%0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 8 %P e14734 %T Wearable Digital Sensors to Identify Risks of Postpartum Depression and Personalize Psychological Treatment for Adolescent Mothers: Protocol for a Mixed Methods Exploratory Study in Rural Nepal %A Poudyal,Anubhuti %A van Heerden,Alastair %A Hagaman,Ashley %A Maharjan,Sujen Man %A Byanjankar,Prabin %A Subba,Prasansa %A Kohrt,Brandon A %+ Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington School of Medicine and Health Sciences, 2120 L Street, Suite 600, Washington, DC, 20037, United States, 1 (202) 741 2888, bkohrt@gwu.edu %K developing countries %K feasibility studies %K mobile health %K mother-child interaction %K postpartum depression %K psychotherapy %D 2019 %7 11.09.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is a high prevalence of untreated postpartum depression among adolescent mothers with the greatest gap in services in low- and middle-income countries. Recent studies have demonstrated the potential of nonspecialists to provide mental health services for postpartum depression in these low-resource settings. However, there is inconsistency in short-term and long-term benefits from the interventions. Passive sensing data generated from wearable digital devices can be used to more accurately distinguish which mothers will benefit from psychological services. In addition, wearable digital sensors can be used to passively collect data to personalize care for mothers. Therefore, wearable passive sensing technology has the potential to improve outcomes from psychological treatments for postpartum depression. Objective: This study will explore the use of wearable digital sensors for two objectives: First, we will pilot test using wearable sensors to generate passive sensing data that distinguish adolescent mothers with depression from those without depression. Second, we will explore how nonspecialists can integrate data from passive sensing technologies to better personalize psychological treatment. Methods: This study will be conducted in rural Nepal with participatory involvement of adolescent mothers and health care stakeholders through a community advisory board. The first study objective will be addressed by comparing behavioral patterns of adolescent mothers without depression (n=20) and with depression (n=20). The behavioral patterns will be generated by wearable digital devices collecting data in 4 domains: (1) the physical activity of mothers using accelerometer data on mobile phones, (2) the geographic range and routine of mothers using GPS (Global Positioning System) data collected from mobile phones, (3) the time and routine of adolescent mothers with their infants using proximity data collected from Bluetooth beacons, and (4) the verbal stimulation and auditory environment for mothers and infants using episodic audio recordings on mobile phones. For the second objective, the same 4 domains of data will be collected and shared with nonspecialists who are delivering an evidence-based behavioral activation intervention to the depressed adolescent mothers. Over 5 weeks of the intervention, we will document how passive sensing data are used by nonspecialists to personalize the intervention. In addition, qualitative data on feasibility and acceptability of passive data collection will be collected for both objectives. Results: To date, a community advisory board comprising young women and health workers engaged with adolescent mothers has been established. The study is open for recruitment, and data collection is anticipated to be completed in November 2019. Conclusions: Integration of passive sensing data in public health and clinical programs for mothers at risk of perinatal mental health problems has the potential to more accurately identify who will benefit from services and increase the effectiveness by personalizing psychological interventions. %M 31512581 %R 10.2196/14734 %U http://www.researchprotocols.org/2019/8/e14734/ %U https://doi.org/10.2196/14734 %U http://www.ncbi.nlm.nih.gov/pubmed/31512581 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e14668 %T The Elusive Path Toward Measuring Health Outcomes: Lessons Learned From a Pseudo-Randomized Controlled Trial of a Large-Scale Mobile Health Initiative %A Mechael,Patricia %A Kaonga,Nadi Nina %A Chandrasekharan,Subhashini %A Prakash,Muthu Perumal %A Peter,Joanne %A Ganju,Aakash %A Murthy,Nirmala %+ HealthEnabled, 4101 Albemarle St NW Apt 521, Washington, DC, 20016, United States, 1 9732228252, pmechael@gmail.com %K India %K mHealth %K maternal health %K child health %K research %D 2019 %7 21.08.2019 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X Mobile health (mHealth) offers new opportunities to improve access to health services and health information. It also presents new challenges in evaluating its impact, particularly in linking the use of a technology intervention that aims to improve health behaviors with the health outcomes that are impacted by changed behaviors. The availability of data from a multitude of sources (paper-based and electronic) provides the conditions to facilitate making stronger connections between self-reported data and clinical outcomes. This commentary shares lessons and important considerations based on the experience of applying new research frameworks and incorporating maternal and child health records data into a pseudo-randomized controlled trial to evaluate the impact of mMitra, a stage-based voice messaging program to improve maternal, newborn, and child health outcomes in urban slums in India. %M 31436165 %R 10.2196/14668 %U http://mhealth.jmir.org/2019/8/e14668/ %U https://doi.org/10.2196/14668 %U http://www.ncbi.nlm.nih.gov/pubmed/31436165 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e13516 %T Analysis of Digital Documentation Speed and Sequence Using Digital Paper and Pen Technology During the Refugee Crisis in Europe: Content Analysis %A Kehe,Kai %A Girgensohn,Roland %A Swoboda,Walter %A Bieler,Dan %A Franke,Axel %A Helm,Matthias %A Kulla,Martin %A Luepke,Kerstin %A Morwinsky,Thomas %A Blätzinger,Markus %A Rossmann,Katalyn %+ Department F, Bundeswehr Medical Academy, Ingolstädter Str 240, Munich, 80939, Germany, 49 31687422, kai.kehe@lrz.uni-muenchen.de %K digital documentation %K digital pen %K digital paper %K refugee camp %K refugee crisis %K Europe %K Germany %K epidemiology %D 2019 %7 19.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The Syria crisis has forced more than 4 million people to leave their homeland. As a result, in 2016, an overwhelming number of refugees reached Germany. In response to this, it was of utmost importance to set up refugee camps and to provide humanitarian aid, but a health surveillance system was also implemented in order to obtain rapid information about emerging diseases. Objective: The present study describes the effects of using digital paper and pen (DPP) technology on the speed, sequence, and behavior of epidemiological documentation in a refugee camp. Methods: DPP technology was used to examine documentation speed, sequence, and behavior. The data log of the digital pens used to fill in the documentation was analyzed, and each pen stroke in a field was recorded using a timestamp. Documentation time was the difference between first and last stroke on the paper, which includes clinical examination and translation. Results: For three months, 495 data sets were recorded. After corrections had been made, 421 data sets were considered valid and subjected to further analysis. The median documentation time was 41:41 min (interquartile range 29:54 min; mean 45:02 min; SD 22:28 min). The documentation of vital signs ended up having the strongest effect on the overall time of documentation. Furthermore, filling in the free-text field clinical findings or therapy or measures required the most time (mean 16:49 min; SD 20:32 min). Analysis of the documentation sequence revealed that the final step of coding the diagnosis was a time-consuming step that took place once the form had been completed. Conclusions: We concluded that medical documentation using DPP technology leads to both an increase in documentation speed and data quality through the compliance of the data recorders who regard the tool to be convenient in everyday routine. Further analysis of more data sets will allow optimization of the documentation form used. Thus, DPP technology is an effective tool for the medical documentation process in refugee camps. %M 31429420 %R 10.2196/13516 %U http://mhealth.jmir.org/2019/8/e13516/ %U https://doi.org/10.2196/13516 %U http://www.ncbi.nlm.nih.gov/pubmed/31429420 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e13309 %T Using Telemedicine to Diagnose Surgical Site Infections in Low- and Middle-Income Countries: Systematic Review %A Sandberg,Charlotte E J %A Knight,Stephen R %A Qureshi,Ahmad Uzair %A Pathak,Samir %+ Faculty of Health Sciences, University of Bristol, First Floor, 5 Tyndall Avenue, Bristol, BS8 1UD, United Kingdom, 44 117 928 9000, cs14961@bristol.ac.uk %K surgical site infection %K wound infection %K developing country %K low- and middle-income countries %K telemedicine %K postoperative %K follow-up %D 2019 %7 19.08.2019 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: A high burden of preventable morbidity and mortality due to surgical site infections (SSIs) occurs in low- and middle-income countries (LMICs), and most of these SSIs occur following discharge. There is a high loss to follow-up due to a wide geographical spread of patients, and cost of travel can result in delayed and missed diagnoses. Objective: This review analyzes the literature surrounding the use of telemedicine and assesses the feasibility of using mobile phone technology to both diagnose SSIs remotely in LMICs and to overcome social barriers. Methods: A literature search was performed using Medline, Embase, CINAHL, PubMed, Web of Science, the Cochrane Central Register of Controlled Trials and Google Scholar. Included were English language papers reporting the use of telemedicine for detecting SSIs in comparison to the current practice of direct clinical diagnosis. Papers were excluded if infections were not due to surgical wounds, or if SSIs were not validated with in-person diagnosis. The primary outcome of this review was to review the feasibility of telemedicine for remote SSI detection. Results: A total of 404 articles were screened and three studies were identified that reported on 2082 patients across three countries. All studies assessed the accuracy of remote diagnosis of SSIs using predetermined telephone questionnaires. In total, 44 SSIs were accurately detected using telemedicine and an additional 14 were picked up on clinical follow-up. Conclusions: The use of telemedicine has shown to be a feasible method in remote diagnosis of SSIs. Telemedicine is a useful adjunct for clinical practice in LMICs to decrease loss to postsurgical follow-up. %M 31429414 %R 10.2196/13309 %U http://mhealth.jmir.org/2019/8/e13309/ %U https://doi.org/10.2196/13309 %U http://www.ncbi.nlm.nih.gov/pubmed/31429414 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e14540 %T A Novel Mobile Health Tool for Home-Based Identification of Neonatal Illness in Uganda: Formative Usability Study %A Vanosdoll,Madison %A Ng,Natalie %A Ho,Anthony %A Wallingford,Allison %A Xu,Shicheng %A Matin,Shababa Binte %A Verma,Neha %A Farzin,Azadeh %A Golden,W Christopher %A Yazdi,Youseph %A Waiswa,Peter %A Labrique,Alain %A Acharya,Soumyadipta %+ Center for Bioengineering Innovation and Design, Department of Biomedical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD, 21218, United States, 1 4105167074, acharya@jhu.edu %K neonatal %K community health workers %K maternal %K Uganda %K World Health Organization %K smartphone app %K digital health %K mobile health %K telemedicine %D 2019 %7 15.