us
grou
p d
iscu
ssio
ns.
CH
Ws
sup
por
ted
by
mob
ile p
hon
es c
orre
ctly
tre
ated
97.1
% o
f fe
ver
case
s, 8
8.2
% o
f p
neu
mon
ia c
ases
an
d 9
2.4
% o
f d
iarr
hoe
a ca
ses.
Wh
erea
s tr
ain
ed C
HW
s w
ith
out
mob
ile p
hon
e ap
pro
pri
atel
y tr
eate
d fev
er in
93.6
%
case
s, p
neu
mon
ia in
92.3
% a
nd
dia
rrh
oea
in 9
0.4
%. H
owev
er, s
ign
ifica
nt
imp
rove
men
ts in
clin
ical
ou
tcom
es w
hen
com
par
ed b
etw
een
mob
ile
ph
one
and
non
-mob
ile p
hon
e su
pp
orte
d C
HW
s w
ere
un
pro
ven
in t
his
d
emon
stra
tion
. Qu
alit
ativ
e ev
alu
atio
n s
how
ed im
pro
vem
ents
in t
reat
men
t p
lan
nin
g, s
up
ply
an
d lo
gist
ical
man
agem
ent,
an
d e
ffici
ency
.
-Sm
all s
amp
le s
ize
and
lim
ited
obse
rvat
ion
p
erio
d. L
ack o
f in
form
atio
n o
n
dev
elop
men
t of
th
e m
obile
ph
one
tool
an
d m
itig
atio
n o
f an
y ch
alle
nge
s en
cou
nte
red
.
10.
Nd
iaye
2018 [
40],
Se
neg
al, 4
4 6
82
ch
ildre
n, c
areg
iver
s an
d 9
1 h
ealt
h w
orker
s,
Mal
aria
Two
stra
tegi
es t
o im
pro
ve r
epor
tin
g of
acu
te
emer
gen
cies
(A
Es)
du
rin
g SM
C c
amp
aign
s w
ere
eval
uat
ed a
s co
mp
ared
to
the
nat
ion
al
spon
tan
eou
s re
por
tin
g sy
stem
. Hea
lth
p
osts
wer
e al
loca
ted
into
th
ree
arm
s: S
afet
y m
onit
orin
g u
sin
g th
e n
atio
nal
sys
tem
of
spon
tan
eou
s re
por
tin
g th
rou
gh t
he
nat
ion
al
rep
orti
ng
form
(th
e n
atio
nal
sys
tem
),
com
ple
ted
by
ph
ysic
ian
s or
nu
rses
at
hea
lth
fa
cilit
ies
usi
ng
mob
ile p
hon
es (
enh
ance
d
spon
tan
eou
s re
por
tin
g), c
omp
lete
d b
y n
urs
es
at h
ealt
h p
osts
an
d b
y C
HW
s w
ith
act
ive
follo
w-u
p o
f ch
ildre
n a
t h
ome
afte
r to
inqu
ire
abou
t A
Es
and
col
lect
rec
ord
on
a s
ymp
tom
ca
rd (
acti
ve s
urv
eilla
nce
).
Rat
e ra
tios
wer
e u
sed
to
com
par
e ra
tes
bet
wee
n s
urv
eilla
nce
met
hod
s, a
ge
grou
ps,
an
d c
alen
dar
mon
ths,
est
imat
ed u
sin
g Poi
sson
reg
ress
ion
1145
ev
ents
wer
e re
por
ted
ove
r 3 m
onth
s w
ith
a r
ate
of 3
0.6
(95%
CI =
28.8
-32.4
) p
er 1
000 c
hild
ren
tre
ated
per
mon
th, c
omp
ared
to
1.6
5 (
95%
CI =
1.2
7-
2.1
5)
per
1000 p
er m
onth
in h
ealt
h p
osts
usi
ng
nat
ion
al s
yste
m. E
nh
ance
d
rep
orti
ng
wit
h C
HW
s u
sin
g m
obile
ph
ones
als
o in
crea
sed
rep
orti
ng
by
18-f
old
(ra
te r
atio
18.5
, 95%
CI
8.6
5-3
9.7
). T
he
mos
t co
mm
only
rep
orte
d
sym
pto
ms
wer
e fe
ver,
vom
itin
g an
d a
bd
omin
al p
ain
. No
seri
ous
adve
rse
dru
g re
acti
ons
wer
e d
etec
ted
des
pit
e in
crea
sed
su
rvei
llan
ce.
-T
he
lack
of su
itab
le
con
trol
s to
est
ablis
h
the
rate
of sy
mp
tom
s in
ch
ildre
n w
ho
did
n
ot r
ecei
ve S
MC
. T
her
e m
igh
t h
ave
bee
n
rep
orti
ng
bia
s, b
oth
by
care
give
rs a
nd
by
CH
Ws.
C
areg
iver
s bec
ause
th
ey
mig
ht
hav
e n
ot r
epor
ted
on
sym
pto
ms
not
list
ed
on t
he
sym
pto
m c
ard
, an
d C
HW
s bec
ause
th
eir
trai
nin
g em
ph
asiz
ed o
n
the
kn
own
sid
e ef
fect
s of
SM
C d
rugs
.
11.
Fin
ette
2019 [
42],
B
urk
ina
Fas
o, E
cuad
or,
and
Ban
glad
esh
, 861
ch
ildre
n 2
-60 m
onth
s of
age
an
d 4
9 C
HW
s.
Pn
eum
onia
, dia
rrh
oea,
m
alar
ia.
Stu
dy
des
crib
es d
evel
opm
ent
and
init
ial
valid
atio
n t
esti
ng
of a
n m
Hea
lth
pla
tfor
m,
ME
DSI
NC
des
ign
ed for
hea
lth
wor
ker
s to
p
erfo
rm c
linic
al r
isk a
sses
smen
ts o
f ch
ildre
n.
Clin
ical
ass
essm
ents
mad
e by
CH
Ws
thro
ugh
M
ED
SIN
C w
ere
corr
elat
ed b
lind
ly a
nd
in
dep
end
entl
y w
ith
th
ose
mad
eby2
2 lo
cal
hea
lth
car
e p
rofe
ssio
nal
s (L
HPs)
.
Res
ult
s sh
owed
an
84%
an
d 9
9%
cor
rela
tion
bet
wee
n C
HW
gen
erat
ed
asse
ssm
ents
an
d t
hos
e co
nd
uct
ed b
y H
CPs.
Tri
age
reco
mm
end
atio
n
dis
trib
uti
ons
of M
ED
SIN
C w
ere
hig
hly
cor
rela
ted
wit
h t
hos
e of
Loc
al h
ealt
h
care
pro
vid
ers
wh
erea
s u
sabili
ty a
nd
fea
sibili
ty r
esp
onse
s w
ere
colle
ctiv
ely
pos
itiv
e fo
r ea
se o
f u
se, l
earn
ing,
an
d jo
b p
erfo
rman
ce.
-Les
s ac
cura
te a
sses
smen
t of
sp
ecifi
city
an
d
sen
siti
vity
.
Tabl
e 1.
Con
tin
ued
CHW-based mHealth approaches to common child infections
www.jogh.org • doi: 10.7189/jogh.10.020438 9 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
Sr.
Auth
or, y
eAr,
coun
try,
tArg
et
grou
p, in
fect
ion,
And S
Ampl
e Si
ze
met
hodo
logy
Key f
indi
ngS
BehA
viou
r chA
nge
oBSe
rved
limit
Atio
nS
12.
Boy
ce 2
019 [
41],
M
alaw
i, 799 H
SAs
in
the
tria
l an
d 4
7 K
IIs
wit
h s
takeh
old
ers
rep
rese
nti
ng
all
leve
ls o
f th
e iC
CM
im
ple
men
tati
on
Syst
em a
nd
ch
ildre
n
2-5
9 m
onth
s of
age
. Pn
eum
onia
, dia
rrh
oea,
m
alar
ia
Th
is s
tud
y co
mp
ared
th
e u
se o
f an
iCC
M
enab
led
mob
ile a
pp
licat
ion
by
CH
W (
HSA
s)
to p
aper
-bas
ed m
anag
emen
t to
ols.
Th
is
was
fu
rth
er s
up
ple
men
ted
by
con
du
ctio
n
of 4
7 k
ey in
form
ant
inte
rvie
ws
abou
t th
e p
erce
pti
ons
of H
SAs
on Q
ual
ity
of C
are
(QoC
) an
d s
ust
ain
abili
ty o
f th
e iC
CM
bas
ed m
obile
ap
plic
atio
n.
Mob
ile p
hon
e en
able
d H
SAs
asse
ssed
sic
k c
hild
ren
bas
ed o
n iC
CM
gu
idel
ines
mor
e of
ten
th
an H
SAs
usi
ng
pap
er-b
ased
too
ls for
cou
gh
(ad
just
ed p
rop
orti
on, 9
8%
vs
91%
; P <
0.0
1)
and
five
ph
ysic
al d
ange
r si
gns
incl
ud
ing
ches
t in
-dra
win
g, a
lert
nes
s, p
alm
ar p
allo
r, m
aln
ouri
shm
ent,
an
d o
edem
a (8
0%
vs
62%
; P <
0.0
1),
bu
t n
ot for
an
d d
iarr
hoe
a (9
4%
vs
87%
; P =
0.0
3).
81%
of m
obile
bas
ed H
SAs
corr
ectl
y cl
assi
fied
ill c
hild
ren
bas
ed o
n d
ange
r si
gns
as c
omp
ared
to
58%
of H
SAs
usi
ng
pap
er-b
ased
to
ols
(P <
0.0
1).
No
diffe
ren
ces
exis
ted
for
th
eir
trea
tmen
ts (
P =
0.2
7).
In
terv
iew
res
pon
den
ts s
tate
d t
hat
usi
ng
mob
ile a
pp
licat
ion
en
sure
s p
roto
col
adh
eren
ce. B
arri
ers
to c
onsi
sten
t an
d w
ide
use
incl
ud
ed h
ard
war
e p
roble
ms
and
lim
ited
res
ourc
es.
Th
e st
ud
y w
as n
ot p
art
of t
he
init
ial p
rogr
am
des
ign
, res
earc
her
s co
uld
not
ran
dom
ize
the
inte
rven
tion
nor
hav
e a
bas
elin
e as
sess
men
t.
