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BackgroundMobile health (mHealth) describes the use of portable electronic devices with software applications to provide health services and manage patient information. With approximately 5 billion mobile phone users globally, opportunities for mobile technologies to play a formal role in health services, particularly in low- and middle-income countries, are increasingly being recognized. mHealth can also support the performance of health care workers by the dissemination of clinical updates, learning materials, and reminders, particularly in underserved rural locations in low- and middle-income countries where community health workers deliver integrated community case management to children sick with diarrhea, pneumonia, and malaria. ObjectiveOur aim was to conduct a thematic review of how mHealth projects have approached the intersection of cellular technology and public health in low- and middle-income countries and identify the promising practices and experiences learned, as well as novel and innovative approaches of how mHealth can support community health workers. MethodsIn this review, 6 themes of mHealth initiatives were examined using information from peer-reviewed journals, websites, and key reports. Primary mHealth technologies reviewed included mobile phones, personal digital assistants (PDAs) and smartphones, patient monitoring devices, and mobile telemedicine devices. We examined how these tools could be used for education and awareness, data access, and for strengthening health information systems. We also considered how mHealth may support patient monitoring, clinical decision making, and tracking of drugs and supplies. Lessons from mHealth trials and studies were summarized, focusing on low- and middle-income countries and community health workers. ResultsThe review revealed that there are very few formal outcome evaluations of mHealth in low-income countries. Although there is vast documentation of project process evaluations, there are few studies demonstrating an impact on clinical outcomes. There is also a lack of mHealth applications and services operating at scale in low- and middle-income countries. The most commonly documented use of mHealth was 1-way text-message and phone reminders to encourage follow-up appointments, healthy behaviors, and data gathering. Innovative mHealth applications for community health workers include the use of mobile phones as job aides, clinical decision support tools, and for data submission and instant feedback on performance. ConclusionsWith partnerships forming between governments, technologists, non-governmental organizations, academia, and industry, there is great potential to improve health services delivery by using mHealth in low- and middle-income countries. As with many other health improvement projects, a key challenge is moving mHealth approaches from pilot projects to national scalable programs while properly engaging health workers and communities in the process. By harnessing the increasing presence of mobile phones among diverse populations, there is promising evidence to suggest that mHealth can be used to deliver increased and enhanced health care services to individuals and communities, while helping to strengthen health systems.

Objectives: To evaluate the impact of Newhints community-based surveillance volunteer (CBSV) assessments and referrals on access to care for sick newborns and on existing inequities in access. Design: We evaluated a prospective cohort nested within the Newhints cluster-randomised controlled trial. Setting: Community-based intervention involving more than 750 000, predominantly rural, population in seven contiguous districts in the Brong-Ahafo Region, Ghana. Participants: Participants were recently delivered women (from more than 120 000 women under surveillance) and their 16 168 liveborn babies. Qualitative in-depth interviews with referral narratives (IDIs) were conducted with 92 mothers, CBSVs and health facility front-desk and maternity/paediatrics ward staff. Interventions: Newhints trained and effectively supervised 475 CBSVs (existing within the Ghana Health Service) in 49 of 98 supervisory zones (clusters) to assess and refer newborns with any of the 10-keydanger signs to health facilities within the first week after birth; promote independent care seeking for sick newborns and problem-solve around barriers between November 2008 and December 2009. Primary outcomes: The main evaluation outcomes were rates of compliance with referrals and independent care seeking for newborn illnesses. Results: Of 4006 sampled, 2795 (69.8%) recently delivered women received CBSV assessment visits and 279 (10.0%) newborns were referred with danger signs. Compliance with referrals was unprecedentedly high (86.0%) with women in the poorest quintile (Q1) complying better than the least poor (Q5):87.5%(Q1) vs 69.7%(Q5); p=0.038. Three-quarters went to hospitals; 18% were admitted and 58% received outpatient treatment. Some (24%) mothers were turned away at facilities and follow-on IDIs showed that some of these untreated babies subsequently died. Independent care seeking for severe newborn illness increased from 55.4% in control to 77.3% in Newhints zones, especially among Q1 where care seeking almost doubled (95.0% vs 48.6%; RR=1.94 (1.32, 2.84); p=0.001). Rates were the highest among rural residents but urban residents complied quicker. Conclusions: Home visits are feasible and a potentially pro-poor approach to link sick newborns to facilities. Its effectiveness in improving survival hinges on matched improvement in facility quality of care. [ABSTRACT FROM AUTHOR]