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: While early identification of neonatal illness can impact neonatal mortality rates and reduce the burden of treatment, identifying subtle clinical signs and symptoms of possible severe illness is especially challenging in neonates. The World Health Organization and the United Nations Children’s Fund developed the Integrated Management of Neonatal Childhood Illness guidelines, an evidence-based tool highlighting seven danger signs to assess neonatal health. Currently, many mothers in low-resource settings rely on home visits from community health workers (CHWs) to determine if their baby is sick. However, CHWs visit infrequently, and illness is often detected too late to impact survival. Thus, delays in illness identification pose a significant barrier to providing expedient and effective care. Neonatal Monitoring (NeMo), a novel neonatal assessment tool, seeks to increase the frequency of neonatal screening by task-shifting identification of neonatal danger signs from CHWs to mothers. Objective: This study aimed to explore the usability and acceptability of the NeMo system among target users and volunteer CHWs by assessing ease of use and learnability. Methods: Simulated device use and semistructured interviews were conducted with 32 women in the Iganga-Mayuge districts in eastern Uganda to evaluate the usability of the NeMo system, which involves a smartphone app paired with a low cost, wearable band to aid in identification of neonatal illness. Two versions of the app were evaluated using a mixed methods approach, and version II of the app contained modifications based on observations of the first cohort’s use of the system. During the posed scenario simulations, participants were offered limited guidance from the study team in order to probe the intuitiveness of the NeMo system. The ability to complete a set of tasks with the system was tested and recorded for each participant and closed- and open-ended questions were used to elicit user feedback. Additionally, focus groups with 12 CHWs were conducted to lend additional context and insight to the usability and feasibility assessment. Results: A total of 13/22 subjects (59%) using app version I and 9/10 subjects (90%) using app version II were able to use the phone and app with no difficulty, despite varying levels of smartphone experience. Following modifications to the app’s audio instructions in version II, participants’ ability to accurately answer qualitative questions concerning neonatal danger signs improved by at least 200% for each qualitative danger sign. All participants agreed they would trust and use the NeMo system to assess the health of their babies. Furthermore, CHWs emphasized the importance of community sensitization towards the system to encourage its adoption and regular use, as well as the decision to seek care based on its recommendations. Conclusions: The NeMo system is an intuitive platform for neonatal assessment in a home setting and was found to be acceptable to women in rural Uganda. %M 31418428 %R 10.2196/14540 %U http://mhealth.jmir.org/2019/8/e14540/ %U https://doi.org/10.2196/14540 %U http://www.ncbi.nlm.nih.gov/pubmed/31418428 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 7 %P e12672 %T Mobile Helpline and Reversible Contraception: Lessons From a Controlled Before-and-After Study in Rural India %A Kulathinal,Sangita %A Joseph,Bijoy %A Säävälä,Minna %+ The Family Federation of Finland (Väestöliitto), Kalevankatu 16, Helsinki, 00100, Finland, 358 405736557, minna.saavala@vaestoliitto.fi %K contraception behavior %K family planning services %K organizations, nonprofit %K cell phone use %K mobile phone %K information seeking behavior %K mHealth %K call center %K South Asia %K India %D 2019 %7 09.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Researchers and activists have expressed concerns over the lack of availability and nonuse of reversible, modern, contraceptive methods in India for decades. New attempts to increase access, availability, and acceptance of reversible contraceptives need to be developed, instead of relying solely on female sterilization. Mobile health (mHealth) initiatives may offer one way to serve underprivileged populations who face challenges in sexual and reproductive health (SRH) in countries such as India. Objective: This study aimed to examine the outcome of an mHealth intervention for enhancing knowledge of, and practices related to, reversible contraceptives in rural Western India. Methods: We implemented a nonrandomized controlled trial (before-and-after study in an intervention area and a control area) in the Indian state of Maharashtra. The intervention in this case was a mobile-based SRH helpline provided by a nongovernmental organization (NGO). Baseline and follow-up surveys were carried out in two government-run primary health center areas, one each in the intervention and control area, and 405 respondents were surveyed in the two rounds. An interview-based structured questionnaire suitable for a low-literacy environment was used to collect data. The effect of the intervention was estimated using logistic regression, adjusted for gender, by calculating robust standard errors to take into account the clustering of individuals by the area (intervention or control). In each regression model, the effect of intervention was estimated by including a term for interaction between the intervention area and the period before and after the intervention. The exponent of the regression coefficient of the interaction term corresponding to the period after the intervention, along with the 95% CI, is reported here. The odds ratio for the control village multiplied by this exponent gives the odds ratio for the intervention village. Calls received in the intervention were recorded and their topics analyzed. Results: The current use of reversible contraception (18% increase in intervention area vs 2% increase in control area; 95% CI) has seen changes. The proportion of respondents who had heard of contraception methods from an NGO rose in the intervention area by 23% whereas it decreased in the control area by 1% (95% CI). However, the general level of awareness of reversible contraception, shown by the first contraceptive method that came to respondents’ mind, did not improve. Demand for wider SRH information beyond contraception was high. Men and adolescents, in addition to married women, made use of the helpline. Conclusions: A mobile helpline that one can confidentially approach at a time most convenient to the client can help provide necessary information and support to those who need reversible contraception or other sexual health information. Services that integrate mHealth in a context-sensitive way to other face-to-face health care services add value to SRH services in rural India. %R 10.2196/12672 %U http://mhealth.jmir.org/2019/7/e12672/ %U https://doi.org/10.2196/12672 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 7 %P e13503 %T A Smart and Multifaceted Mobile Health System for Delivering Evidence-Based Secondary Prevention of Stroke in Rural China: Design, Development, and Feasibility Study %A Wu,Na %A Gong,Enying %A Wang,Bo %A Gu,Wanbing %A Ding,Nan %A Zhang,Zhuoran %A Chen,Mengyao %A Yan,Lijing L %A Oldenburg,Brian %A Xu,Li-Qun %+ Center of Excellence for mHealth and Smart Healthcare, China Mobile Research Institute, China Mobile Communications Corporation, 32 Xuanwumen West Street, Xicheng District, Beijing, 100032, China, 86 158 0169 6688 ext 35971, xuliqun@chinamobile.com %K stroke %K secondary prevention %K rural health services %K mobile application %K software design %K China %D 2019 %7 19.07.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) technologies hold great promise in improving the delivery of high-quality health care services. Yet, there has been little research so far applying mHealth technologies in the context of delivering stroke care in resource-limited rural regions. Objective: This study aimed to introduce the design and development of an mHealth system targeting primary health care providers and to ascertain its feasibility in supporting the delivery of a System-Integrated techNology-Enabled Model of cAre (SINEMA) service for strengthening secondary prevention of stroke in rural China. Methods: The SINEMA mHealth system was designed by a multidisciplinary team comprising public health researchers, neurologists, and information and communication technology experts. The iterative co-design and development of the mHealth system involved the following 5 steps: (1) assessing the needs of relevant end users through in-depth interviews of stakeholders, (2) designing the functional modules and evidence-based care content, (3) designing and building the system and user interface, (4) improving and enhancing the system through a 3-month pilot test in 4 villages, and (5) finalizing the system and deploying it in field trial, and finally, evaluating its feasibility through a survey of the dominant user group. Results: From the in-depth interviews of 49 relevant stakeholders, we found that village doctors had limited capacity in caring for village-dwelling stroke patients in rural areas. Primary health care workers demonstrated real needs in receiving appropriate training and support from the mHealth system as well as great interests in using the mHealth technologies and tools. Using these findings, we designed a multifaceted mHealth system with 7 functional modules by following the iterative user-centered design and software development approach. The mHealth system, aimed at 3 different types of users (village doctors, town physicians, and county managers), was developed and utilized in a cluster-randomized controlled trial by 25 village doctors in a resource-limited county in