Th
ey w
ere,
th
eref
ore,
u
nab
le t
o d
eter
min
e if
an
y d
iffe
ren
ces
exis
ted
bet
wee
n t
he
grou
ps
pri
or
to t
he
imp
lem
enta
tion
of
the
mob
ile a
pp
licat
ion
.
13.
Ism
ail 2
017 [
50],
Ken
ya,
9 m
onth
s to
14-y
-old
ch
ildre
n; 5
3 2
77 v
illag
es
in t
he
46 c
oun
ties
. M
easl
es a
nd
ru
bel
la
In t
his
stu
dy
use
of a
mob
ile p
hon
e ap
plic
atio
n w
as a
sses
sed
for
nat
ion
al le
vel
pla
nn
ing
and
imp
lem
enta
tion
of a
mea
sles
ru
bel
la (
MR
) ca
mp
aign
in K
enya
. Dat
a co
llect
ion
was
don
e u
sin
g 7 d
ata
colle
ctio
n
form
s (v
illag
e fo
rms)
Rea
l tim
e d
ata
was
rec
eive
d fro
m 4
6 o
f 47 c
oun
ties
. Th
e m
icro
pla
nn
ing
pro
cess
was
don
e w
ith
in a
ver
y sh
ort
tim
e of
4 w
eeks,
com
par
ed t
o th
e 2013 p
olio
mic
ro p
lan
s w
hic
h t
ook m
ore
than
on
e ye
ar t
o be
subm
itte
d
to t
he
nat
ion
al le
vel.
Mor
e th
an 3
mill
ion
ch
ildre
n w
ho
wer
e n
ot c
aptu
red
in
th
e n
atio
nal
pla
n w
ere
cap
ture
d b
y th
e m
icro
-pla
ns.
98%
had
map
ped
al
l th
e p
lace
s w
her
e th
e ta
rget
age
ch
ildre
n c
ould
be
fou
nd
. How
ever
, th
e u
plo
adin
g of
th
e d
ata
by
the
sub c
oun
ty t
eam
s w
ere
not
get
tin
g as
fas
t as
p
lan
ned
wit
h in
com
ple
te d
raft
s in
th
e sy
stem
lead
ing
to c
logg
ing.
-U
ncl
ear
bac
kgr
oun
d
and
intr
odu
ctio
n a
nd
m
eth
odol
ogy
of d
ata
colle
ctio
n.
14.
Alt
hau
s 2017 [
52],
T
anza
nia
, 150 c
hild
ren
ag
ed 2
-59 m
o, h
ealt
h
wor
ker
s. M
alar
ia,
pn
eum
onia
, UT
I,
dys
ente
ry, d
iarr
hoe
a,
typ
hoi
d fev
er.
Th
e st
ud
y as
sess
ed t
he
imp
act
of a
n e
lect
ron
ic
Alg
orit
hm
for
man
agem
ent
of c
hild
hoo
d
dis
ease
s on
Hea
lth
care
wor
ker
per
form
ance
an
d a
nti
mic
robia
l pre
scri
pti
on. N
ine
pri
mar
y h
ealt
h c
are
faci
litie
s (H
Fs)
wer
e ra
nd
omiz
ed
into
th
ree
arm
s: 1
) p
aper
alg
orit
hm
, 2)
smar
tph
one
bas
ed e
lect
ron
ic a
lgor
ith
m a
nd
3)
con
trol
. Mai
n o
utc
omes
: Pro
por
tion
of
child
ren
ch
ecked
for
dan
ger
sign
s Pro
por
tion
of
ch
ildre
n g
iven
an
tibio
tics
.
Use
of el
ectr
onic
too
l by
CH
Ws
vs p
aper
led
to
a si
gnifi
can
t in
crea
se in
ch
ildre
n c
hec
ked
for
dan
ger
sign
s (4
1%
vs
74%
, P =
0.0
4).
In
con
trol
arm
, d
ange
rs s
ign
s w
ere
chec
ked
in o
nly
3%
of th
e ch
ildre
n (
ran
ge: 2
%-4
%
amon
g th
ree
HF
s), I
n t
he
pap
er a
rm, d
ange
r si
gns
wer
e ch
ecked
in 4
1%
of
th
e ch
ildre
n (
ran
ge: 1
6%
-71%
am
ong
thre
e H
Fs,
aR
R a
s co
mp
ared
wit
h
con
trol
arm
, 95%
CI:
14.4
, 95%
CI=
3.4
-69.7
,), w
her
eas
in t
he
elec
tron
ic
arm
, dan
ger
sign
s w
ere
chec
ked
in 7
4%
of th
e ch
ildre
n (
ran
ge: 6
3%
-94%
, 30.9
, 95%
CI=
9.2
-120.2
).Tw
o-th
ird
s of
th
e ch
ildre
n h
ad t
hei
r m
ain
sy
mp
tom
s ch
ecked
in t
he
con
trol
arm
(77%
, ran
ge: 6
4%
-91%
) an
d t
he
pap
er a
rm (
75%
, ran
ge: 6
8%
-82%
, 1.0
[0.8
-1.2
]), w
her
eas
in t
he
elec
tron
ic
arm
, alm
ost
all t
he
child
ren
had
th
eir
sym
pto
ms
chec
ked
(99%
, ran
ge: 9
8%
-100%
, 1.3
, 95%
CI=
1.2
-1.3
. Ad
dit
ion
ally
, th
e p
rop
orti
on o
f ch
ildre
n w
ith
C
HW
s’ d
isea
se c
lass
ifica
tion
s m
atch
ing
that
of th
e ex
per
ts w
as lo
w in
bot
h
con
trol
(34%
, ran
ge in
th
e th
ree
HF
s: 2
2%
-56%
) an
d p
aper
arm
s (3
9%
, ra
nge
: 35%
-42%
, 1.1
, 95%
CI=
0.7
-1.9
) bu
t sl
igh
tly
hig
her
in t
he
elec
tron
ic
one
(53%
, ran
ge: 4
7%
-59%
, 1.6
, 95%
CI=
1.0
-2.5
). S
imila
rly,
th
e p
rop
orti
on
of c
hild
ren
pre
scri
bed
an
tibio
tics
was
mu
ch lo
wer
in t
he
inte
rven
tion
s th
an
in t
he
con
trol
arm
(70%
, ran
ge 6
0%
-85%
in t
he
con
trol
; 26%
, ran
ge 1
4%
-37%
, 0.4
, 95%
CI=
0.2
-0.6
) in
th
e p
aper
; an
d 2
5%
, ran
ge: 1
7%
-33%
, 0.3
, 95%
CI=
0.2
-0.5
in t
he
elec
tron
ic a
rm.
-T
he
smal
l nu
mber
of H
Fs
invo
lved
, th
eir
dis
par
itie
s in
siz
e, a
nd
th
e re
lati
vely
sm
all n
um
ber
of
con
sult
atio
ns
obse
rved
lim
its
the
pow
er o
f th
e an
alys
is.
Tabl
e 1.
Con
tin
ued
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 10 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
Sr.
Auth
or, y
eAr,
coun
try,
tArg
et
grou
p, in
fect
ion,
And S
Ampl
e Si
ze
met
hodo
logy
Key f
indi
ngS
BehA
viou
r chA
nge
oBSe
rved
limit
Atio
nS
Qu
alit
ativ
e st
ud
y:15.
Jon
es 2
018 [
48],
Ken
ya, 3
4 c
areg
iver
s of
child
ren
. Mal
aria
Th
e st
ud
y (t
hro
ugh
FG
Ds
of c
areg
iver
s fr
om
bot
h in
terv
enti
on a
nd
con
trol
arm
s) e
xplo
red
par
tici
pan
ts’ e
xper
ien
ces
in a
n R
CT
tri
al o
n
effe
cts
of t
ext
mes
sage
rem
ind
ers
on p
aed
iatr
ic
adh
eren
ce t
o ar
tem
eth
er-l
um
efan
trin
e(A
L)
and
iden
tifi
cati
on o
f fa
ctor
s th
at c
ontr
ibu
te t
o
hig
h a
dh
eren
ce r
ates
.
Inte
rven
tion
-arm
par
tici
pan
ts r
epor
ted
th
at t
ext
mes
sage
s w
ere
effe
ctiv
e
dos
ing
rem
ind
ers.
Car
egiv
ers
from
bot
h a
rms
men
tion
ed t
hat
in d
epth
inst
ruct
ion
s p
laye
d a
n im
por
tan
t ro
le in
tre
atm
ent
adh
eren
ce. T
hey
als
o
men
tion
ed t
hat
am
ong
the
con
trib
uti
ng
fact
ors
to h
igh
qu
alit
y ca
re a
nd
adh
eren
ce t
o d
osin
g in
stru
ctio
ns,
res
pec
tfu
l an
d p
erso
nal
ized
tre
atm
ent
of
care
give
rs fro
m t
rial
CH
Ws
was
for
efro
nt.
-G
ap b
etw
een
tri
al e
nd
and
FG
D o
f w
as lo
ng
to h
ave
affe
cted
th
e
mem
ory.
16.
Gin
sbu
rg 2
016
[46]
, Gh
ana,
71
resp
ond
ents
; Dis
tric
t
Hea
lth
ad
min
istr
ator
s,
hea
lth
car
e as
sist
ants
,
com
mu
nit
y h
ealt
h
offi
cers
(C
HO
s),
com
mu
nit
y h
ealt
h
nu
rses
(C
HN
s) a
nd
care
give
rs o
f 2 m
o-
and
5 y
-old
ch
ildre
n.
Pn
eum
onia
.
A d
esig
n-s
tage
qu
alit
ativ
e p
ilot
stu
dy
was
con
du
cted
to
asse
ss fea
sibili
ty, u
sabili
ty,
and
acc
epta
bili
ty o
f m
Pn
eum
onia
(m
obile
app
licat
ion
to
dia
gnos
e, c
lass
ify
and
man
age
pn
eum
onia
) in
six
hea
lth
cen
ters
an
d fi
ve
com
mu
nit
y-bas
ed h
ealt
h p
lan
nin
g an
d
serv
ices
cen
ters
.
Hea
lth
ad
min
istr
ator
s re
por
ted
ap
p w
ould
be
use
ful i
f ap
pro
ved
by
nat
ion
al
and
reg
ion
al d
ecis
ion
mak
ers.