Background: Male involvement in various health practices is recognized as an important factor in improving maternal and child health outcomes. Male involvement interventions involve men in a variety of ways, at varying levels of inclusion and use a range of outcome measures. There is little agreement on how male involvement should be measured and some authors contend that male involvement may actually be detrimental to women's empowerment and autonomy. Few studies explore the realities, perceptions, determinants and efficacy of male involvement in newborn care, especially in African contexts. Methods: Birth narratives of recent mothers (n = 25), in-depth interviews with recent fathers (n = 12) and two focus group discussions with fathers (n = 22) were conducted during the formative research phase of a community-based newborn care trial. Secondary analysis of this qualitative data identified emergent themes and established overall associations related to male involvement, newborn care and household roles in a rural African setting. Results: Data revealed that gender dictates many of the perceptions and politics surrounding newborn care in this context. The influence of mother-in-laws and generational power dynamics were also identified as significant. Women alone perform almost all tasks related to newborn care whereas men take on the traditional responsibilities of economic providers and decision makers, especially concerning their wives' and children's health. Most men were interested in being more involved in newborn care but identified barriers to increased involvement, many of which related to gendered and generational divisions of labour and space. Conclusions: Men defined involvement in a variety of ways, even if they were not physically involved in carrying out newborn care tasks. Some participant comments revealed potential risks of increasing male involvement suggesting that male involvement alone should not be an outcome in future interventions. Rather, the effect of male involvement on women's autonomy, the dynamics of senior women's influence and power and the real impact on health outcomes should be considered in intervention design and implementation. Any male involvement intervention should integrate a detailed understanding of context and strategies to include men in maternal and child health should be mutually empowering for both women and men. [ABSTRACT FROM AUTHOR]

Background: The fact that tuberculosis can be treated with the DOTS strategy (Directly Observed Treatment, Short-course) is not enough to control the disease. Patients have to find their way to tuberculosis treatment first. To better understand the route to tuberculosis treatment in rural Nepal we interviewed twenty-six patients under treatment. Methods: In semi-structured interviews patients shared their disease history and health seeking behaviour. The analysis focused on the encounters with the health care system before enrolment in the tuberculosis treatment program. Results: Patient routes often started in the medical shop and led via intricate routes with multiple providers to facilities with higher qualified and more competent staff where tuberculosis was diagnosed. Several factors influenced the route to tuberculosis treatment. Besides known patients factors (such as severity of complaints, the ability to pay for services, availability of services and peer support for choosing a provider) specific health services factors were also identified. These included the perceived quality, costs and service level of a provider, and lack of provider initiated referral. Self referral because of waned trust in the provider was very common. In contrast, once tuberculosis was considered a possible diagnosis, referral to diagnostic testing and tuberculosis treatment was prompt. Conclusion: Patient routes towards tuberculosis treatment are characterised by self referral and include both private and public health care providers. Once tuberculosis is suspected referral for diagnosis and treatment is prompt. Given the importance of the private practitioners in the patient routes, quality improvement initiatives need to address not only the public sector but the private health care sector as well. [ABSTRACT FROM AUTHOR]

