labrique mitchell grading the-evidence-combined_v4 #mh4mh
DESCRIPTION
#mh4mh #mHealthTRANSCRIPT
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The Evidence Gap • Is there evidence to show that mHealth
strategies lead to improved health?
• How strong is that evidence?
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mHealth is not monolithic: This impacts -- evaluation, indicators, business models,
opportunities and strategies for scale.
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INTERVENTION(OF(KNOWN(EFFICACY(
EFFECTIVE(COVERAGE(
mHEALTH:((A(Health(Systems(Catalyst(
Jo(Y,(Labrique(AB(et(al.(In#Press#2013((
(ShiF(focus(from(“Does(mHealth(work?”(to(“Does(
mHealth(op.mize#what(we(know(works(?”((
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2011: < 13% of primary evidence = High Strength
41% “inconclusive”
Source: PubMed, GSMA Literature Review of State of Evidence on mHealth 2011
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mHealth Technical Evidence Review Group for RMNCH
“m-TERG”
“Providing governments and implementing agencies objective, evidence-based guidance for the selection and scale of mHealth strategies
across the reproductive, maternal, newborn and child health continuum”
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Two Initial Areas Selected Do mHealth strategies: ! improve provider adherence to care and
treatment guidelines ?
! reduce stockouts of essential maternal health
drugs and commodities?
PROVIDER(ADHERENCE(
STOCKOUTS(
mTERG&
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Bridging the Evidence Gap - Methods 1. Document Search “beyond the peer-reviewed”:
articles, reports, blogs, presentations using extended strategy, ‘sleuthing’ references and links
2. Included documents which describe: ! Implementation of an mHealth intervention ! Systematic Evaluation Methodology
3. Tag document using WHO mTERG taxonomy
4. Grade document quality using WHO mTERG instrument
5. Summary / Synthesis of overall direction, magnitude and consistency of effect
mTERG&
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• A(flexible(approach(that(allows(the(grading(of(reporWng(and(methodology(for(varied(study(designs(
• &Domain&1:&ReporWng(and(Methodology(–(This(is(indicaWve(of(the(quality(of(methodological(rigor(employed(by(the(studies(under(consideraWon,(as(well(as(the(reporWng(standards(that(have(been(adhered(to.(
• Domain&2:(EssenWal(mHealth(criteria(–(Classifies(the(studies(under(consideraWon(based(on(the(quality(of(informaWon(presented(about(the(mHealth(intervenWon.((
Grading&quality&of&evidence
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Two Initial Areas Selected Do mHealth strategies: ! improve provider adherence to care and
treatment guidelines ?
! reduce stockouts of essential maternal health
drugs and commodities?
PROVIDER(ADHERENCE(
STOCKOUTS(
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Provider Competence, Accountability, Effectiveness.
Client Knowledge and Self-Efficacy
Availability of Commodities, Health Workers, Equipment
Improved Information about individuals,
populations, providers, facilities, outcomes,
Improved HEALTH
Outcomes
Improved Quality of Care
Improved Health
Behaviors
Improved Efficiency + Coverage
Provider
Client
System
Remote Client to Provider (Telemedicine)
Provider Training and Education Provider Work Planning and Scheduling
Disease Prevention
Provider to Provider Communication
Human Resource Management Electronic Decision Support
Appointment Reminders Treatment Adherence
Mass Messaging Campaigns
Health Education or Promotion Hotlines and Information Services
Registries/Vital Events Tracking
Insurance
Payment for Services Savings Accounts
Electronic Health Records Data Collection and Reporting
Point of Care Diagnostics Disease Management
Referrals
Cold Chain Management Performance Based Incentives
Stock Out Prevention Counterfeit Prevention
Maintenance of Equipment Commodity Tracking
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Provider Competence, Accountability, Effectiveness.
Client Knowledge and Self-Efficacy
Availability of Commodities, Health Workers, Equipment
Improved Information about individuals,
populations, providers, facilities, outcomes,
Improved HEALTH
Outcomes
Improved Quality of Care
Improved Health
Behaviors
Improved Efficiency + Coverage
Provider
Client
System
Remote Client to Provider (Telemedicine)
Provider Training and Education Provider Work Planning and Scheduling
Disease Prevention
Provider to Provider Communication
Human Resource Management Electronic Decision Support
Appointment Reminders Treatment Adherence
Mass Messaging Campaigns
Health Education or Promotion Hotlines and Information Services
Registries/Vital Events Tracking
Insurance
Payment for Services Savings Accounts
Electronic Health Records Data Collection and Reporting
Point of Care Diagnostics Disease Management
Referrals
Cold Chain Management Performance Based Incentives
Stock Out Prevention Counterfeit Prevention
Maintenance of Equipment Commodity Tracking
PROVIDER(ADHERENCE(
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Search Strategy PROVIDER(ADHERENCE(
Ar#cles(iden#fied(through(database(search(and(use(of(search(engines(using(a(
combina#on(of(search(terms(n=#1,499#
Poten#ally(eligible(ar#cles(remaining(n#=#1,459#
Titles(and(abstracts(of(1,459(poten#ally(eligible(ar#cles(screened(
Applica#on(of(inclusion(and(exclusion(criteria(to(1,459(ar#cles(
53#ar,cles#tagged#using#the#taxonomy#tool#
21#ar,cles#graded#using#the#grading#tool#
1,406#ar,cles#excluded#• 161(were(not(mobile(health(
related((• 1,117(did(not(meet(health(
domain(criteria(• 105(did(not(meet(mHealth(
applica#on(criteria(• 11(did(not(meet(target(user(
criteria(• 12(only(briefly(men#oned(the(use(
of(mHealth(for(decision(support((#
Iden
#fica#o
n(Screen
ing(
Eligib
ility(
Inclu
sion(
40#duplicate#ar,cles#removed#
#32#ar,cles#did#not#meet#grading#
criteria#• 7(did(not(provide(descrip#on(of(
evalua#on(of(mHealth(program(• 2(did(not(provide(descrip#on(of(
implementa#on(of(mHealth(program((
• 13(did(not(provided(descrip#on(of(evalua#on(or(implementa#on(of(mHealth(program(
#
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Completeness of description of methodology Completeness of description of technology, intervention
Quality of Information PROVIDER(ADHERENCE(
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! Domain(1(score(ranged(from(5(to(37(points(out(of(a(maximum(47apoint(score((11(to(79%)m(suggesWng(large(
variaWons(in(quality(and(methodology(of(reporWng(
(
! Only(three(of(the(21(graded(studies(achieved(a(score(
>75%(for(Domain(2((essenWal(mHealth(criteria),(which(indicates(that(most(studies(do(not(adequately(describe(
the(mHealth(intervenWon(they(are(reporWng(on.((
&
Can mHealth strategies be used to improve provider adherence to care and treatment guidelines?