HC
Ps
felt
usi
ng
the
app
wou
ld im
pro
ve
accu
rate
pat
ien
t ca
re. T
hey
sta
ted
th
at t
he
app
licat
ion
was
eas
y to
use
an
d
pro
vid
ed t
he
hea
lth
wor
ker
s co
nfi
den
ce in
dia
gnos
is a
nd
tre
atm
ent
of
child
ren
. Maj
or c
hal
len
ges
of a
pp
licat
ion
wer
e el
ectr
icit
y re
qu
irem
ents
for
char
gin
g an
d a
dd
itio
nal
tim
e re
qu
ired
to
com
ple
te t
he
app
licat
ion
. Som
e
care
give
rs s
aw t
he
app
as
a si
gn o
f m
oder
nit
y, in
crea
sin
g th
eir
tru
st in
th
e
care
pro
vid
ed t
o th
eir
child
ren
. A few
of th
e ca
regi
vers
wer
e sl
igh
tly
hes
itan
t
and
/or
con
fuse
d r
egar
din
g th
e n
ew t
ech
nol
ogy.
-In
flu
ence
on
tim
e sp
ent
per
pat
ien
t d
ue
to
add
itio
nal
ass
essm
ent
of p
neu
mon
ia c
ases
per
stan
dar
d o
f ca
re.
17.
Bes
sat
2019 [
47],
Bu
rkin
a F
aso,
21 h
ealt
h
wor
ker
s. C
omm
on
child
hoo
d il
lnes
ses
Th
is s
tud
y w
as c
ond
uct
ed in
th
e fr
ame
of
a la
rge-
scal
e im
ple
men
tati
on o
f an
e-I
MC
I
tool
dev
elop
ed. 1
2 in
-dep
th in
terv
iew
s an
d
2 foc
us-
grou
ps
wer
e co
nd
uct
ed fro
m h
ealt
h
wor
ker
s of
10 p
rim
ary
care
fac
iliti
es. T
hem
es
wer
e id
enti
fied
th
rou
gh q
ual
itat
ive
dat
a
anal
ysis
sof
twar
e.
Use
rs s
how
ed a
hig
h le
vel o
f sa
tisf
acti
on a
lth
ough
on
e of
th
e m
ajor
inco
nve
nie
nce
s p
erce
ived
was
slo
wn
ess
of t
he
table
t. S
ever
al c
omm
on
illn
esse
s w
ere
iden
tifi
ed a
s m
issi
ng
in t
he
algo
rith
m a
lon
g w
ith
gu
idan
ce for
feve
r. O
nly
five
use
rs s
tate
d t
hat
an
tibio
tics
had
no
acti
on o
n v
iral
dis
ease
s.
Th
e to
ol w
as p
erce
ived
to
be
imp
rovi
ng
pat
ien
t m
anag
emen
t an
d r
atio
nal
use
of an
tibio
tics
. Pos
itiv
e ch
ange
s in
hea
lth
fac
ility
org
anis
atio
n w
ere
also
rep
orte
d, s
uch
as
task
sh
ifti
ng
and
imp
rove
d t
riag
e.
-In
flu
ence
of re
sear
cher
on r
esea
rch
an
d v
ice
vers
a w
ere
not
ad
dre
ssed
.
Res
ult
s m
ay n
ot b
e
gen
eral
izab
le t
o u
rban
sett
ings
.
18.
Ide
2019 [
41],
Mal
awi,
17 H
SAs
and
28 c
areg
iver
s.
Mal
aria
, dia
rrh
oea,
an
d
pn
eum
onia
Th
is s
tud
y w
as c
ond
uct
ed in
th
e fr
ame
of
a la
rge-
scal
e im
ple
men
tati
on o
n u
se o
f an
mh
ealt
h t
ool o
n iC
CM
. Dat
a w
as c
olle
cted
thro
ugh
sem
i-st
ruct
ure
d in
terv
iew
s w
ith
HSA
s an
d c
areg
iver
s. D
edu
ctiv
e an
d in
du
ctiv
e
app
roac
hes
wer
e u
sed
du
rin
g d
ata
anal
ysis
.
Nea
rly
all H
SAs
pre
ferr
ed t
he
Ap
p o
ver
rou
tin
e p
aper
bas
ed C
CM
. Mos
t of
the
HSA
s st
ated
th
at t
he
app
licat
ion
was
less
pro
ne
to e
rror
s an
d t
her
efor
e
mor
e re
liable
, fac
ilita
tin
g m
ore
accu
rate
dia
gnos
es a
nd
tre
atm
ent
of c
hild
ren
.
It a
lso
led
to
enh
ance
d p
rofe
ssio
nal
con
fid
ence
an
d r
esp
ect
wit
hin
th
e
com
mu
nit
y. A
few
als
o m
enti
oned
th
at t
hey
did
not
tru
st t
he
resu
lts
blin
dly
.
Car
egiv
er r
eact
ion
s to
th
e A
pp
’s v
alid
ity
was
mix
ed b
ut
lean
ed t
owar
ds
favo
ura
ble
. Man
y H
SAs
also
wel
com
ed t
he
mob
ile t
ech
nol
ogy
as t
he
way
of
the
futu
re a
nd
als
o fe
lt it
was
acc
epta
ble
wit
hin
th
eir
com
mu
nit
y. U
sabili
ty
feat
ure
s in
clu
ded
fas
ter
pro
visi
on o
f ca
re, p
orta
bili
ty, i
mp
rove
d d
ura
bili
ty,
and
mor
e ef
fici
ent
and
eas
ier
mon
thly
rep
orti
ng
to t
he
Dis
tric
t H
ealt
h
Offi
cer.
In
adeq
uat
e m
obile
net
wor
k c
over
age
or e
lect
rici
ty s
hor
tage
s w
ere
the
mai
n c
hal
len
ges.
-In
flu
ence
of re
sear
cher
on r
esea
rch
an
d v
ice
vers
a w
ere
not
ad
dre
ssed
.
Tabl
e 1.
Con
tin
ued
CHW-based mHealth approaches to common child infections
www.jogh.org • doi: 10.7189/jogh.10.020438 11 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
Sr.
Auth
or, y
eAr,
coun
try,
tArg
et
grou
p, in
fect
ion,
And S
Ampl
e Si
ze
met
hodo
logy
Key f
indi
ngS
BehA
viou
r chA
nge
oBSe
rved
limit
Atio
nS
19
.G
insb
urg
20
15
[4
6],
Gh
ana,
7 H
CP
s
Th
is s
tud
y w
as a
des
ign
-sta
ge u
sab
ilit
y fi
eld
test
of
a m
ob
ile
app
lica
tion
(m
Pn
eum
on
ia)
wit
h t
he
aim
of
dev
elop
ing
a u
ser-
frie
nd
ly
dia
gnost
ic a
nd
man
agem
ent
aid
for
chil
dh
ood
pn
eum
on
ia t
hat
wou
ld i
mp
rove
dia
gnost
ic a
ccu
racy
an
d f
acil
itat
e ad
her
ence
by
hea
lth
car
e p
rovi
der
s to
est
abli
shed
guid
elin
es i
n l
ow
-res
ou
rce
sett
ings
All
HC
Ps
exp
ress
ed a
des
ire
and
wil
lin
gnes
s to
use
th
e ap
pli
cati
on
.
Th
ey,
how
ever
, fe
lt t
hat
nom
inal
tra
inin
g an
d a
deq
uat
e te
chn
ical
su
pp
ort
wou
ld b
e re
qu
ired
for
firs
t-ti
me
use
rs.
Ove
rall
, al
l H
CP
s p
refe
rred
to u
se
mP
neu
mon
ia o
ver
the
pap
er-b
ased
tools
.
-Sm
all
sam
ple
siz
e. N
o
stat
emen
t lo
cati
ng
rese
arch
er c
ult
ura
lly
or
theo
reti
call
y. I
nfl
uen
ce
of
rese
arch
er o
n
rese
arch
an
d v
ice
vers
a
wer
e n
ot
add
ress
ed.
20
.Sv
ege
20
18
[3
9],
Mal
awi,
37
5 c
areg
iver
s.
Mal
aria
Stu
dy
was
con
du
cted
to d
eter
min
e w
hic
h
stra
tegy
(st
and
ard
car
e vs
tex
t m
essa
ge
rem
ind
er b
ased
)is
bes
t su
ited
for
larg
e-sc
ale
and
lon
g-ti
me
imp
lem
enta
tion
of
post
-
dis
char
ge m
alar
ia c
hem
op
reve
nti
on
(P
MC
)
in a
reas
of
hig
h m
alar
ia t
ran
smis
sion
.30
in-d
epth
in
terv
iew
s an
d 5
focu
s gr
ou
p
dis
cuss
ion
s w
ere
con
du
cted
wit
h c
areg
iver
s
of
chil
dre
n w
ho r
ecen
tly
com
ple
ted
th
e la
st
trea
tmen
t co
urs
e in
a r
and
om
ised
pla
ceb
o-
con
troll
ed t
rial
usi
ng
text
mes
sage
s on
PM
C.
Lac
k o
f m
on
ey f
or
trav
el e
xpen
ses
was
id
enti
fied
as
on
e of
the
mai
n
hu
rdle
s in
th
e fa
cili
ty-b
ased
stu
dy
arm
s w
her
eas
a m
ajor
stre
ngt
h w
as
incr
ease
d f
oll
ow
-up
car
e an
d c
on
tin
uou
s co
nta
ct w
ith
hea
lth
per
son
nel
.
Most
of
the
resp
on
den
ts i
n f
acil
ity-
bas
ed s
tud
y ar
ms
wer
e in
fav
ou
r of
the
dru
g d
eliv
ery
thro
ugh
a c
om
mu
nit
y-b
ased
ap
pro
ach
. In
form
ants
pre
ferr
ed t
ext
mes
sage
rem
ind
ers
sen
t d
irec
tly
to t
hei
r p
hon
es r
ath
er
than
wai
tin
g on
th
ese
visi
ts a
nd
des
crib
ed t
ext
mes
sage
s as
a “
qu
ick
”
and
“ea
sy”
way
of
con
veyi
ng
rem
ind
ers
dir
ectl
y to
car
egiv
ers.
Bar
rier
s
incl
ud
ed t
he
chal
len
ge o
f p
hon
e u
sage
, la
ck o
f el
ectr
icit
y, i
nad
equ
ate
char
gin
g se
rvic
es a
nd
net
work
pro
ble
ms.