rural China to manage 637 stroke patients between July 2017 and July 2018. In the end, a survey on the usability and functions of the mHealth system among village doctors (the dominant group of users, response rate=96%, 24/25) revealed that most of them were satisfied with the essential functions provided (71%) and were keen to continue using it (92%) after the study. Conclusions: The mHealth system was feasible for assisting primary health care providers in rural China in delivering the SINEMA service on the secondary prevention of stroke. Further research and initiatives in scaling up the SINEMA approach and this mHealth system to other resource-limited regions in China and beyond will likely enhance the quality and accessibility of essential secondary prevention among stroke patients. ClinicalTrial: ClinicalTrials.gov NCT03185858; https://clinicaltrials.gov/ct2/show/NCT03185858 International Registered Report Identifier (IRRID): RR2-10.1016/j.ahj.2018.08.015 %M 31325288 %R 10.2196/13503 %U http://mhealth.jmir.org/2019/7/e13503/ %U https://doi.org/10.2196/13503 %U http://www.ncbi.nlm.nih.gov/pubmed/31325288 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 7 %P e13221 %T Text Message Reminders and Unconditional Monetary Incentives to Improve Measles Vaccination in Western Kenya: Study Protocol for the Mobile and Scalable Innovations for Measles Immunization Randomized Controlled Trial %A Gibson,Dustin G %A Kagucia,E Wangeci %A Were,Joyce %A Obor,David %A Hayford,Kyla %A Ochieng,Benard %+ Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Room E8650, Baltimore, MD, 21205, United States, 1 443 287 8763, dgibso28@jhu.edu %K measles vaccine %K text messaging %K Kenya %K vaccination coverage %D 2019 %7 09.07.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Globally, 21 million children do not receive the measles vaccine each year. With high levels of mobile phone access and ownership, opportunities exist to leverage mobile health technologies to generate demand for immunization. Objective: The aim of the Mobile and Scalable Innovations for Measles Immunization trial is to determine if text message (short message service, SMS) reminders, either with or without mobile phone–based incentives, can improve measles immunization coverage and timeliness in rural western Kenya. Methods: This is a 3-arm, parallel, randomized controlled trial (RCT). Using simple randomization, caregivers in Siaya County, Kenya, will be randomized and evenly allocated to 1 of 3 study arms: (1) control, (2) SMS reminders only, and (3) SMS reminders plus a 150 Kenyan Shilling (KES) incentive. Participants assigned to the SMS group will be sent SMS reminders 3 days before and on the day before the measles immunization visit scheduled for when the child is 9 months of age. Participants in the incentive arm will, in addition to SMS reminders as above, be sent an unconditional 150 KES mobile-money incentive to their mobile phone 3 days before the child becomes 9 months of age. Children will be followed up to the age of 12 months to assess the primary outcome, a measles vaccination by 10 months of age. Log-binomial regressions will be used to calculate relative risks. Results: Enrollment was completed in March 2017. We enrolled 537 caregivers and their infants into the following groups: control (n=179), SMS reminders only (n=179), and SMS reminders plus 150 KES (n=179). Results will be made publicly available in 2020. Conclusions: Few RCTs have examined the effect of text message reminders to improve measles immunization coverage. This is the first study to assess the effect of SMS reminders with and without unconditionally provided mobile-money incentives to improve measles immunization coverage. Trial Registration: ClinicalTrials.gov NCT02904642; https://clinicaltrials.gov/ct2/show/NCT02904642 (Archived by WebCite® at http://www.webcitation.org/78r7AzD2X). International Registered Report Identifier (IRRID): RR1-10.2196/13221 %M 31290405 %R 10.2196/13221 %U http://www.researchprotocols.org/2019/7/e13221/ %U https://doi.org/10.2196/13221 %U http://www.ncbi.nlm.nih.gov/pubmed/31290405 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 6 %P e12631 %T Understanding the Use of Smartphone Apps for Health Information Among Pregnant Chinese Women: Mixed Methods Study %A Wang,Na %A Deng,Zequn %A Wen,Li Ming %A Ding,Yan %A He,Gengsheng %+ Department of Nutrition and Food Hygiene, School of Public Health, Fudan University, No. 130 Dongan Road, Shanghai, 200032, China, 86 21 54237229, gshe@shmu.edu.cn %K mobile applications %K pregnancy %K consumer health information %K health promotion %D 2019 %7 18.06.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Hospital-based health promotion resources to assist pregnant women in adopting a healthy lifestyle and optimizing gestational weight gain are important, but with limited effects. Increasingly, women are using mobile apps to access health information during the antenatal period. Objective: The aims of the study were to investigate app-usage by Chinese women during pregnancy and to gain a better understanding of their views and attitudes toward apps containing health information. Methods: A mixed methods study design was applied. Study participants were recruited from 2 maternity hospitals in Shanghai, China, between March and July 2018. A self-administered Web-based survey was conducted with 535 pregnant Chinese women on their sources of health information and reasons for using apps during pregnancy. A total of 4 semistructured focus groups were also conducted with the pregnant women (n=28). Results: The use of pregnancy-related apps and the internet was common among the respondents. Almost half of the women had used pregnancy-related apps. Specifically, the use of apps for health information declined as pregnancy progressed from 70% (35/50) in the first trimester to 41.3% (143/346) in the third trimester. The main reason for using an app was to monitor fetal development (436/535, 81.5%), followed by learning about nutrition and recording diet in pregnancy (140/535, 26.2%). The women found that the apps were useful and convenient and can support lifestyle modifications during pregnancy. However, some apps also contained misinformation or incorrect information that could cause anxiety as reported by the participants. Many women expressed the need for developing an app containing evidence-based, well-informed, and tailored health information to support them during pregnancy. Conclusions: The study suggests that apps were widely used by many Chinese women during pregnancy to monitor fetal development, to obtain diet and physical activity information, and to track their body changes. The women highly appreciated the evidence-based information, expert opinions, and tailored advice available on apps. Smartphone apps have the potential to deliver health information for pregnant women. %M 31215516 %R 10.2196/12631 %U http://mhealth.jmir.org/2019/6/e12631/ %U https://doi.org/10.2196/12631 %U http://www.ncbi.nlm.nih.gov/pubmed/31215516 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 6 %P e11701 %T Addressing Depression Comorbid With Diabetes or Hypertension in Resource-Poor Settings: A Qualitative Study About User Perception of a Nurse-Supported Smartphone App in Peru %A Brandt,Lena R %A Hidalgo,Liliana %A Diez-Canseco,Francisco %A Araya,Ricardo %A Mohr,David C %A Menezes,Paulo R %A Miranda,J Jaime %+ CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Avenida Armendariz 497, Miraflores, Lima, Peru, 51 12416978, fdiezcanseco@gmail.com %K mental health %K depression %K noncommunicable diseases %K mHealth %K smartphone %K developing countries %D 2019 %7 18.06.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Smartphone apps could constitute a cost-effective strategy to overcome health care system access barriers to mental health services for people in low- and middle-income countries. Objective: The aim of this paper was to explore the patients’ perspectives of CONEMO (Emotional Control, in Spanish: Control Emocional), a technology-driven, psychoeducational, and nurse-supported intervention delivered via a smartphone app aimed at reducing depressive symptoms in people with diabetes, hypertension or both who attend public health care centers, as well as the nurses’ feedback about their role and its feasibility to be scaled up. Methods: This study combines data from 2 pilot studies performed in Lima, Peru, between 2015 and 2016, to test the feasibility of CONEMO. Interviews were conducted with 29 patients with diabetes, hypertension or both with comorbid depressive symptoms who used CONEMO and 6 staff nurses who accompanied the intervention. Using a content analysis approach, interview notes from patient interviews were transferred to a digital format, coded, and categorized into 6 main domains: the perceived health benefit, usability, adherence, user satisfaction with the app, nurse’s support, and suggestions to improve the intervention. Interviews with nurses were analyzed by the same approach and categorized into 4 domains: general feedback, evaluation of training, evaluation of study activities, and feasibility of implementing this intervention within the existing structures of health system. Results: Patients perceived improvement in their emotional health because of CONEMO, whereas some also reported better physical health. Many encountered some difficulties with using CONEMO, but resolved them with time and practice. However, the interactive elements of the app, such as short message service, android notifications, and pop-up messages were mostly perceived as challenging. Satisfaction with CONEMO was high, as was the self-reported adherence. Overall, patients evaluated the nurse accompaniment positively, but they suggested improvements in the technological training and an increase in the amount of contact. Nurses reported some difficulties in completing their tasks and explained that the CONEMO intervention activities competed with their everyday work routine. Conclusions: Using a nurse-supported smartphone app to reduce depressive symptoms among people with chronic diseases is possible and mostly perceived beneficial by the patients, but it requires context-specific adaptations regarding the implementation of a task shifting approach within the public health care system. These results provide valuable information about user feedback for those building mobile health interventions for depression. %M 31215511 %R 10.2196/11701 %U https://mental.jmir.org/2019/6/e11701/ %U https://doi.org/10.2196/11701 %U http://www.ncbi.nlm.nih.gov/pubmed/31215511 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 5 %N 2 %P e13359 %T Prevalence of Schistosoma Haematobium Measured by a Mobile Health System in an Unexplored Endemic Region in the Subprefecture of Torrock, Chad %A Lalaye,Didier %A