Objectives. To assess the reliability and validity of a translated version of the American Hospital-level Consumer Assessment of Health Plans Survey® (H-CAHPS) instrument for use in Dutch health care. Data Sources/Study Setting. Primary survey data from adults aged 18 years or more who were recently discharged from two multispecialty city hospitals in the Netherlands. Study Design. We used forward and backward translation procedures and a panel of experts to adapt the 66-item pilot H-CAHPS into a 70-item Dutch instrument. Descriptive statistics and standard psychometric methods were then used to test the reliability and validity of the new instrument. Data Collection. From late November 2003 to early January 2004, the survey was administered by mail to 1,996 patients discharged within the previous 2 months. Principal Findings. Analyses supported the reliability and validity of the following 7-factor H-CAHPS structure for use in Dutch hospitals: on doctor's communication, nurses' communication, discharge information, communication about medication, pain control, physical environment of hospital, and nursing services. The internal consistency reliability of the scales ranged from 0.60 to 0.88. Items related to “family receiving help when on visit,”“hospital staff introducing self,” and “admission delays” did not improve the psychometric properties of the new instrument. Conclusions. These findings suggest that the H-CAHPS instrument is reliable and valid for use in the Dutch context. However, more research will be needed to support its equivalence to the United States version, and its use for between-hospital comparisons. [ABSTRACT FROM AUTHOR]

Background In 2009, on the basis of promising evidence from trials in south Asia, WHO and UNICEF issued a joint statement about home visits as a strategy to improve newborn survival. In the Newhints trial, we aimed to test this home-visits strategy in sub-Saharan Africa by assessing the effect on all-cause neonatal mortality rate (NMR) and essential newborn-care practices. Methods The Newhints cluster randomised trial was undertaken in 98 zones in seven districts in the Brong Ahafo Region, Ghana. 49 zones were randomly assigned to the Newhints intervention and 49 to the control intervention by use of restricted randomisation with stratification to ensure comparability between interventions. Community-based surveillance volunteers (CBSVs) in Newhints zones were trained to identify pregnant women in their community and to make two home visits during pregnancy and three in the first week of life to promote essential newborn-care practices, weigh and assess babies for danger signs, and refer as necessary. Primary outcomes were NMR and coverage of key essential newborn-care practices. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00623337. Findings 16168 (99%) of 16 329 deliveries between November, 2008, and December, 2009, were livebirths; the status at 1 month was known for 15 619 (97%) livebirths. 482 neonatal deaths were recorded. Coverage data were available from 6029 women in Newhints zones; of these 4358 (72%) reported having CBSV visits during pregnancy and 3815 (63%) reported having postnatal visits. This coverage increased substantially from June, 2009, after the introduction of new implementation strategies and reached almost 90% for pregnancy visits by the end of the trial and 75% for postnatal visits. The Newhints intervention significantly increased coverage of key essential newborn- care behaviours, except for four or more antenatal-care visits (5975 [76%] of 7859 vs 5988 [74%] of 8121, respectively; relative risk 1.02, 95% CI 0.96-1.09; p=0.52) and baby delivered in a facility (5373 [68%] vs 5539 [68%], respectively; 0.97, 0.81-1.14; p=0.69). The largest increase was for care-seeking, with 102 (77%) of 132 sick babies in Newhints zones taken to a hospital or clinic compared with 77 (55%) of 139 in control zones (1.43, 1.17-1.76; p=0.001). Increases were also noted in bednet use during pregnancy (5398 [69%] of 7859 vs 5135 [63%] of 8121, respectively; 1.12, 1.03-1.21; p=0-005), money saved for delivery or emergency (5730 [86%] of 6681 vs 5525 [80%] of 6941, respectively; 1.09, 1.05-1.12; p<0.0001), transport arranged in advance for facility (2496 [37%] vs 2061 [30%], respectively; 1.30, 1.12-1.49; p=0.0004), birth assistant for home delivery washed hands with soap (1853 [93%] of 1992 vs 1817 [87%] of 2091, respectively; 1.05, 1.02-1.09; p=0.001), initiation of breastfeeding in less than 1 h of birth (3743 [49%] of 7673 vs 3280 [41%] of 7921, respectively; 1.22, 1.07-1.40; p=0.004), skin to skin contact (3355 [44%] vs 1931 [24%], respectively; 2.30, 1.85-2.87; p=0.0002), first bath delayed for longer than 6 h (3131 [41%] vs 2269 [29%], respectively; 1.65, 1.27-2.13; p<0.0001), exclusive breastfeeding for 26-32 days (1217 [86%] of 1414 vs 1091 [80%] of 1371; 1.10, 1.04-1.16; p=0.001), and baby sleeping under bednet for 8-56 days (4548 [79%] of 5756 vs 4291 [73%] of 5846; 1.09, 1.03-1.15; p=0.002). There were 230 neonatal deaths in the Newhints zones compared with 252 in the control zones. The overall NMRs per 1000 livebirths were 29.8 and 31.9, respectively (0.92, 0.75-1.12; p=0.405). Interpretation The reduction in NMR with Newhints is consistent with the reductions achieved in three trials undertaken in programme settings in south Asia. Because there is no suggestion of any heterogeneity (p=0.850) between these trials and Newhints, the meta-analysis summary estimate of a reduction of 12% (95% CI 5-18) provides the best evidence for the likely effect of the home-visits strategy delivered within programmes in sub-Saharan Africa and in south Asia. Improvements in the quality of delivery and neonatal care in health facilities and development of innovative, effective strategies to increase coverage of home visits on the day of birth could lead to the achievement of more substantial reductions. Funding WHO, Bill & Melinda Gates Foundation, and UK Department for International Development. [ABSTRACT FROM AUTHOR]