Alt
hou
gh c
areg
iver
s m
ajorl
y
char
acte
rise
d H
SAs
as h
elp
ful
and
gen
erou
s, t
her
e w
ere
som
e w
ho
call
ed t
hem
laz
y an
d n
egli
gen
t. T
he
maj
ori
ty o
f re
spon
den
ts r
ank
ed t
ext
mes
sage
s as
th
eir
pre
ferr
ed m
eth
od
acr
oss
all
stu
dy
arm
s.
Incr
ease
d f
oll
ow
up
car
e an
d
con
tin
uin
g
con
tact
wit
h
hea
lth
car
e
per
son
nel
alon
g w
ith
com
mit
men
t
to c
om
ply
wit
h t
reat
men
t
guid
elin
es.
Red
uce
d m
ale
par
tici
pat
ion
. N
o
stat
emen
t lo
cati
ng
rese
arch
er c
ult
ura
lly
or
theo
reti
call
y. I
nfl
uen
ce
of
rese
arch
er o
n
rese
arch
an
d v
ice
vers
a
wer
e n
ot
add
ress
ed.
Cost
eva
luat
ion
stu
dy:
21
.Z
uro
vac
20
12
[5
3],
Ken
ya,1
19
hea
lth
work
ers
for
scen
ario
1,
20
00
0 f
or
scen
ario
3.
15
3 3
79
ch
ild
ren
for
scen
ario
1 a
nd
2.
3 m
illi
on
ch
ild
ren
for
scen
ario
th
ree.
Stu
dy
des
crib
es c
ost
s an
d c
ost
-eff
ecti
ven
ess
un
der
th
ree
imp
lem
enta
tion
sce
nar
ios:
(1
)
as i
mp
lem
ente
d u
nd
er s
tud
y co
nd
itio
ns
in s
tud
y ar
eas;
(2
) if
th
e in
terv
enti
on
was
rou
tin
ely
imp
lem
ente
d b
y th
e M
inis
try
of
Hea
lth
in
sam
e ar
eas;
an
d (
3)
if t
he
inte
rven
tion
was
nat
ion
ally
sca
led
up
.
Un
der
th
e st
ud
y co
nd
itio
ns,
var
iou
s co
sts
of
the
inte
rven
tion
wer
e fo
un
d
to b
e U
SD1
9 3
42
wh
ereb
y 4
5%
was
for
dev
elop
ing
and
pre
test
ing
of
text
-mes
sage
s, 1
2%
for
dev
elop
ing
text
-mes
sage
dis
sem
inat
ion
sys
tem
,
29
% f
or
coll
ecti
ng
hea
lth
work
ers’
ph
on
e n
um
ber
s, a
nd
13
% f
or
sen
din
g
text
-mes
sage
s an
d m
on
itori
ng
of
the
syst
em.
It w
as e
stim
ated
th
at i
f
this
wer
e im
ple
men
ted
by
the
MoH
, th
e co
sts
wou
ld b
e 2
8%
low
er
(USD
13
,92
0)
attr
ibu
ted
to l
ow
er c
ost
s of
coll
ecti
ng
hea
lth
work
ers’
nu
mb
ers.
Nat
ion
al s
cale
up
cost
wou
ld b
e U
SD9
7 3
50
wit
h m
ajori
ty
cost
s (6
6%
) fo
r d
isse
min
atin
g te
xt-m
essa
ges.
Th
e co
st p
er a
dd
itio
nal
chil
d c
orr
ectl
y m
anag
ed w
as U
SD0
.50
un
der
stu
dy
con
dit
ion
s,
USD
$0
.36
if
imp
lem
ente
d b
y th
e M
oH
, an
d U
SD0
.03
if
imp
lem
ente
d
nat
ion
ally
.
-D
id n
ot
test
fre
qu
ency
and
du
rati
on
of
rem
ind
ers.
Did
not
focu
s on
du
rati
on
bey
on
d 6
mon
ths
of
inte
rven
tion
.
Tabl
e 1.
Con
tin
ued
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 12 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
Sr.
Auth
or, y
eAr,
coun
try,
tArg
et
grou
p, in
fect
ion,
And S
Ampl
e Si
ze
met
hodo
logy
Key f
indi
ngS
BehA
viou
r chA
nge
oBSe
rved
limit
Atio
nS
Mix
ed m
eth
ods
stu
dy:
22.
Ric
har
ds
2016
[52]
, Eth
iop
ia, 5
7
resp
ond
ents
; pol
icy
mak
ers,
hea
lth
car
e
pro
vid
ers:
hea
lth
-
exte
nsi
on-w
orker
s,
hea
lth
cen
tre
hea
ds,
dis
tric
t h
ealt
h
offi
cers
, Zon
al H
ealt
h
Dep
artm
ent
(ZH
D)
rep
rese
nta
tive
s an
d
Reg
ion
al H
ealt
h B
ure
au
(RH
B)
HM
IS O
ffice
rs.
Tu
ber
culo
sis
Th
e st
ud
y as
sess
ed fea
sibili
ty o
f u
sin
g eH
ealt
h
by
fem
ale
hea
lth
ext
ensi
on w
orker
s (H
EW
s)
wit
hin
th
eir
core
du
ties
on
tu
ber
culo
sis,
mat
ern
al c
hild
hea
lth
, an
d g
end
er e
qu
ity.
Mix
ed m
eth
od b
asel
ine
dat
a co
llect
ion
was
un
der
taken
th
rou
gh q
uan
tita
tive
qu
esti
onn
aire
s (n
= 5
7)
and
pu
rpos
ivel
y
sam
ple
d q
ual
itat
ive
sem
i-st
ruct
ure
d in
terv
iew
s
(n =
10)
and
foc
us
grou
p d
iscu
ssio
ns
(n =
3).
67%
of th
e 12 D
HO
s, 8
1%
of th
e 27 H
CH
s an
d a
ll th
e 18 H
EW
s d
id n
ot
kn
ow w
hat
eH
ealt
h is
. Mob
ile p
hon
e co
mm
un
icat
ion
was
val
ued
an
d u
sed
by
HE
Ws
for
enab
ling
clie
nts
to
acce
ss h
ealt
h fac
iliti
es, c
oord
inat
ing
care
,
shar
ing
info
rmat
ion
wit
h c
olle
agu
es a
nd
offi
ces,
an
d o
bta
inin
g re
sou
rces
.
In s
ome
case
s, n
etw
ork n
on a
vaila
bili
ty a
nd
diffi
cult
y ch
argi
ng
wer
e an
issu
e. A
bili
ty t
o ac
cess
info
rmat
ion
an
d o
rgan
ize
it w
as p
erce
ived
to
be
the
mos
t ben
efici
al e
lem
ent
of H
MIS
by
mos
t H
EW
s. D
elay
of 3-7
d o
f re
ceip
t
of H
MIS
rep
orts
an
d E
ngl
ish
lan
guag
e as
a b
arri
er w
as h
igh
ligh
ted
in
trad
itio
nal
sys
tem
. Eff
ecti
ve h
ealt
h c
are
del
iver
y, m
onit
orin
g an
d e
valu
atio
n
of t
hei
r p
erfo
rman
ce in
del
iver
ing
the
16 h
ealt
h p
ackag
es w
as r
epor
ted
as
thei
r m
ain
rol
e by
all H
EW
s. T
hu
s, t
he
Hea
lth
Man
agem
ent
Info
rmat
ion
Syst
em (
HM
IS)
was
see
n a
s im
por
tan
t by
all p
arti
cip
ants
, bu
t w
ith
chal
len
ges
of in
form
atio
n q
ual
ity,
acc
ura
cy, r
elia
bili
ty, a
nd
tim
elin
ess.
-In
abili
ty t
o as
sess
th
e
dis
tan
ce a
nd
fre
qu
ency
of
trav
el o
f H
EW
s to
acc
ess
the
Inte
rnet
, an
d la
ck o
f
qu
anti
tati
ve d
ata
to v
erify
the
dat
a in
con
sist
enci
es.
Coh
ort
stu
dy:
23
Mey
ers
2016 [
51],
Nep
al, 1
6 C
omm
un
ity
hea
lth
wor
ker
s, 2
710
case
s of
Dia
rrh
oea
&
373 A
cute
Res
pir
ator
y
Infe
ctio
ns
Th
e st
ud
y ai
med
to
eval
uat
e if c
omm
un
ity-
bas
ed s
urv
eilla
nce
sys
tem
s ca
n c
aptu
re
tem
por
al t
ren
ds
in a
cute
res
pir
ator
y in
fect
ion
s
and
dia
rrh
oea.
It
com
par
ed t
he
infe
ctio
n r
ates
from
com
mu
nit
y (t
hro
ugh
mob
ile p
hon
e-
bas
ed d
ata
colle
ctio
n b
y C
HW
s) a
nd
hos
pit
al
and
ass
ign
ed t
hre
e le
vels
of d
isea
se a
ctiv
ity
(low
, med
ium
, an
d h
igh
) to
eac
h w
eek for
12
mo.
CH
Ws
rep
orte
d 3
73 c
ases
of A
RI
and
2710 c
ases
of d
iarr
hoe
a. U
sin
g a
squ
are
root
tra
nsf
orm
atio
n o
f ea
ch c
omm
un
ity
and
hos
pit
al-b
ased
rat
e, t
he
auth
ors
cate
gori
zed
th
e tr
ansf
orm
ed c
omm
un
ity
hea
lth
rat
es b
y te
rtile
s: lo
w,
med
ium
, an
d h
igh
. Res
ult
s sh
owed
th
at for
dia
rrh
oea,
th
ere
wer
e si
gnifi
can
t
diffe
ren
ces
bet
wee
n lo
w v
s h
igh
(P =
0.0
01)
and
med
ium
vs
hig
h (
P =
0.0
4)
tert
iles
in p
ost-
hoc
com
par
ison
s bet
wee
n h
osp
ital
an
d C
HW
rat
es w
her
eas
for
AR
I, t
he
only
sig
nifi
can
t d
iffe
ren
ce w
as b
etw
een
low
vs
hig
h (
P =
0.0
1).