de Bruijn,Mirjam E %A de Jong,Tom PVM %+ Julius Global Health Center, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584CX, Netherlands, 31 887555555, lalaye84@gmail.com %K Schistosoma haematobium %K prevalence %K Chad %K neglected tropical diseases %K mobile health %D 2019 %7 18.06.2019 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Schistosoma haematobium is a parasitic digenetic trematode responsible for schistosomiasis (also known as bilharzia). The disease is caused by penetration of the skin by the parasite, spread by intermediate host molluscs in stagnant waters, and can be treated by administration of praziquantel. Schistosomiasis is considered to be an important but neglected tropical disease. Objective: The aim of this pilot study was to investigate the prevalence of schistosomiasis in the subprefecture of Torrock, an endemic area in Chad where no earlier investigation had been conducted and no distribution system for pharmacotherapy has ever existed. Methods: This study examined 1875 children aged 1 to 14 years over a period of 1 year. After centrifugation, urine examination was performed by a direct microscopic investigation for eggs. The investigation was conducted with a mobile health (mHealth) approach, using short message service (SMS) for communication among parents, local health workers, a pharmacist, and a medical doctor. An initial awareness campaign requested parents to have their children examined for schistosomiasis. Urine was then collected at home by the parents following the SMS request. Urine results that proved positive were sent to a medical doctor by SMS, who in turn ordered a pharmacist by SMS to distribute praziquantel to the infected children. Results: Direct microscopic examination of urine found 467 positive cases (24.9% of the total sample). Of all male and female samples, 341 (34%) and 127 (14.4%) samples were positive, respectively. The infection rate was equally distributed over age groups. The newly developed mHealth system had a limited level of participation (8%) from an estimated total of 25,000 children in the target group. Conclusions: The prevalence of schistosomiasis in children in the subprefecture of Torrock is moderately high. Efforts will be required to enhance the awareness of parents and to reach a larger percentage of the population. Systematic governmental measures should be put in place as soon as possible to increase awareness in the area and to diagnose and treat cases of schistosomiasis. %M 31215519 %R 10.2196/13359 %U http://publichealth.jmir.org/2019/2/e13359/ %U https://doi.org/10.2196/13359 %U http://www.ncbi.nlm.nih.gov/pubmed/31215519 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 5 %P e10923 %T The Twazon Arabic Weight Loss App: App-Based Intervention for Saudi Women With Obesity %A Alnasser,Aroub %A Kyle,Janet %A Aloumi,Najla %A Al-Khalifa,Abdulrahman %A Marais,Debbi %+ Food Science and Nutrition Dept, King Saud University, Riyadh,, Saudi Arabia, 966 118056476, aroub@ksu.edu.sa %K obesity %K weight loss %K mobile applications %K smartphone %K obesity management %K mHealth %D 2019 %7 28.05.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: By 2022, it is estimated that the rate of female obesity (78%) in Saudi Arabia will almost double that of males (41%). Despite being mainly attributed to poor diet, sedentary lifestyle, and a lack of health awareness, behavioral modification interventions are relatively new to the population; bariatric surgery continues to be the treatment of choice for comorbidities. However, neither pre nor postoperative diet and exercise are promoted. Evidence-informed mobile health (mHealth) weight loss apps and interventions may be an effective tool for delivering a culturally relevant intervention. Objective: This study aimed to determine the feasibility of a weight loss intervention that tests the effectiveness of Twazon, an originally designed Arabic weight-loss app that promotes lifestyle modification specific to Arab populations. Methods: A pre-post single‐arm pilot study was carried out among a sample of 240 overweight volunteer Saudi women residing in Riyadh, Saudi Arabia who used the Twazon app over a 4-month period. Anthropometric, diet, and physical activity measures were assessed 3 times: baseline, 2-months and 4-months; frequency of app use and system usability were evaluated during the 2 latter data collection periods. Repeated measures analysis of variance was used to identify changes over time. Results: A total of 40 participants completed the 4-month intervention with an attrition rate of 83%. An evaluation of the frequency of app use fostered 2 groups: engaged users (65%) and unengaged users (35%). At 4 months, the engaged users experienced more successful outcomes; body weight was lowered on average by 1.3 (SD 0.6) kg (P=.18), waist circumference (WC) was reduced by 4.9 (SD 1.1) cm (P<.001), and daily energy consumption was decreased by >600 calories (P=.002). Unengaged users experienced minor changes in body weight, WC, and reduced energy intake. Conclusions: The findings have demonstrated that engagement with the Twazon app renders positive changes in body weight, WC, and energy intake. mHealth weight loss apps and interventions have the potential to be effective in promoting weight loss and healthy lifestyle modification in Saudi Arabia and similar populations. %M 31140444 %R 10.2196/10923 %U http://mhealth.jmir.org/2019/5/e10923/ %U https://doi.org/10.2196/10923 %U http://www.ncbi.nlm.nih.gov/pubmed/31140444 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 5 %P e12879 %T Using Mobile Health to Support Clinical Decision-Making to Improve Maternal and Neonatal Health Outcomes in Ghana: Insights of Frontline Health Worker Information Needs %A Amoakoh,Hannah Brown %A Klipstein-Grobusch,Kerstin %A Grobbee,Diederick E %A Amoakoh-Coleman,Mary %A Oduro-Mensah,Ebenezer %A Sarpong,Charity %A Frimpong,Edith %A Kayode,Gbenga A %A Agyepong,Irene Akua %A Ansah,Evelyn K %+ Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, PO Box 85500, Utrecht, 3508 GA, Netherlands, 233 264545762, ansomaame@hotmail.com %K mHealth %K maternal health %K neonatal health %K health care systems %K developing countries %K decision-making %K information retrieval systems %D 2019 %7 24.05.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Developing and maintaining resilient health systems in low-resource settings like Ghana requires innovative approaches that adapt technology to context to improve health outcomes. One such innovation was a mobile health (mHealth) clinical decision-making support system (mCDMSS) that utilized text messaging (short message service, SMS) of standard emergency maternal and neonatal protocols via an unstructured supplementary service data (USSD) on request of the health care providers. This mCDMSS was implemented in a cluster randomized controlled trial (CRCT) in the Eastern Region of Ghana. Objective: This study aimed to analyze the pattern of requests made to the USSD by health workers (HWs). We assessed the relationship between requests made to the USSD and types of maternal and neonatal morbidities reported in health facilities (HFs). Methods: For clusters in the intervention arm of the CRCT, all requests to the USSD during the 18-month intervention period were extracted from a remote server, and maternal and neonatal health outcomes of interest were obtained from the District Health Information System of Ghana. Chi-square and Fisher exact tests were used to compare the proportion and type of requests made to the USSD by cluster, facility type, and location; whether phones accessing the intervention were shared facility phones or individual-use phones (type-of-phone); or whether protocols were accessed during the day or at night (time-of-day). Trends in requests made were analyzed over 3 6-month periods. The relationship between requests made and the number of cases reported in HFs was assessed using Spearman correlation. Results: In total, 5329 requests from 72 (97%) participating HFs were made to the intervention. The average number of requests made per cluster was 667. Requests declined from the first to the third 6-month period (44.96% [2396/5329], 39.82% [2122/5329], and 15.22% [811/5329], respectively). Maternal conditions accounted for the majority of requests made (66.35% [3536/5329]). The most frequently accessed maternal conditions were postpartum hemorrhage (25.23% [892/3536]), other conditions (17.82% [630/3536]), and hypertension (16.49% [583/3536]), whereas the most frequently accessed neonatal conditions were prematurity (20.08% [360/1793]), sepsis (15.45% [277/1793]), and resuscitation (13.78% [247/1793]). Requests made to the mCDMSS varied significantly by cluster, type of request (maternal or neonatal), facility type and its location, type-of-phone, and time-of-day at 6-month interval (P<.001 for each variable). Trends in maternal and neonatal requests showed varying significance over each 6-month interval. Only asphyxia and sepsis cases showed significant correlations with the number of requests made (r=0.44 and r=0.79; P<.001 and P=.03, respectively). Conclusions: There were variations in the pattern of requests made to the mCDMSS over time. Detailed information regarding the use of the mCDMSS provides insight into the information needs of HWs for decision-making and an opportunity to focus support for HW training and ultimately improved maternal and neonatal health. %M 31127719 %R 10.2196/12879 %U http://mhealth.jmir.org/2019/5/e12879/ %U https://doi.org/10.2196/12879 %U http://www.ncbi.nlm.nih.gov/pubmed/31127719 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 5 %P e13049 %T A Smartphone Game to Prevent HIV Among Young Africans (Tumaini): Assessing Intervention and Study Acceptability Among Adolescents and Their Parents in a Randomized Controlled Trial %A Sabben,Gaëlle %A Mudhune,Victor %A Ondeng'e,Ken %A Odero,Isdorah %A Ndivo,Richard %A Akelo,Victor %A Winskell,Kate %+ Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30322, United States, 1 4046833103, gaelle.sabben@emory.edu %K HIV %K youth %K sub-Saharan Africa %K Kenya %K serious game %K narrative %K smartphone %K pilot study %K randomized controlled trial %K acceptability %D 2019 %7 21.05.