PROVIDER(ADHERENCE(
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! The studies that were methodologically sound showed significant improvement of HW performance when using mHealth Examples: o In(South(Africa,(Rhode(and(colleagues(randomized(24(primary(care(nurses(to(
be(trained(in(IMCI(using(tradiWonal(paperabased(guidelines,(and(concluded(that(nurses(who(used(the(IMCI(decisionasupport(tool(were(significantly(more(likely(
to(make(an(accurate(diagnosis((p<0.001).(
o (In(rural(Kenya,(Zurovac(et(al(randomized(outpaWent(health(workers(with(
mobile(phones(to(receive(text(message(reminders(about(naWonal(pediatric(
malaria(guidelines(to(improve(and(sustain(protocol(adherence.(For(health(workers(who(received(the(SMS(reminders,(correct(management(of(pediatric(
malaria(increased(by(almost(25%(at(both(6(months(and(12(months((
! The use of mHealth varied: e-training, peer to peer, SMS reminders,
decision support
PROVIDER(ADHERENCE(
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Two Initial Areas Selected Do mHealth strategies: ! improve provider adherence to care and
treatment guidelines ?
! reduce stockouts of essential maternal health
drugs and commodities?
PROVIDER(ADHERENCE(
STOCKOUTS(
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Provider Competence, Accountability, Effectiveness.
Client Knowledge and Self-Efficacy
Availability of Commodities, Health Workers, Equipment
Improved Information about individuals,
populations, providers, facilities, outcomes,
Improved HEALTH
Outcomes
Improved Quality of Care
Improved Health
Behaviors
Improved Efficiency + Coverage
Provider
Client
System
Remote Client to Provider (Telemedicine)
Provider Training and Education Provider Work Planning and Scheduling
Disease Prevention
Provider to Provider Communication
Human Resource Management Electronic Decision Support
Appointment Reminders Treatment Adherence
Mass Messaging Campaigns
Health Education or Promotion Hotlines and Information Services
Registries/Vital Events Tracking
Insurance
Payment for Services Savings Accounts
Electronic Health Records Data Collection and Reporting
Point of Care Diagnostics Disease Management
Referrals
Cold Chain Management Performance Based Incentives
Stock Out Prevention Counterfeit Prevention
Maintenance of Equipment Commodity Tracking
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Provider Competence, Accountability, Effectiveness.
Client Knowledge and Self-Efficacy
Availability of Commodities, Health Workers, Equipment
Improved Information about individuals,
populations, providers, facilities, outcomes,
Improved HEALTH
Outcomes
Improved Quality of Care
Improved Health
Behaviors
Improved Efficiency + Coverage
Provider
Client
System
Remote Client to Provider (Telemedicine)
Provider Training and Education Provider Work Planning and Scheduling
Disease Prevention
Provider to Provider Communication
Human Resource Management Electronic Decision Support
Appointment Reminders Treatment Adherence
Mass Messaging Campaigns
Health Education or Promotion Hotlines and Information Services
Registries/Vital Events Tracking
Insurance
Payment for Services Savings Accounts
Electronic Health Records Data Collection and Reporting
Point of Care Diagnostics Disease Management
Referrals
Cold Chain Management Performance Based Incentives
Stock Out Prevention Counterfeit Prevention
Maintenance of Equipment Commodity Tracking
STOCKOUTS(
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Search Strategy STOCKOUTS(
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Completeness of description of methodology Completeness of description of technology, intervention
STOCKOUTS(Quality of Information
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• (Overall,(a(majority(of(the(evidence(was(anecdotal(and(the(evidence(to(suggest(effecWveness(of(use(of(mHealth(strategies(to(
prevent(stockaouts(is(weak(
• (A(number(of(projects(are(being(currently(
implemented((but(have(limited(published(
results(on(effecWveness(
The Evidence Gap
STOCKOUTS(
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The Evidence Gap - Overall
! Across both domains, there are many interventions but most are incompletely described
! Almost none have design that allow rigorous evaluation ! Almost none have control groups ! It is impossible to compare or combine study results due
to lack of standardization ! The nature of the exact interventions differs ! Differing indicators make meta-analyses difficult(
PROVIDER(ADHERENCE(
STOCKOUTS(