Clinical practice guidelines are used widely to improve the quality of primary health care in different health systems, including those of low-income countries. Often developed at international level and adapted to national contexts to increase the feasibility of effective uptake, guideline initiatives aim to transfer global scientific knowledge into local practice. The WHO's Practical Approach to Lung Health (PAL) is an example of such an initiative and is currently being developed to improve the quality of care for youths and adults with respiratory diseases. We assessed ex-ante the feasibility of successful implementation of PAL in a pilot programme in rural Nepal, studying three components: the quality of the innovation (i.e. the guidelines), the effectiveness of the implementation strategy (i.e. training) and the receptiveness of the social system of health staff at all levels (i.e. social and organizational characteristics). We assessed the guideline innovation with the AGREE instrument for guidelines, the intended implementation strategy by critical comparison with literature on effective strategies, and the social system with both a stakeholder analysis and a descriptive analysis of the health care system at district level. This ex-ante assessment of an adaptive local implementation of international WHO guidelines showed that in July 2002 the 'implementability' of the package was challenged on the three components studied. To increase the chances of successful implementation, the national guideline development process should be improved and the implementation strategy needs to be upgraded. In order to successfully transfer global knowledge into local practice, we need to develop additional multifactorial sustained interventions that tackle other culture-specific and health system-specific barriers as well. The primary health workers are key informants for these barriers.

Aims: To estimate the cost-effectiveness of the current screening programme on Familial Hypercholesterolaemia (FH) in relatives of diagnosed FH-patients in The Netherlands., Methods and Results: Data from 2229 screened FH-relatives, including age, sex, risk factor status and screening outcome, were combined with the Framingham risk function and national disease-specific cost data to arrive at a model-based comparison of survival and costs, with and without the screening programme. Cost-effectiveness ratios were computed for various treatment strategies, with no screening as reference. Costs per life year gained varied between 25.5- and 32-thousand Euros, depending upon the precise treatment strategy after a positive screen. The costs for screening (tracing the FH-positive individuals) were much lower than the follow-up costs (treatment), of which 80% were costs for statins. Consequently, the costs per life year gained of alternative screening programmes are about the same., Conclusion: The cost-effectiveness ratio of FH screening is within the range requiring explicit political consideration in The Netherlands. As the costs of statin treatment are the single most important determinant of costs, policy decisions reduce to decisions on the acceptability of statin treatment for this risk group. Pending major changes in statin price, clear guidelines should be developed on how screen positive individuals should be treated, since not all of them have an elevated cholesterol level., (Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd.)