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Young people aged 15 to 24 years account for one-third of new adult HIV infections. Controlling the HIV epidemic requires effective interventions targeted toward young people and their needs. Smartphone games offer a promising avenue for reaching this population with evidence-based HIV prevention interventions. It is crucial to the effectiveness of these interventions that they be acceptable and intrinsically motivating to adolescents as well as acceptable to their parents. Objective: Tumaini is a narrative-based smartphone game designed to help prevent HIV among young Africans aged 11 to 14 years by delaying first sex and increasing condom use at first sex. Following a 16-day feasibility study of Tumaini, we assessed the acceptability (1) of the intervention, where acceptability was operationalized as appeal, relevance, value, usability, and understandability, and (2) of this study and a planned future randomized controlled efficacy trial. Methods: During the randomized feasibility study (n=60) of Tumaini in western Kenya in spring 2017, 30 participants used the intervention on a study-provided smartphone. The app automatically logged participant interaction with the game in time-stamped log files. All 30 participants completed an Audio Computer-Assisted Self-Interview–based game experience survey, and 27 took part in 4 focus group discussions (FGDs) about the game’s appeal, relevance, value, usability, and understandability. Their parents (n=22) also participated in 4 FGDs about the acceptability of the intervention, of this study, and of a planned efficacy trial. Survey data were analyzed using SAS software (SAS Institute Inc); FGD transcripts were coded and analyzed in MAXQDA 12 (Verbi GmbH); and gameplay log files were analyzed using Microsoft Excel. Results: Adolescent participants’ survey responses indicated that Tumaini scored well with players on all indicators of acceptability (appeal, relevance, value, usability, and understandability). Focus group analyses aligned with these findings and emphasized a high degree of player engagement with the game, which was supported by log file analysis. Adolescent participants were eager for additional content, and parents were receptive to a longer study involving biomarkers, based on their positive experiences with this study. There is scope to improve communication with parents about their role in the intervention. As the game was tested in beta version, there is also scope to fine-tune some of the game mechanics to increase usability. Conclusions: This study shows the strong acceptability of an interactive smartphone-based game both to adolescents and their parents in western Kenya and that of the study methods used to pilot-test the intervention. It also suggests that longitudinal efficacy studies of this type of intervention, including those using biomarkers, have the potential to be acceptable among parents. Trial Registration: ClinicalTrials.gov NCT03054051; https://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW) %M 31115348 %R 10.2196/13049 %U http://mhealth.jmir.org/2019/5/e13049/ %U https://doi.org/10.2196/13049 %U http://www.ncbi.nlm.nih.gov/pubmed/31115348 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 8 %N 2 %P e12664 %T EasyDetectDisease: An Android App for Early Symptom Detection and Prevention of Childhood Infectious Diseases %A Ponum,Mahvish %A Hasan,Osman %A Khan,Saadia %+ School of Electrical Engineering and Computer Science, National University of Sciences and Technology, Islamabad, Pakistan, Islamabad, 440000, Pakistan, 92 3067826262, mponum.msit15seecs@seecs.edu.pk %K infectious diseases %K mHealth %K causes of death %D 2019 %7 14.05.2019 %9 Original Paper %J Interact J Med Res %G English %X Background: Infectious diseases often lead to death among children under 5 years in many underdeveloped and developing countries. One of the main reasons behind this is an unawareness of disease symptoms among mothers and child caregivers. To overcome this, we propose the EasyDetectDisease mobile health app to educate mothers about the early symptoms of pediatric diseases and to provide them with practical advice for preventing the spread of such diseases in children under 5 years. The EasyDetectDisease app includes detailed knowledge of infectious diseases, including the corresponding symptoms, causes, incubation period, preventive measures, nutritional guidelines such as breastfeeding, video tutorials of child patients, and video guidelines by pediatric health experts to promote child health. It also provides information on the diagnosis of the infectious diseases based on symptoms. Objective: The objective of this study was to evaluate the usability (eg, ease of use, easy detection of disease, functionality, and navigation of interfaces) of the EasyDetectDisease app among mothers of children under 5 years of age. Methods: Two health sessions, held in Pakistan, were used to evaluate the usability of EasyDetectDisease by 30 mothers of children under 5 years. The app was evaluated based on various quantitative and qualitative measures. Results: The participating mothers confirmed that they were able to diagnose diseases accurately and that after following the instructions provided, their children recovered rapidly without any nutritional deficiency. All participating mothers showed an interest in using the EasyDetectDisease app if made available by governmental public health agencies, and they suggested its inclusion in all mobile phones as a built-in health app in the future. Conclusions: EasyDetectDisease was modified into a user-friendly app based on feedback collected during the usability sessions. All participants found it acceptable and easy to use, especially illiterate mothers. The EasyDetectDisease app proved to be a useful tool for child health care at home and for the treatment of infectious diseases and is expected to reduce the mortality rate of children under 5 years of age. %M 31094329 %R 10.2196/12664 %U http://www.i-jmr.org/2019/2/e12664/ %U https://doi.org/10.2196/12664 %U http://www.ncbi.nlm.nih.gov/pubmed/31094329 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 5 %P e13963 %T Development and Implementation of a Mobile Phone–Based Prevention of Mother-To-Child Transmission of HIV Cascade Analysis Tool: Usability and Feasibility Testing in Kenya and Mozambique %A Kawakyu,Nami %A Nduati,Ruth %A Munguambe,Khátia %A Coutinho,Joana %A Mburu,Nancy %A DeCastro,Georgina %A Inguane,Celso %A Zunt,Andrew %A Abburi,Neil %A Sherr,Kenneth %A Gimbel,Sarah %+ Center for Global Health Nursing, University of Washington, Box 357263, Seattle, WA, 98195, United States, 1 206 221 7477, nkawakyu@uw.edu %K mHealth %K quality improvement %K engineering %K HIV %K mother to child transmission %K implementation science %D 2019 %7 13.05.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Prevention of mother-to-child HIV transmission (PMTCT) care cascade failures drive pediatric HIV infections in sub-Saharan Africa. As nurses’ clinical and management role in PMTCT expand, decision-support tools for nurses are needed to facilitate identification of cascade inefficiencies and solutions. The mobile phone–based PMTCT cascade analysis tool (mPCAT) provides health facility staff a quick summary of the number of patients and percentage drop-off at each step of the PMCTC care cascade, as well as how many women-infant pairs would be retained if a step was optimized. Objective: The objective of this study was to understand and improve the mPCAT’s core usability factors and assess the health workers’ experience with using the mPCAT. Methods: Overall, 2 rounds of usability testing were conducted with health workers from 4 clinics and leading experts in maternal and child health in Kenya and Mozambique using videotaped think aloud assessment techniques. Semistructured group interviews gauged the understanding of mPCAT’s core usability factors, based on the Nielsen Usability Framework, followed by development of cognitive demand tables describing the needed mPCAT updates. Post adaptation, feasibility was assessed in 3 high volume clinics over 12 weeks. Participants completed a 5-point Likert questionnaire designed to measure ease of use, convenience of integration into work, and future intention to use the mPCAT. Focus group discussions with nurse participants at each facility and in-depth interviews with nurse managers were also conducted to assess the acceptability, use, and recommendations for adaptations of the mPCAT. Results: Usability testing with software engineers enabled real-time feedback to build a tool following empathic design principles. The revised mPCAT had improved navigation and simplified data entry interface, with only 1 data entry field per page. Improvements to the results page included a data visualization feature and the ability to share results through WhatsApp. Coding was simplified to enable future revisions by nontechnical staff—critical for context-specific adaptations for scale-up. Health care workers and facility managers found the tool easy to use (mean=4.3), used the tool very often (mean=4.1), and definitely intended to continue to use the tool (mean=4.8). Ease of use was the most common theme identified, with emphasis on how the tool readily informed system improvement decision making. Conclusions: The mPCAT was well accepted by frontline health workers and facility managers. The collaborative process between software developer and user led to the development of a more user-friendly, context-specific tool that could be easily integrated into routine clinical practice and workflow. The mPCAT gave frontline health workers and facility managers an immediate, direct, and tangible way to use their clinical documentation and routinely reported data for decision making for their own clinical practice and facility-level improvements. %M 31094351 %R 10.2196/13963 %U http://mhealth.jmir.org/2019/5/e13963/ %U https://doi.org/10.2196/13963 %U http://www.ncbi.nlm.nih.gov/pubmed/31094351 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 5 %P e11497 %T Achieving Sustainability and Scale-Up of Mobile Health Noncommunicable Disease Interventions in Sub-Saharan Africa: Views of Policy Makers in Ghana %A Opoku,Daniel %A Busse,Reinhard %A Quentin,Wilm %+ Faculty VII Economics and Management, Institute of Technology and Management, Department of Health Care Management, Technische Universität Berlin, Straße des 17. Juni 135, Administrative office H80, Berlin, 10623, Germany, 49 3031429222, Daniel.Opoku@TU-Berlin.de %K implementation science %K mHealth %K eHealth %K noncommunicable diseases %K disease management %K sub-Saharan Africa %K qualitative research %K health policy %D 2019 %7 03.05.