-Se
veri
ty o
f ill
nes
s w
as
not
cat
ered
as
this
mig
ht
hav
e le
d t
o d
iscr
epan
cy
as t
he
hos
pit
als
usu
ally
atte
nd
mor
e se
vere
case
s an
d le
ss s
ever
e
usu
ally
do
not
rea
ch t
he
faci
litie
s. C
omp
arat
or o
f
hos
pit
al d
ata
are
not
gol
d
stan
dar
d.
CI
– co
nfid
ence
inte
rval
, iC
CM
– in
tegr
ated
com
mu
nit
y ca
se m
anag
emen
t, S
D –
sta
nd
ard
dev
iati
on, M
CQ
– m
ult
iple
ch
oice
qu
esti
on, E
P I
- ex
pan
ded
pro
gram
of im
mu
niz
atio
n, C
HW
– c
omm
un
ity
hea
lth
wor
k-
er, Q
oC –
qu
alit
y of
car
e, H
IV –
hu
man
im
mu
nod
efic
ien
cy v
iru
s, T
B –
tu
ber
culo
sis,
SM
S –
shor
t m
essa
ge s
ervi
ce, PN
C –
pre
nat
al c
are,
HC
Ws
– h
ealt
h c
are
wor
ker
s, H
ep B
– h
epat
itis
B, A
RI
– ac
ute
res
pir
ator
y in
fect
ion
s, A
Es
– ac
ute
em
erge
nci
es, H
CPs
– h
ealt
h c
are
pro
fess
ion
als,
KII
– k
ey in
form
ant
inte
rvie
ws,
MR
– m
easl
es, r
ubel
la, U
TI
– u
rin
ary
trac
t in
fect
ion
s, H
Fs
– h
ealt
h c
are
faci
litie
s, F
GD
– foc
us
grou
p d
iscu
s-si
ons,
AL –
art
emet
her
-lu
mef
antr
ine,
CH
O –
com
mu
nit
y h
ealt
h o
ffic
ers,
CH
N –
com
mu
nit
y h
ealt
h n
urs
es, e
-IM
CI
– el
ectr
onic
inte
grat
ed m
anag
emen
t of
ch
ildh
ood
illn
esse
s, P
MC
- p
ost-
dis
char
ge m
alar
ia c
hem
o-p
reve
nti
on, U
SD –
Un
ited
Sta
tes
dol
lar,
ZH
D –
zon
al h
ealt
h d
epar
tmen
t, R
HB
– r
egio
nal
hea
lth
bu
reau
, HM
IS –
hea
lth
man
agem
ent
info
rmat
ion
sys
tem
, DH
Os
– d
istr
ict
hea
lth
off
icer
s, H
CH
s –
hea
lth
car
e h
ead
s,
HE
Ws
– h
ealt
h e
xten
sion
wor
ker
s
Tabl
e 1.
Con
tin
ued
CHW-based mHealth approaches to common child infections
www.jogh.org • doi: 10.7189/jogh.10.020438 13 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
Table 2. Quality assessment
rAndomized control triAlS
Sr N
Study characteristics Zurovac et al [36]
Donovan et al [35]
Li Chen et al [39]
Zakus et al[34]
Davis et al[37]
Talisuna et al [38]
1. Randomization Y Y Y Y Y Y2. Allocation concealment Y N U U Y Y
3. Blinding
Y (Nn- blinding of treatment providers and outcome assessors)
N U U
Y (Nn- blinding of treatment providers and outcome assessors)
N
4. Follow up complete Y U Y U Y Y
5.Reliable outcome measurement with use of appropriate analysis
Y Y Y Y Y Y
QuASi-experimentAl StudieS
Study characteristics Xeuatvongsa et al [45]
Tumusiime et al [43]
Kabakyenga K et al [44]
Ndiaye et al [40]
Finette et al [42]
Boyce et al [41]
Ismail et al [50]
Althaus et al [52]
1. Clarity on cause and effect Y Y Y Y Y Y Y Y
2. Inclusion of control Y N N N Y Y N Y
3. Similarity of comparisons Y Y U N Y Y U Y
4. Measurement of both outcome and exposure U Y U U U Y Y Y
5. Complete follow up U U U Y U U U U
6.Reliable outcome measurement with use of appropriate analysis
Y N N Y Y Y Y Y
QuAlitAtive StudieS +1 mixed method (richArdS et Al [52])Study characteristics Jones et
al [48]Ginsburg et al [46]
Bessat et al [47]
Ide et al [41]
Ginsburg et al [51]
Svege et al [39]
Richards et al [52]
1. Congruity b/w research methodology and research question Y Y Y Y Y Y Y
2. Congruity b/w research methodology and data collection methods Y Y Y Y U Y N
3. Congruity b/w research methodology and data analysis U Y Y Y Y Y Y
4. Congruity b/w research methodology and result interpretation Y Y Y Y Y Y Y
5. Researcher influence addressed N Y N N N N N
6. Participant voices represented Y Y Y Y Y Y Y
croSS-SectionAl StudieS +1 mixed method
Study characteristics Richards et al [52]
1. Clearly defined inclusion criteria U
2. Detailed description of study setting and study subjects Y
3. Valid and reliable measurement of exposure U
4. Use of objective, standard criteria for measurement of condition U
5. Identification of confounding factors N
6. Reliable outcome measurement with use of appropriate analysis U
cohort StudieS
Study characteristics Meyers et al [51]
1. Similarity among two groups and recruitment from same population N
2. Similarity in exposure measurement Y
3. Valid and reliable measurement of exposure Y
4. Identification of confounding factors U
5. Valid and reliable measurement of outcome Y
6. Follow up complete N
7. Reliable outcome measurement with use of appropriate analysis Y
coSt evAluAtion
Study characteristics Zurovac et al [53]
1. Well defined question Y
2. Comprehensive description of alternatives Y
3. Identification of all important and relevant costs and outcomes for each alternative Y
4. Established clinical effectiveness U
5. Accurate measurement of costs and outcomes Y
6. Costs and outcomes valued credibly Y
7. Costs and outcomes adjusted for differential timing U
8. Incremental analysis of costs and consequences Y
9. Study results include all issues of concern to users U
10. Generalizable results Y
*Yes – present, No – absent, U – unable to identify
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 14 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
mHealth technology
In the majority of the studies, the focus was the use of mHealth as an adjunct to the regular activities of the CHWs. The most common types of mobile phone approaches were use of mobile applications for decision support, text message reminders and applications for electronic health record system. However, none of these approaches used a theoretically informed behaviour change model while developing the intervention. Table 3 summarises the various mHealth approaches across the studies.
Table 3. mHealth approaches
Sr. no
StudieS mheAlth ApproAchtheoreticAlly informed BehAviour chAnge model
Decision support through mobile application
Text message reminders Electronic health records Yes/No
1.Zurovac D et al
(1&2) [36,53]-
One-way communication of
text-message reminders on pae-
diatric malaria case-management
accompanied by “motivating”
quotes through an automated
message delivery system.
- No
2.Xeuatvongsa et
al [45]-
To facilitate communication be-
tween the Volunteer health work-
ers and health care providers to
improve Hep B immunization
rates
- No
3.Tumusiime D et
al [43]
mHealth based application on in-
tegrated community case manage-
ment (ICCM)
- - No
4.Kabakyenga K
et al [44]
Use of mobile phones augmenting
integrated community case man-
agement (ICCM)
- - No
5.Ndiaye et al
[40]- -
Reporting of adverse events of
chemoprovectin using mobile
phones (enhanced spontaneous
reporting), completed by nurses
at health posts and by Communi-
ty health workers.
No
6.Finette et al
[42]
Mobile application through phy-
sician-based logic to generate in-
tegrated clinical risk assessments,
triage, treatment, and follow-up
recommendations for common
childhood illness management
- - No
7. Boyce et al [41]mHealth based application for
ICCM- - No
8.Althaus et al
[52]
mHealth based application for
ICCM- - No
9. Jones et al [48] -
Reminders for caregivers on ad-
herence to malaria management
guidelines
- No
10.Ginsburg et al
[46]
Mobile Application to diagnose,
classify, and manage childhood
pneumonia
- - No
11. Bessat et al [47]
Mobile application on treatment
decision making, dosage calcula-
tion, standardization of treatment
and rational use of medication for
common childhood illnesses
- - No
12. Ide et al [41]mHealth based application for
ICCM- - No
CHW-based mHealth approaches to common child infections
www.jogh.org • doi: 10.7189/jogh.10.020438 15 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
Sr. no
StudieS mheAlth ApproAchtheoreticAlly informed BehAviour chAnge model
Decision support through mobile application
Text message reminders Electronic health records Yes/No
13. Svege et al [39] -
Reminders for caregivers to ob-
tain medications for malaria from
health facilities through timely
follow up
- No
14.Richards et al
[52]- -
Health management information
system on tuberculosisNo
15.Meyers et al
[51]
Decision support by tracking pa-
tients, follow up and next steps of
care for common respiratory and
diarrhoeal illnesses
- Patients follow up data entry. No
16. Ismail et al [50] - -
Patient data collection through
mobile application in Measles and
Rubella campaign
No
17.Donovan et al
[35]
Tablets with application contain-
ing videos on detection, treat-
ment, and prevention of pneu-
monia.
- - No
18.Li Chen et al
[39]- -
Mobile application with four
modules: 1) making appoint-
ments; 2) recording vaccination
status; 3) tracking overdue chil-
dren; and 4) providing education
No
19. Zakus et al [34]
Decision support for iCCM and
management of drugs and sup-
plies for childhood malaria, pneu-
monia, and diarrhoea
- - No
20. Davis et al [37] -SMS-facilitated household TB
contact investigation- No
21.Talisuna et al
[38]-
SMS based reminders to care-
givers of children under five to
adhere to national antimalarial
guidelines. Reminders were also
sent for follow up visits to the
health facilities.
No
mHealth – mobile health, Hep B – hepatitis B, ICCM – integrated community case management, SMS – short message service, TB – tuberculosis
Table 3. Continued
Decision support for illness management
The most common mHealth approach focused on ensuring CHWs’ compliance to standards and guide-lines for health services [22,34,35,40,42-44,46,47,52]. Most commonly, these applications involved use of an electronic algorithm for childhood illness management which aided in standardisation of treatment, rational use of medication and timely referral through a series of guided steps within the mobile appli-cation [42-44,47,51,52].