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: A growing body of evidence shows that mobile health (mHealth) interventions may improve treatment and care for the rapidly rising number of patients with noncommunicable diseases (NCDs) in sub-Saharan Africa (SSA). A recent realist review developed a framework highlighting the influence of context factors, including predisposing characteristics, needs, and enabling resources (PNE), for the long-term success of mHealth interventions. The views of policy makers will ultimately determine implementation and scale-up of mHealth interventions in SSA. However, their views about necessary conditions for sustainability and scale-up remain unexplored. Objective: This study aimed to understand the views of policy makers in Ghana with regard to the most important factors for successful implementation, sustainability, and scale-up of mHealth NCD interventions. Methods: Members of the technical working group responsible for Ghana’s national NCD policy were interviewed about their knowledge of and attitude toward mHealth and about the most important factors contributing to long-term intervention success. Using qualitative methods and applying a qualitative content analysis approach, answers were categorized according to the PNE framework. Results: A total of 19 policy makers were contacted and 13 were interviewed. Interviewees had long-standing work experience of an average of 26 years and were actively involved in health policy making in Ghana. They were well-informed about the potential of mHealth, and they strongly supported mHealth expansion in the country. Guided by the PNE framework’s categories, the policy makers ascertained which critical factors would support the successful implementation of mHealth interventions in Ghana. The policy makers mentioned many factors described in the literature as important for mHealth implementation, sustainability, and scale-up, but they focused more on enabling resources than on predisposing characteristics and need. Furthermore, they mentioned several factors that have been rather unexplored in the literature. Conclusions: The study shows that the PNE framework is useful to guide policy makers toward a more systematic assessment of context factors that support intervention implementation, sustainability, and scale-up. Furthermore, the framework was refined by adding additional factors. Policy makers may benefit from using the PNE framework at the various stages of mHealth implementation. Researchers may (and should) use the framework when investigating reasons for success (or failure) of interventions. %M 31066706 %R 10.2196/11497 %U https://mhealth.jmir.org/2019/5/e11497/ %U https://doi.org/10.2196/11497 %U http://www.ncbi.nlm.nih.gov/pubmed/31066706 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e11957 %T Needs Analysis for a Parenting App to Prevent Unintentional Injury in Newborn Babies and Toddlers: Focus Group and Survey Study Among Chinese Caregivers %A Ning,Peishan %A Gao,Deyue %A Cheng,Peixia %A Schwebel,David C %A Wei,Xiang %A Tan,Liheng %A Xiao,Wangxin %A He,Jieyi %A Fu,Yanhong %A Chen,Bo %A Yang,Yang %A Deng,Jing %A Wu,Yue %A Yu,Renhe %A Li,Shukun %A Hu,Guoqing %+ Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, 110 Xiangya Road, Changsha, 410078, China, 86 073184805414, huguoqing009@gmail.com %K injury %K child %K mobile health %K education %K intervention %K parenting %K mhealth %D 2019 %7 30.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: With the growing popularity of mobile health technology, app-based interventions delivered by smartphone have become an increasingly important strategy toward injury prevention. Objective: This study aimed to develop a framework supporting the design of an app-based intervention to prevent unintentional injury, targeted for caregivers of Chinese children aged 0 to 6 years. Methods: A theory-based mixed-method study, including focus groups and Web-based quantitative survey, was performed. Adult caregivers who care for children aged 0 to 6 years and own a smartphone were recruited into 2 sequential stages of research. First, focus groups were conducted among the caregivers at community health care centers and preschools from December 2015 to March 2016. Focus groups (8-10 participants per group) explored awareness, experiences, and opinions of caregivers toward using an app to prevent unintentional injury among children. Second, based on the focus groups findings, a Web-based quantitative survey was designed and distributed to caregivers in November 2016; it collected information on specific needs for the app-based intervention. Thematic analysis and quantitative descriptive analyses were performed. Results: In total, 12 focus groups were completed, involving 108 caregivers. Most participants expressed a strong desire to learn knowledge and skills about unintentional child injury prevention and held positive attitudes toward app-based interventions. Participants expressed multiple preferences concerning the app-based intervention, including their contents, functions, interactive styles, installation and registration logistics, and privacy protection and information security. Following the focus groups, 1505 caregivers completed a WeChat-based quantitative survey, which generated roughly similar results to those of focus groups and added numerical metrics concerning participants’ preferences on what to learn, when to learn it, and how to learn it. A detailed framework was established involving 5 components: (1) content design, (2) functional design, (3) interactive style, (4) installation and registration logistics, and (5) privacy protection and information security, and 15 specific requirements. Conclusions: We developed a framework that can be used as a guide to design app-based interventions for parents and caregivers, specifically for unintentional injury prevention of children aged 0 to 6 years. %M 31038465 %R 10.2196/11957 %U http://mhealth.jmir.org/2019/4/e11957/ %U https://doi.org/10.2196/11957 %U http://www.ncbi.nlm.nih.gov/pubmed/31038465 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e11842 %T Patients’ and Doctors’ Perceptions of a Mobile Phone–Based Consultation Service for Maternal, Neonatal, and Infant Health Care in Bangladesh: A Mixed-Methods Study %A Alam,Mafruha %A Banwell,Cathy %A Olsen,Anna %A Lokuge,Kamalini %+ National Centre for Epidemiology and Population Health, Research School of Population Health, The Australian National University, 62 Mills Road, Canberra, 2601, Australia, 61 6125 5602, mafruha.alam@gmail.com %K mobile-based consultation %K mHealth %K remote diagnosis %K referral %D 2019 %7 22.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: A mobile-based consultation service, or telehealth, can be used for remote consultations with health care professionals for screening, self-care management, and referral. In rural Bangladesh, where there is high demand for scarce male and even scarcer female doctors, remote consultations may help women seeking maternal and child health care. Aponjon is a mHealth service in Bangladesh that provides weekly voice or text messages to pregnant women, new mothers, and family members on various aspects of maternal, neonatal, and infant health. Subscribers can also access a dedicated 24*7 call center to discuss maternal, neonatal, and infant health or emergencies with medically trained doctors. The service provides advice, primary diagnoses, prescriptions, and referrals to subscriber callers. Objective: We investigated the Aponjon service to understand access, acceptability, usability, benefits, and challenges of a mobile phone-based consultation service. Methods: We conducted call log data analysis for September to November 2015 to understand how many unique subscribers accessed the service, who accessed the service, the geographical distribution of callers, and the purpose of the calls. We also conducted a qualitative exploratory substudy of eight married women and eight married men who were subscribers to and accessed the service during this time to understand their experiences. We interviewed 11 doctors from the same service who provided phone consultations to subscribers. Results: Approximately 3894 unique subscribers accessed the service for single or multiple consultations during the study period; 68.36% (2662/3894) of subscribers were from rural households, and 53.00% (2064/3894) of calls were made by pregnant women or new mothers. Approximately 96.08% (5081/5288) calls were nonurgent, 2.69% (142/5288) semiurgent, and 1.23% (65/5288) urgent. Almost 64.7% (134/207) semiurgent or urgent calls came between 8 PM and 8 AM. Callers found the consultation service trustworthy, cost-effective, and convenient. The doctors dispelled misconceptions and promoted good health care practices, regular health check-ups, and responsible use of medicine. They helped families understand the severity of sicknesses and advised them to seek care at health facilities for semiurgent or urgent conditions. The service lacked a pro-poor policy to support talk times of subscribers from poor households and a proper referral system to help patients find the right care at the right facilities. Conclusions: Although a regular messaging service is constrained by a one-way communication system, this service using the same platform, gave subscribers access to an abbreviated “consultation” with medical doctors. The consultations provided subscribers with valued medical advice and support, although they were limited in their population reach and their integration into the wider medical system. Further research is required to understand the impact of advice and referral, cost-effectiveness, and willingness to pay for mHealth consultation services, but this research suggests that these services should be supported or even expanded. %M 31008716 %R 10.2196/11842 %U http://mhealth.jmir.org/2019/4/e11842/ %U https://doi.org/10.2196/11842 %U http://www.ncbi.nlm.nih.gov/pubmed/31008716 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e11687 %T Mobile Health for Tuberculosis Management in South India: Is Video-Based Directly Observed Treatment an Acceptable Alternative? %A Kumar,Anil A %A De Costa,Ayesha %A Das,Arundathi %A Srinivasa,GA %A D'Souza,George %A Rodrigues,Rashmi %+ Department of Community Health, St John's Medical College, St John's National Academy of Health Sciences, Koramangala 4th Block, Bangalore, 560034, India, 91 9845389538, rashmijr@gmail.com %K medical informatics %K tuberculosis %K mHealth %K adherence %K mobile phone %K reminder %K SMS %K voice call %K DOT %K vDOT %K video DOT %D 2019 %7 03.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: With the availability of low-cost mobile devices and the ease of internet access, mobile health (mHealth) is digitally revolutionizing the health sector even in resource-constrained settings. It is however necessary to assess end-user perceptions before deploying potential interventions. Objective: This study aimed to assess the mobile phone usage patterns and the acceptability of mobile phone support during care and treatment in patients with tuberculosis (TB) in South India. Methods: This exploratory study was conducted at an urban private tertiary care teaching hospital and nearby public primary-level health care facilities in Bangalore, South India. We recruited 185 patients with TB through consecutive sampling. Subsequent to written informed consent, participants responded to an interviewer-administered pretested questionnaire. The questionnaire included questions on demographics, phone usage patterns, and the benefits of using of mobile phone technology to improve health outcomes and treatment adherence. Frequency, mean, median, and SD or interquartile range were used to describe the data. Bivariate associations were assessed between demographics, clinical details, phone usage, and mHealth communication preferences using the chi-square test and odds ratios. Associations with a P value ≤.20 were included in a logistic regression model. A P value of <.05 was considered significant. Results: Of the 185 participants, 151 (81.6%) used a mobile phone, and half of them owned a smartphone. The primary use of the mobile phone was to communicate over voice calls (147/151, 97.4%). The short message service (SMS) text messaging feature was used by only 66/151 (43.7%) mobile phone users. A total of 87 of the 151 mobile phone users (57.6%) knew how to use the camera. Only 41/151 (27.2%) mobile phone users had used their mobile phones to communicate with their health care providers. Although receiving medication reminders via mobile phones was acceptable to all participants, 2 participants considered repeated reminders as an intrusion of their privacy. A majority of the participants (137/185, 74.1%) preferred health communications via voice calls. Of the total participants, 123/185 (66.5%) requested reminders to be sent only at specific times during the day, 22/185 (11.9%) suggested reminders should synchronize with their prescribed medication schedule, whereas 40/185 (21.6%) did not have any time preferences. English literacy was associated with a preference for SMS in comparison with voice calls. Most participants (142/185, 76.8%) preferred video-based directly observed treatment when compared with in-person directly observed treatment. Conclusions: Although mobile phones for supporting health and treatment adherence were acceptable to patients with TB, mHealth interventions should consider language, mode of communication, and preferred timing for communication to improve uptake. %M 30942696 %R 10.2196/11687 %U http://mhealth.jmir.org/2019/4/e11687/ %U https://doi.org/10.2196/11687 %U http://www.ncbi.nlm.nih.gov/pubmed/30942696 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e12745 %T A Smartphone App to Assist Smoking Cessation Among Aboriginal Australians: Findings From a Pilot Randomized Controlled Trial %A Peiris,David %A Wright,Lachlan %A News,Madeline %A Rogers,Kris %A Redfern,Julie %A Chow,Clara %A Thomas,David %+ The George Institute for Global Health, UNSW Sydney, 1 King St, Newtown,, Australia, 61 280524513, dpeiris@georgeinstitute.org %K smoking cessation %K oceanic ancestry group %K mobile apps %D 2019 %7 02.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) apps have the potential to increase smoking cessation, but little research has been conducted with Aboriginal communities in Australia. Objective: We conducted a pilot study to assess the feasibility and acceptability and explore the effectiveness of a novel mHealth app to assist Aboriginal people to quit smoking. Methods: A pilot randomized controlled trial (RCT) and process evaluation comprising usage analytics data and in-depth interviews was conducted. Current Aboriginal smokers (>16 years old), who were willing to make a quit attempt in the next month, were recruited from Aboriginal Community Controlled Health Services and a government telephone coaching service. The intervention was a multifaceted Android or iOS app comprising a personalized profile and quit plan, text and in-app motivational messages, and a challenge feature allowing users to compete with others. The comparator was usual cessation support services. Outcome data collection and analysis were conducted blinded to treatment allocation. The primary outcome was self-reported continuous smoking abstinence verified by carbon monoxide breath testing at 6 months. Secondary outcomes included point prevalence of abstinence and use of smoking cessation therapies and services. Results: A total of 49 participants were recruited. Competing service delivery priorities, the lack of resources for research, and lack of support for randomization to a control group were the major recruitment barriers. At baseline, 23/49 (47%) of participants had tried to quit in recent weeks. At 6-month follow-up, only 1 participant (intervention arm) was abstinent. The process evaluation highlighted low to moderate app usage (3-10 new users per month and 4-8 returning users per month), an average of 2.9 sessions per user per month and 6.3 min per session. Key themes from interviews with intervention participants (n=15) included the following: (1) the powerful influence of prevailing social norms around acceptability of smoking; (2) high usage of mobile devices for phone, text, and social media but very low use of other smartphone apps; (3) the role of family and social group support in supporting quit attempts; and (4) low awareness and utilization of smoking cessation support services. Despite the broad acceptability of the app, participants also recommended technical improvements to improve functionality, greater customization of text messages, integration with existing social media platforms, and gamification features. Conclusions: Smoking cessation apps need to be integrated with commonly used functions of mobile phones and draw on social networks to support their use. Although they have the potential to increase utilization of cessation support services and treatments, more research is needed to identify optimal implementation models. Robust evaluation is critical to determine their impact; however, an RCT design may not be feasible in this setting. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12616001550493; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371792 (Archived by WebCite at http://www.webcitation.org/76TiV7HA6). %M 30938691 %R 10.2196/12745 %U https://mhealth.jmir.org/2019/4/e12745/ %U https://doi.org/10.2196/12745 %U http://www.ncbi.nlm.nih.gov/pubmed/30938691 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e12652 %T Improving Linkage to and Retention in Care in Newly Diagnosed HIV-Positive Patients Using Smartphones in South Africa: Randomized Controlled Trial %A Venter,Willem Daniel Francois %A Fischer,Alex %A Lalla-Edward,Samanta Tresha %A Coleman,Jesse %A Lau Chan,Vincent %A Shubber,Zara %A Phatsoane,Mothepane %A Gorgens,Marelize %A Stewart-Isherwood,Lynsey %A Carmona,Sergio %A Fraser-Hurt,Nicole %+ Wits Reproductive Health and HIV Institute, University of Witwatersrand, Hillbrow Health Precinct, 22 Esselen St, Johannesburg, 2001, South Africa, 27 011 358 5500, afischer@wrhi.ac.za %K cell phones %K HIV %K app %K Africa %K linkage to care %K patient information %D 2019 %7 02.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: South Africa provides free antiretroviral therapy for almost 5 million people living with HIV, but only 71% of the eligible people are on treatment, representing a shortfall in the care cascade, especially among men and youth. Many developing countries have expanded access to smartphones; success in health apps raises the possibility of improving this cascade. Objective: SmartLink is a health app for Android smartphones providing HIV-related laboratory results, information, support, and appointment reminders to engage and link patients to care. This study aimed to evaluate the ability of SmartLink to improve linkage to care for HIV-positive smartphone owners. Methods: This study was a multisite randomized controlled trial in Johannesburg. The intervention arm received the app (along with referral to a treatment site) and the control arm received the standard of care (referral alone). Linkage to care was confirmed by an HIV-related blood test reported on the National Health Laboratory Service database between 2 weeks and 8 months after initiation. Results: A total of 345 participants were recruited into the study; 64.9% (224/345) of the participants were female and 44.1% (152/345) were aged less than 30 years. In addition, 46.7% (161/345) were employed full time, 95.9% (331/345) had at least secondary school education, and 35.9% (124/345) were from Zimbabwe. Linkage to care between 2 weeks and 8 months was 48.6% (88/181) in the intervention arm versus 45.1% (74/164) in the control (P=.52) and increased to 64.1% (116/181) and 61.0% (100/164) (P=.55), respectively, after the initial 8-month period. Moreover, youth aged 18 to 30-years showed a statistically significant 20% increase in linkage to care for the intervention group. Conclusions: Youth aged less than 30 years have been historically difficult to reach with traditional interventions, and the SmartLink app provides a proof of concept that this population reacts to mobile health interventions that engage patients in HIV care. Trial Registration: ClinicalTrials.gov NCT02756949; https://clinicaltrials.gov/ct2/show/NCT02756949 (Archived by WebCite at http://www.webcitation.org/6z1GTJCNW) %M 30938681 %R 10.2196/12652 %U https://mhealth.jmir.org/2019/4/e12652/ %U https://doi.org/10.2196/12652 %U http://www.ncbi.nlm.nih.gov/pubmed/30938681 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11785 %T The Development of an Arabic Weight-Loss App Akser Waznk: Qualitative Results %A Alturki,Ryan %A Gay,Valerie %+ School of Electrical and Data Engineering, Faculty of Engineering and Information Technology, University of Technology Sydney, 81 Broadway, Ultimo, Sydney, 2007, Australia, 61 410583330, ryan.m.alturki@student.uts.edu.au %K weight loss %K mobile app %K obesity %K physical activity %K smartphone %K mHealth %K motivation %D 2019 %7 14.