In a cluster RCT of paper vs electronic algorithm for assessment of childhood illness conducted in Tanza-nia. Results showed that the use of electronic tool by CHWs vs paper led to a significant increase in chil-dren checked for danger signs (41% vs 74%, P = 0.04).and fewer prescription of antibiotics (70%, range 60%-85% in the control; 26%, range 14%-37%, adjusted risk ratio (aRR) 0.4 (95% CI = 0.2-0.6) in the paper; and 25%, range: 17%-33%, aRR 0.3 (95% CI = 0.2-0.5) in the electronic arm) [52].
Similarly, another cluster RCT conducted in Southwest Niger explored the use of a smartphone applica-tion by CHWs to support quality case management of children under five years of age presenting with diarrhoea, malaria, and pneumonia and to provide timely clinical data. The mHealth equipped CHWs showed a 3.4% higher QoC score (mean difference of 0.83 points) P = 0.009 with appropriate referrals
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 16 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
(Mean QoC score of 2.7 in intervention vs 2.8 in the control group) and treatment scores (Mean QoC score of 8.3 in intervention vs 8.4 in the control group) similar to controls [34].
A quasi-experimental study conducted in Senegal to determine adverse event (AE) reporting of chemo-prevention through smartphone application usage by CHWs divided health posts, into three arms; na-tional system, enhanced spontaneous reporting (completed by physicians or nurses at health facilities using mobile phones) and active surveillance (completed by nurses at health posts and by CHWs with active follow-up of children at home). Results showed that the incidence of reported AEs was 2.4 using the national system, 30.6 using enhanced spontaneous reporting, and 21.6 using active surveillance per 1000 children treated per month [40].
Another quasi-experimental study in Malawi comparing adherence to iCCM guidelines by CHWs using mHealth- and paper-based tools demonstrated increased quality of care (QoC) in under five children with pneumonia, diarrhoea, and malaria whereby 80% of the CHWs in intervention group using the mHealth tool managed illnesses according to a gold standard as compared to 50% in control group [41].
In a study of development of an mHealth-based severity assessment, triage, treatment, and follow-up rec-ommendation platform for use by CHWs with 2-60 month-old children, initial validation, usability, and acceptability testing was performed by comparing clinical assessments by CHWs with those of standard (health care professionals-HCPs). Results showed an 84% and 99% correlation between CHW generated assessments and those conducted by HCPs [42].
Not all studies demonstrated statistically significant differences between control and intervention groups, eg, a pilot RCT in Uganda, determined the impact of training of CHWs about under five pneumonia us-ing educational videos on mobile tablets. Results showed intervention improved by 3.2/24 points and control 2.6/24 points, t = 1.15, P = 0.254 [35].
In a pre-trial implementation study in Uganda, mobile phone enabled software was developed aiming to improve competence of CHWs on Integrated Community Case Management(iCCM) and to strengthen reporting of data on danger signs of acutely ill under five-children [43]. It showed that the CHWs were able to master the required technology to improve provision of services to children in their village and expedite referral to appropriate levels of care [43].
The impact of this study was assessed in a subsequent observational study in Uganda through quantita-tive measures and qualitative evaluation using household surveys, in-depth interviews, and focus group discussions [44]. Results showed that 92.6% of acute cases were correctly managed and gains were shown in treatment planning apart from supply management and logistical efficiency.
A qualitative study in Ghana showed that an mHealth tool with an integrated digital version of IMCI algo-rithm and a software-based breath counter and pulse oximeter for pneumonia management appeared to help CHWs in correct diagnosis and treatment of children. Challenges included electricity requirements for charging and the increased time needed to complete the application [46].
Another qualitative study conducted in Burkina Faso in the context of a large-scale implementation of an electronic (e-IMCI) tool used by CHWs revealed a high level of satisfaction with the tool and that CHWs perceived the tool to be improving patient management and rational use of antibiotics [47].
Similarly, in another qualitative study evaluating impact and acceptability of an iCCM based mHealth tool used by CHWs, results showed that there was preference for usage of the mHealth tool as compared to paper-based tools [51].
A cohort study in Nepal evaluated a community-based surveillance system in which CHWs used mHealth technology to record diarrhoeal diseases and acute respiratory infections. The authors categorized the transformed community health rates by tertiles: low, medium, and high. Results showed that for diar-rhoea, there were significant differences between low vs high (P = 0.001) and medium vs high (P = 0.04) tertiles in post-hoc comparisons between hospital and CHW rates whereas for ARI, the only significant difference was between low vs high (P = 0.01) [36]. They concluded that there was a modest correlation between hospital and community data and that use of mobile phones by CHWs might be a useful adjunct to other health care related and community related data sources for surveillance.
Text message reminders
The second most common approach was the use of text messages as an adjunct to regular management of an illness or management using a mHealth application. The text messages focused mainly on remind-
CHW-based mHealth approaches to common child infections
www.jogh.org • doi: 10.7189/jogh.10.020438 17 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
ers sent to the CHWs on household visits, and to caregivers for their children’s follow-up visits and ad-herence to treatment.
A cluster RCT in Kenya demonstrated that correct artemether-lumefantrine (AL) management improved by 23.7% (95% confidence interval (CI) = 9.0-33.7, P = 0.0007) immediately after the intervention and by 24.5% (95% CI = 11.6-35.7, P = 0.0001) six months after the intervention when text message remind-ers were sent to the CHWs on following national malaria management guidelines [53]. Authors of the same study also determined the cost-effectiveness of the use of these text message reminders on adher-ence to national malarial treatment guidelines and demonstrated the cost per additional child correctly managed was US$0.50 under study conditions, US$0.36 if implemented by the ministry of health in the same study locations under routine, and USD 0.03 if implemented nationally after being scaled-up [37].
Another RCT in Uganda on use of mHealth for diagnosis of TB by CHWs on general public showed that for children under five, yield of clinically and biologically confirmed cases was 5.2% in the intervention arm as compared to 3.8% in the control arm upon sending SMSs on sputum test results and/or follow up instructions [38].
An open label RCT was conducted in Kenya to test additional effects of SMS reminders on caregivers’ ad-herence to AL therapy with return to the health facility Results showed that, all AL doses were complet-ed for 97.6% (282/289) of children in the control and 97.8% (267/273) in the intervention group (odds ratio (OR) = 1.10; 95% CI = 0.37-3.33; P = 0.860). Sending SMS reminders significantly increased odds of children returning to the facility on day 3 (81.4 vs 74.0%; OR = 1.55; 95% CI = 1.15-2.08; P = 0.004) and on day 28 (63.4 vs 52.5%; OR = 1.58; 95% CI = 1.30-1.92; P < 0.001) [45].
In a quasi-experimental study in Lao People Democratic Republic where text messages were used as re-minders to caregivers for timely immunization of children, the difference in Hepatitis B vaccination cover-age improved over the time of the intervention by57% (interquartile range (IQR) = 32%-88%, P < 0.0001) in the intervention districts as compared to control districts (20%, IQR = 0%-50%, P < 0.0001) [48].
A qualitative study in Kenya after this RCT on the impact of text message reminders to caregivers of chil-dren with malaria showed that there is direct benefit of use of text message reminders to caregivers to administer medication for under five children with malaria timely coupled with messages on completion of course and following standard treatment guidelines [49].
In another qualitative study conducted in Malawi on text message reminders for remembering treatment dates of children with malaria, reminders were reported to be a ‘quick’ and ‘easy’ way of communicating with the caregivers directly [39].
Electronic health records
A third approach of use of mHealth was electronic health records (EHR) focusing on collection of patient data through mobile phone applications with subsequent generation of reports.
An RCT study conducted in China on use of a mobile application by village doctors to record vaccina-tion status, make appointments, track children, and provide education to caregivers demonstrated that there was a positive behaviour change among caregivers. This was shown by a significant increase in full vaccination coverage from baseline to end-line in intervention (67% (95% CI = 58%-75%) to 84% (95% CI = 76%-90%), P = 0.028) and control groups (71% (95% CI = 62%-79%) to 82% (95% CI = 74%-88%), P = 0.014) [39].
A study conducted in Kenya on micro planning for a measles rubella campaign showed that data collec-tion through a mobile application was time efficient as CHWs were able to collect data on three million children from 46 counties within four weeks using standard data collection forms incorporated within a mobile application [50].
Demonstration of behaviour change and use of behaviour change models for intervention design
There were only three studies which reported behaviour change, for instance, the pre-implementation study in Uganda on use of mobile application as decision support, where behaviour change was demon-strated in the form of improved care seeking by caregivers due to the establishment of better relationships between caregivers and the CHWs [44]. Similarly, RCTs in Kenya and Uganda on text message reminder on AL and TB management respectively, demonstrated behaviour change by caregivers in terms of time-ly follow up and administration of antimalarial medication to children [38,53].
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 18 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
It was also observed that during the design of these interventions none of the studies demonstrated used of any behaviour change models or the use of any theoretically informed frameworks for classifying be-haviour change within these interventions.
DISCUSSIONThis systematic review was conducted to explore current CHW based mHealth approaches for management of common infections in children under five with respect to inducing behaviour change and found 23 arti-cles. The results showed that most of the approaches have used mobile applications to improve diagno-sis through decision support, text messaging for education and/or reminders, and electronic health re-cording. Thus, the focus of these studies was more on health care service delivery and education about recognising or managing illness rather than prevention. The majority of the studies were also not clear-ly able to demonstrate behaviour change as most did not measure the behaviours targeted in the inter-vention. This has serious consequences as it prevents assessment of the effects of the intervention on the targeted behaviours that are expected to lead to health benefits. Additionally, the quality of the evidence available in these articles was not of high quality with only two studies covering all aspects of quality as assessed by the reviewers.
Developing and implementing interventions to change behaviour can be challenging [26]. Evidence has shown that intervention development usually starts without a systematic method and without drawing on any theories of behaviour change. Instead, personal experiences or a superficial analysis of the subject may be used as the starting point for intervention design, compromising the desired effects of the inter-vention [54]. One way of systematically characterising interventions enabling their outcomes to be linked with actions is the Behaviour Change Wheel (BCW) [26]. It has nine intervention functions and seven policy categories linked to the Capability-Opportunity-Motivation Behaviour (COM-B) model a model of behaviour at the hub of the wheel as shown in Figure 2. This allows interventions to be designed with the target behaviour in focus. Using this wheel, one can design an intervention through three stages; un-derstanding of the behaviour to be targeted, identify intervention options to induce behaviour change and identify content and implementation options as shown in Figure 3 [54]. Considering mobile health is gaining momentum due to extensive mobile network coverage, it can be used as a useful tool for in-ducing behaviour change [55]. There is suggestive evidence of the benefit of using mobile applications by CHWs coupled with tailored text message reminders being an effective delivery channel for positive behaviour change through its wide population reach and instant delivery [56-58]. However, for design of effective behaviour change interventions, there is a need for an underpinning framework that incor-porates understanding of the nature of the behaviour to be changed, and an appropriate mechanism for characterising components of an intervention that can make use of this understanding [26].
For successful outcomes, establishment of long lasting and fruitful partnerships between users and policymakers throughout the process of the project is extremely crucial. Some of the good ex-amples whereby policymakers or ownership at na-tional level was established include studies from Ghana and Kenya [46,53]. In addition to this, culturally specific interventions are important as poorly designed non-specific campaigns seem to have a negative impact, especially in terms of lan-guage and literacy barriers [59,60].
The major strengths of our review include the robust data extraction across several databases, inclusion of articles from 1990, a period when mHealth was initiated globally [29]. An addition-al strength is the focus on under five children as compared to other such reviews. Limitations of the study include only drawing on English lan-guage papers and those that were peer reviewed. Figure 2. Behaviour change wheel [54].
CHW-based mHealth approaches to common child infections
www.jogh.org • doi: 10.7189/jogh.10.020438 19 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
Although it is known that CHWs have been engaged in various mHealth based projects, however, our analysis of only 23 articles is not likely to represent this full range of projects. Additionally, the projects reported might not reflect negative results as those are not usually published [61]. As such, this review may be biased toward more positive results. Further, due to the heterogeneity of methods and design ap-proaches in this evolving field of research, a meta-analysis was not feasible.
CONCLUSION
Coupling of mobile technology with CHWs has the potential to benefit communities in improving man-agement of illnesses in children under-five. High quality evidence of impact of such interventions on be-haviour is relatively sparse and further studies should be conducted using theoretically informed frame-works/models of behaviour change.
Figure 3. Stages of designing behaviour change interventions [54].
Acknowledgements: We are grateful to Marshall Dozier, Academic Librarian at the University of Edinburgh, for her help in developing the search strategy and guiding in data extraction.
Data availability: All data created during this research are openly available from DataShare (http://hdl.handle.net/10283/3732).
Funding: HM is supported by PhD studentships from the NIHR Global Health Research Unit on Respiratory Health (RESPIRE). RESPIRE is funded by the National Institute of Health Research using Official Development Assistance (ODA) funding. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Neither the funder nor the sponsor (University of Edinburgh) contrib-uted to protocol development.
Authorship contributions conceived the idea for this work which was developed with the support of BM, SL, KF and TH. HM and SN did the review. HM wrote the first draft, and all authors contributed to the manuscript. The views expressed in the submitted article are those of the authors and not an official position of the institu-tion or funder.
Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author) and declare no conflicts of interest.
Additional materialOnline Supplementary Document
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 20 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
1 Sacristán JA. Patient-centred medicine and patient-oriented research: improving health outcomes for individual patients. BMC Med Inform Decis Mak. 2013;13:6. Medline:23294526 doi:10.1186/1472-6947-13-6
2 Pakistan Bureau of Statistics. List of Diseases 2019 [updated 2019]. Available: http://www.pbs.gov.pk/content/list-dis-eases. Accessed: 13 December 2019.
3 Kyu HH, Pinho C, Wagner JA, Brown JC, Bertozzi-Villa A, Charlson FJ, et al. Global and national burden of diseases and injuries among children and adolescents between 1990 and 2013: findings from the global burden of disease 2013 study. JAMA Pediatr. 2016;170:267-87. Medline:26810619 doi:10.1001/jamapediatrics.2015.4276
4 National Institute of Population Studies. Pakistan Demographic Health Survey 2017-18: Maryland: The DHS Program; 2019. Available: https://dhsprogram.com/pubs/pdf/FR354/FR354.pdf. Accessed: 16 December 2019.
5 Temmerman M, Khosla R, Bhutta ZA, Bustreo F. Towards a new Global Strategy for Women’s, Children’s, and Adoles-cents’ Health. BMJ. 2015;351:h4414. Medline:26371228 doi:10.1136/bmj.h4414
6 Zaidi AK, Awasthi S, deSilva HJ. Burden of infectious diseases in South Asia. BMJ. 2004;328:811-5. Medline:15070639 doi:10.1136/bmj.328.7443.811
7 Norheim OF, Jha P, Admasu K, Godal T, Hum RJ, Kruk ME, et al. Avoiding 40% of the premature deaths in each coun-try, 2010-30: review of national mortality trends to help quantify the UN sustainable development goal for health. Lan-cet. 2015;385:239-52. Medline:25242039 doi:10.1016/S0140-6736(14)61591-9
8 Tazinya AA, Halle-Ekane GE, Mbuagbaw LT, Abanda M, Atashili J, Obama MT. Risk factors for acute respiratory infec-tions in children under five years attending the Bamenda Regional Hospital in Cameroon. BMC Pulm Med. 2018;18:7. Medline:29338717 doi:10.1186/s12890-018-0579-7
9 Lassi ZS, Musavi NB, Maliqi B, Mansoor N, de Francisco A, Toure K, et al. Systematic review on human resources for health interventions to improve maternal health outcomes: evidence from low- and middle-income countries. Hum Re-sour Health. 2016;14:10. Medline:26971317 doi:10.1186/s12960-016-0106-y
10 Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health. 2014;35:399-421. Medline:24387091 doi:10.1146/annurev-publhealth-032013-182354
11 Zhu N, Allen E, Kearns A, Caglia J, Atun R. Lady health workers in Pakistan: improving access to health care for rural women and families. Boston: Harvard School of Public Health; 2014.
12 Lee J. The Emerging Community Health Worker Sector: Insights from CHWs and Program Managers in the Field. Pa-cific Hospital Preservation & Development Authority, Seattle. 2015.
13 Javanparast S, Windle A, Freeman T, Baum F. Community health worker programs to improve healthcare access and equity: are they only relevant to low-and middle-income countries? Int J Health Policy Manag. 2018;7:943. Med-line:30316247 doi:10.15171/ijhpm.2018.53
14 Winters N, Langer L, Geniets A. Scoping review assessing the evidence used to support the adoption of mobile health (mHealth) technologies for the education and training of community health workers (CHWs) in low-income and mid-dle-income countries. BMJ Open. 2018;8:e019827. Medline:30061430 doi:10.1136/bmjopen-2017-019827
15 Zulliger R. Pakistan’s lady health worker program CHW Central. 2018. Available: https://chwcentral.org/pakistans-la-dy-health-worker-program/. Accessed: 20 January 2020.
16 Puett C, Coates J, Alderman H, Sadruddin S, Sadler K. Does greater workload lead to reduced quality of preventive and curative care among community health workers in Bangladesh? Food Nutr Bull. 2012;33:273-87. Medline:23424894 doi:10.1177/156482651203300408
17 Kok MC, Broerse JE, Theobald S, Ormel H, Dieleman M, Taegtmeyer M. Performance of community health workers: situating their intermediary position within complex adaptive health systems. Hum Resour Health. 2017;15:59. Med-line:28865471 doi:10.1186/s12960-017-0234-z
18 Meister S, Deiters W, Becker S, Simson U, Chen W, Augusto J, et al. mHealth: Challenges and impact on new forms of healthcare. 2015.
19 Jaskiewicz W, Tulenko K. Increasing community health worker productivity and effectiveness: a review of the influence of the work environment. Hum Resour Health. 2012;10:38. Medline:23017131 doi:10.1186/1478-4491-10-38
20 Hanif MS, Yunfei S, Hanif MI. Growth prospects, market challenges and policy measures: Evolution of mobile broad-band in Pakistan. Digital Policy. Regul Gov. 2018;20:42-61. doi:10.1108/DPRG-04-2017-0014
21 Chaiyachati KH, Loveday M, Lorenz S, Lesh N, Larkan L-M, Cinti S, et al. A pilot study of an mHealth application for healthcare workers: poor uptake despite high reported acceptability at a rural South African community-based MDR-TB treatment program. PLoS One. 2013;8:e64662. Medline:23724075 doi:10.1371/journal.pone.0064662
22 Chang LW, Kagaayi J, Arem H, Nakigozi G, Ssempijja V, Serwadda D, et al. Impact of a mHealth intervention for peer health workers on AIDS care in rural Uganda: a mixed methods evaluation of a cluster-randomized trial. AIDS Behav. 2011;15:1776. Medline:21739286 doi:10.1007/s10461-011-9995-x
23 Arem H, Nakyanjo N, Kagaayi J, Mulamba J, Nakigozi G, Serwadda D, et al. Peer health workers and AIDS care in Rakai, Uganda: a mixed methods operations research evaluation of a cluster-randomized trial. AIDS Patient Care STDS. 2011;25:719-24. Medline:21391828 doi:10.1089/apc.2010.0349
24 Beratarrechea A, Abrahams-Gessel S, Irazola V, Gutierrez L, Moyano D, Rubinstein A, et al. Use of mHealth Tools by Community Health Workers (CHWs) in a Pragmatic Cluster Randomized Trial Improves Access, Coverage, and Treat-ment of Uninsured People With High Cardiovascular Disease (CVD) Risk in Two Provinces in Argentina. Circulation. 2018;138(Suppl_1):A12344.
RE
FER
EN
CE
S
CHW-based mHealth approaches to common child infections
www.jogh.org • doi: 10.7189/jogh.10.020438 21 December 2020 • Vol. 10 No. 2 • 020438
VIE
WPO
INTS
PAPE
RS
25 Gagnon M-P, Ngangue P, Payne-Gagnon J, Desmartis M. m-Health adoption by healthcare professionals: a systematic re-view. J Am Med Inform Assoc. 2016;23:212-20. Medline:26078410 doi:10.1093/jamia/ocv052
26 Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing be-haviour change interventions. Implement Sci. 2011;6:42. Medline:21513547 doi:10.1186/1748-5908-6-42
27 Boston University Medical Campus. MPH. Behaviour Change Models; Introduction. Available: https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/BehavioralChangeTheories_print.html#:~:text=The%20TTM%20is%20not%20a,action%2C%20maintenance%2C%20and%20termination. Accessed: 22 January 2020.
28 Braun R, Catalani C, Wimbush J, Israelski D. Community health workers and mobile technology: a systematic review of the literature. PLoS One. 2013;8:e65772. Medline:23776544 doi:10.1371/journal.pone.0065772
29 Waegemann CP. mHealth: History, analysis, and implementation. M-Health innovations for patient-centered care. IGI Global. 2016;1-19.
30 Martínez-Pérez B, De La Torre-Díez I, López-Coronado M. Mobile health applications for the most prevalent condi-tions by the World Health Organization: review and analysis. J Med Internet Res. 2013;15:e120. Medline:23770578 doi:10.2196/jmir.2600
31 Scells H, Zuccon G, Koopman B, Deacon A, Azzopardi L, Geva S, editors. Integrating the framing of clinical questions via PICO into the retrieval of medical literature for systematic reviews. Proceedings of the 2017 ACM on Conference on Information and Knowledge Management; 2017.
32 United Nations. World Mortality 2019 - Highlights 2019. Available: https://www.un.org/development/desa/pd/content/world-mortality-2019-highlights. Accessed: 3 February 2020.
33 Porritt K, Gomersall J, Lockwood C. JBI’s systematic reviews: study selection and critical appraisal. Am J Nurs. 2014;114:47-52. Medline:24869584 doi:10.1097/01.NAJ.0000450430.97383.64
34 Zakus D, Moussa M, Ezechiel M, Yimbesalu JP, Orkar P, Damecour C, et al. Clinical evaluation of the use of an mhealth in-tervention on quality of care provided by Community Health Workers in southwest Niger. J Glob Health. 2019;9:010812. Medline:31263555 doi:10.7189/jogh.09.010812
35 O’Donovan J, Kabali K, Taylor C, Chukhina M, Kading JC, Fuld J, et al. The use of low-cost Android tablets to train community health workers in Mukono, Uganda, in the recognition, treatment and prevention of pneumonia in chil-dren under five: a pilot randomised controlled trial. Hum Resour Health. 2018;16:49. Medline:30231894 doi:10.1186/s12960-018-0315-7
36 Zurovac D, Sudoi RK, Akhwale WS, Ndiritu M, Hamer DH, Rowe AK, et al. The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to malaria treatment guidelines: a cluster randomised trial. Lancet. 2011;378:795-803. Medline:21820166 doi:10.1016/S0140-6736(11)60783-6
37 Davis JL, Turimumahoro P, Meyer AJ, Ayakaka I, Ochom E, Ggita J, et al. Home-based tuberculosis contact in-vestigation in Uganda: a household randomised trial. ERJ Open Res. 2019;5:00112-2019. Medline:31367636 doi:10.1183/23120541.00112-2019
38 Talisuna AO, Oburu A, Githinji S, Malinga J, Amboko B, Bejon P, et al. Efficacy of text-message reminders on paediatric malaria treatment adherence and their post-treatment return to health facilities in Kenya: a randomized controlled trial. Malar J. 2017;16:46. Medline:28122622 doi:10.1186/s12936-017-1702-6
39 Chen L, Du X, Zhang L, van Velthoven MH, Wu Q, Yang R, et al. Effectiveness of a smartphone app on improving im-munization of children in rural Sichuan Province, China: a cluster randomized controlled trial. BMC Public Health. 2016;16:909. Medline:27581655 doi:10.1186/s12889-016-3549-0
40 Ndiaye JA, Diallo I, NDiaye Y, Kouevidjin E, Aw I, Tairou F, et al. Evaluation of Two Strategies for Community-Based Safety Monitoring during Seasonal Malaria Chemoprevention Campaigns in Senegal, Compared with the National Spon-taneous Reporting System. Pharmaceut Med. 2018;32:189-200. Medline:29983573 doi:10.1007/s40290-018-0232-z
41 Boyce SP, Nyangara F, Kamunyori J. A mixed-methods quasi-experimental evaluation of a mobile health application and quality of care in the integrated community case management program in Malawi. J Glob Health. 2019;9:010811. Med-line:31263554 doi:10.7189/jogh.09.010811
42 Finette BA, McLaughlin M, Scarpino SV, Canning J, Grunauer M, Teran E, et al. Development and initial validation of a frontline health worker mHealth assessment platform (MEDSINC®) for children 2–60 months of age. Am J Trop Med Hyg. 2019;100:1556-65. Medline:30994099 doi:10.4269/ajtmh.18-0869
43 Tumusiime DK, Agaba G, Kyomuhangi T, Finch J, Kabakyenga J, MacLeod S. Introduction of mobile phones for use by volunteer community health workers in support of integrated community case management in Bushenyi District, Uganda: development and implementation process. BMC Health Serv Res. 2014;14 Suppl 1:S2. Medline:25079241 doi:10.1186/1472-6963-14-S1-S2
44 Kabakyenga J, Barigye C, Brenner J, Maling S, Buchner D, Nettle-Aquirre A, et al. A demonstration of mobile phone deployment to support the treatment of acutely ill children under five in Bushenyi district, Uganda. Afr Health Sci. 2016;16:89-96. Medline:27358618 doi:10.4314/ahs.v16i1.12
45 Xeuatvongsa A, Datta SS, Moturi E, Wannemuehler K, Philakong P, Vongxay V, et al. Improving hepatitis B birth dose in rural Lao People’s Democratic Republic through the use of mobile phones to facilitate communication. Vaccine. 2016;34:5777-84. Medline:27742222 doi:10.1016/j.vaccine.2016.09.056
46 Ginsburg AS, Tawiah Agyemang C, Ambler G, Delarosa J, Brunette W, Levari S, et al. MPneumonia, an innovation for diagnosing and treating childhood pneumonia in low-resource settings: a feasibility, usability, and acceptability study in Ghana. PLoS One. 2016;11:e0165201. Medline:27788179 doi:10.1371/journal.pone.0165201
RE
FER
EN
CE
S
Mahmood et al.
December 2020 • Vol. 10 No. 2 • 020438 22 www.jogh.org • doi: 10.7189/jogh.10.020438
VIE
WPO
INTS
PAPE
RS
47 Bessat C, Zonon NA, D’Acremont V. Large-Scale implementation of electronic integrated management of childhood illness (eIMCI) at the primary care level in Burkina Faso: a qualitative study on health worker perception of its medical content, usability and impact on antibiotic prescription and resistance. BMC Public Health. 2019;19:449. Medline:31035968 doi:10.1186/s12889-019-6692-6
48 Jones C, Talisuna AO, Snow RW, Zurovac D. “We were being treated like the Queen”: understanding trial factors influenc-ing high paediatric malaria treatment adherence in western Kenya. Malar J. 2018;17:8. Medline:29304798 doi:10.1186/s12936-017-2164-6
49 Svege S, Kaunda B, Robberstad B, Nkosi-Gondwe T, Phiri KS, Lange S. Post-discharge malaria chemoprevention (PMC) in Malawi: caregivers’ acceptance and preferences with regard to delivery methods. BMC Health Serv Res. 2018;18:544. Medline:29996833 doi:10.1186/s12913-018-3327-z
50 Ismail A, Tabu C, Onuekwusi I, Otieno SK, Ademba P, Kamau P, et al. Micro-planning in a wide age range measles rubella (MR) campaign using mobile phone app, a case of Kenya, 2016. Pan Afr Med J. 2017;27 Suppl 3:16. Medline:29296151 doi:10.11604/pamj.supp.2017.27.3.11939
51 Meyers DJ, Ozonoff A, Baruwal A, Pande S, Harsha A, Sharma R, et al. Combining healthcare-based and participatory ap-proaches to surveillance: trends in diarrheal and respiratory conditions collected by a mobile phone system by community health workers in rural Nepal. PLoS One. 2016;11:e0152738. Medline:27111734 doi:10.1371/journal.pone.0152738
52 Rambaud-Althaus C, Shao A, Samaka J, Swai N, Perri S, Kahama-Maro J, et al. Performance of health workers using an electronic algorithm for the management of childhood illness in Tanzania: a pilot implementation study. Am J Trop Med Hyg. 2017;96:249-57. Medline:28077751 doi:10.4269/ajtmh.15-0395
53 Zurovac D, Larson BA, Sudoi RK, Snow RW. Costs and cost-effectiveness of a mobile phone text-message reminder programmes to improve health workers’ adherence to malaria guidelines in Kenya. PLoS One. 2012;7:e52045. Med-line:23272206 doi:10.1371/journal.pone.0052045
54 Michie S, Atkins L, West R. The behaviour change wheel. A guide to designing interventions. 1st ed. Sutton, UK: Sil-verback Publishing. 2014.
55 Thirumurthy H, Lester RT. M-health for health behaviour change in resource-limited settings: applications to HIV care and beyond. Bull World Health Organ. 2012;90:390-2. Medline:22589574 doi:10.2471/BLT.11.099317
56 Cherrington AL, Agne AA, Lampkin Y, Birl A, Shelton TC, Guzman A, et al. Diabetes Connect: developing a mobile health intervention to link diabetes community health workers with primary care. J Ambul Care Manage. 2015;38:333. Medline:26353025 doi:10.1097/JAC.0000000000000110
57 Early J, Gonzalez C, Gordon-Dseagu V, Robles-Calderon L. Use of mobile health (mHealth) technologies and interventions among community health workers globally: a scoping review. Health Promot Pract. 2019;20:805-17. Medline:31179777 doi:10.1177/1524839919855391
58 DeRenzi B, Findlater L, Payne J, Birnbaum B, Mangilima J, Parikh T, et al. Improving community health worker perfor-mance through automated SMS. InProceedings of the Fifth International Conference on Information and Communica-tion Technologies and Development 2012 Mar 12 (pp. 25-34).
59 Mittelmark MBN. Health promotion at the community level: New advances. 1990.60 Ntshebe O, Pitso JM, Segobye AK. The use of culturally themed HIV messages and their implications for future be-
haviour change communication campaigns: the case of Botswana. SAHARA J. 2006;3:466-76. Medline:17605206 doi:10.1080/17290376.2006.9724873
61 Mlinarić A, Horvat M, Supak Smolcic V. Dealing with the positive publication bias: Why you should really publish your negative results. Biochem Med (Zagreb). 2017;27:030201. Medline:29180912 doi:10.11613/BM.2017.030201
RE
FER
EN
CE
S