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Obesity and its related illnesses are a major health problem around the world. Saudi Arabia has one of the highest national obesity rates globally; however, it is not easy to intervene to prevent obesity and becoming overweight owing to Saudi Arabia’s cultural and social norms, and linguistic barriers. In recent years, there has been an exponential growth in the usage of smartphones and apps in Saudi Arabia. These could be used as a cost-effective tool to facilitate the delivery of behavior-modification interventions for obese and overweight people. There are a variety of health and fitness apps that claim to offer lifestyle-modification tools. However, these do not identify the motivational features required to overcome obesity, consider the evidence-based practices for weight management, or enhance the usability of apps by considering usability attributes. Objective: This study aimed to explore the opportunity and the need to develop an Arabic weight-loss app that provides localized content and addresses the issues with existing apps identified here. This study has explained the steps taken to design an Arabic weight-loss app that was developed to facilitate the adjustment of key nutritional and physical activities and behaviors, which considers the social and cultural norms of Saudi Arabia. Methods: Qualitative studies were conducted with 26 obese Saudi Arabians, who tested the level of usability of 2 weight-loss apps and then provided feedback and recommendations. The app Akser Waznk is an interactive, user-friendly app designed primarily for iPhones. It has several features intended to assist users to monitor and track their food consumption and physical activities. The app provides personalized diet and weight loss advice. Unique features such as Let’s Walk are designed to motivate users to walk more. An augmented reality function is implemented to provide information regarding fitness equipment, fruits, and vegetables. The app uses behavior-change techniques to increase activities and healthy behaviors and evidence-informed practices for weight-loss management. The Akser Waznk app considers user privacy and data security by applying a number of guidelines and procedures. Results: The development of the app took 26 months. In all, 7 experts (5 dietitians, and 2 physical activity professionals) evaluated the app’s contents. Moreover, 10 potential users (5 men and 5 women) tested the app’s level of usability, its features, and performance during a pilot study. They reported that the app’s design is interactive, and the motivational features are user-friendly. Conclusions: Mobile technology, such as mobile apps, has the potential to be an effective tool that facilitates the changing of unhealthy lifestyle behaviors within the Saudi community. To be successful, the target group, the usability, motivational features, and social and cultural norms must be considered. %M 30869639 %R 10.2196/11785 %U http://formative.jmir.org/2019/1/e11785/ %U https://doi.org/10.2196/11785 %U http://www.ncbi.nlm.nih.gov/pubmed/30869639 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 3 %P e11420 %T A Mobile Health Wallet for Pregnancy-Related Health Care in Madagascar: Mixed-Methods Study on Opportunities and Challenges %A Muller,Nadine %A Emmrich,Peter Martin Ferdinand %A Rajemison,Elsa Niritiana %A De Neve,Jan-Walter %A Bärnighausen,Till %A Knauss,Samuel %A Emmrich,Julius Valentin %+ Department of Infectious Diseases and Pulmonary Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin, 10117, Germany, 49 30450665296, nadine.muller@charite.de %K pregnancy %K maternal health services %K healthcare financing %K cell phone %K mobile applications %K telemedicine %K maternal mortality %K health expenditures %K marketing of health services %K developing countries %K Madagascar %D 2019 %7 05.03.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile savings and payment systems have been widely adopted to store money and pay for a variety of services, including health care. However, the possible implications of these technologies on financing and payment for maternal health care services—which commonly require large 1-time out-of-pocket payments—have not yet been systematically assessed in low-resource settings. Objective: The aim of this study was to determine the structural, contextual, and experiential characteristics of a mobile phone–based savings and payment platform, the Mobile Health Wallet (MHW), for skilled health care during pregnancy among women in Madagascar. Methods: We used a 2-stage cluster random sampling scheme to select a representative sample of women utilizing either routine antenatal (ANC) or routine postnatal care (PNC) in public sector health facilities in 2 of 8 urban and peri-urban districts of Antananarivo, Madagascar (Atsimondrano and Renivohitra districts). In a quantitative structured survey among 412 randomly selected women attending ANC or PNC, we identified saving habits, mobile phone use, media consumptions, and perception of an MHW with both savings and payment functions. To confirm and explain the quantitative results, we used qualitative data from 6 semistructured focus group discussions (24 participants in total) in the same population. Results: 59.3% (243/410, 95% CI 54.5-64.1) saved toward the expected costs of delivery and, out of those, 64.4% (159/247, 95% CI 58.6-70.2) used household cash savings for this purpose. A total of 80.3% (331/412, 95% CI 76.5-84.1) had access to a personal or family phone and 35.7% (147/412, 95% CI 31.1-40.3) previously used Mobile Money services. Access to skilled health care during pregnancy was primarily limited because of financial obstacles such as saving difficulties or unpredictability of costs. Another key barrier was the lack of information about health benefits or availability of services. The general concept of an MHW for saving toward and payment of pregnancy-related care, including the restriction of payments, was perceived as beneficial and practicable by the majority of participants. In the discussions, several themes pointed to opportunities for ensuring the success of an MHW through design features: (1) intuitive technical ease of use, (2) clear communication and information about benefits and restrictions, and (3) availability of personal customer support. Conclusions: Financial obstacles are a major cause of limited access to skilled maternal health care in Madagascar. An MHW for skilled health care during pregnancy was perceived as a useful and desirable tool to reduce financial barriers among women in urban Madagascar. The design of this tool and the communication strategy will likely be the key to success. Particularly important dimensions of design include technical user friendliness and accessible and personal customer service. %M 30457972 %R 10.2196/11420 %U https://mhealth.jmir.org/2019/3/e11420/ %U https://doi.org/10.2196/11420 %U http://www.ncbi.nlm.nih.gov/pubmed/30457972 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 2 %P e10645 %T Women Using Mobile Phones for Health Communication Are More Likely to Use Prenatal and Postnatal Services in Bangladesh: Cross-Sectional Study %A Tang,Shangfeng %A Ghose,Bishwajit %A Hoque,Md Rakibul %A Hao,Gang %A Yaya,Sanni %+ School of International Development and Global Studies, University of Ottawa, 120 University Private, Ottawa, ON, K1N5J1, Canada, 1 6132624856, brammaputram@gmail.com %K antenatal care %K facility delivery services %K postnatal care %K mHealth %K Bangladesh %D 2019 %7 28.02.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The public health system in Bangladesh has been struggling to provide coverage and utilization of basic maternal health care services in pursuit of achieving maternal and child mortality-related goals. Interestingly, the rapid popularization of mobile technology in the country is transforming the landscape of health care access and delivery. However, little is known regarding the use of mobile phones from the perspective of maternal health care service utilization. Objective: In this study, we aimed to investigate the prevalence and sociodemographic pattern of mobile phone use for health services among women and relationship between the use of mobile phone use and the uptake of essential maternal health services (MHSs). Methods: Cross-sectional data from the Bangladesh Demographic and Health Survey on 4494 mothers aged between 15 and 39 years were used in the analysis. Using mobile phones to get health services or advice was hypothesized to have a positive association with the uptake of basic MHSs (antenatal care, ANC, facility delivery services, postnatal care) and postnatal care for the newborn. Data were analyzed using bivariate and multivariable techniques. Results: More than a quarter (1276/4494, 28.4%; 95% CI 26.8-30.3) of the women aged 15-39 years reported using mobile phones to get health services with significant sociodemographic variations in the use of mobile phones. Analysis of the specific purposes revealed that, in most cases, mobile phones were used to contact service providers and consult with the same about what to do, whereas a smaller proportion reported using mobile phone for the purposes of arranging money and transportation. Multivariable analysis showed that compared with respondents who reported not using mobile phones for health care services, those who used them had higher odds of making 3+ ANC visits and delivering at a health facility. The odds were slightly higher for rural residents than for those in the urban areas. Conclusions: The findings of this study conclude that women who use mobile phones are more likely to use ANC and professional delivery services than those who do not. More in-depth studies are necessary to understand the mechanism through which mobile phone-based services enhance the uptake of maternal health care. %M 30816850 %R 10.2196/10645 %U http://mhealth.jmir.org/2019/2/e10645/ %U https://doi.org/10.2196/10645 %U http://www.ncbi.nlm.nih.gov/pubmed/30816850 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 2 %P e12692 %T Use of Weight-Management Mobile Phone Apps in Saudi Arabia: A Web-Based Survey %A Aljuraiban,Ghadeer S %+ Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Turki Alawwal, Riyadh, 145111, Saudi Arabia, 966 14651122, galjuraiban@ksu.edu.sa %K lifestyle %K mobile app %K weight loss %K mobile phone %D 2019 %7 22.02.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In recent years, the use of mobile phone weight-management apps has increased significantly. Weight-management apps have been found effective in promoting health and managing weight. However, data on user perception and on barriers to app usage are scarce. Objective: This study aimed to investigate the use of weight-management apps and barriers to use as well as reasons for discontinuing use in a sample of mobile phone users in Saudi Arabia. Methods: Mobile phone users aged 18 years and above from the general public in Saudi Arabia completed a Web-based survey. The survey included questions on weight-management app usage patterns, user perceptions concerning weight management, efficacy of weight-management apps, and reasons for discontinuing use. Participants were classified into normal weight (body mass index [BMI]: 18.5 to 24.9 kg/m2) and overweight or obese (BMI: ≥25.0 kg/m2). Results: The survey included 1191 participants; 513 of them used weight-management apps. More overweight or obese respondents used these apps compared with normal weight respondents (319/513, 62.2% vs 194/513, 37.8%, respectively). App features that overweight or obese users were most interested in were mainly the possibility to be monitored by a specialist and barcode identification of calorie content, whereas normal weight users mostly preferred availability of nutrition information of food items. Reasons for discontinuing use among overweight or obese respondents were mainly that monitoring by a specialist was not offered (80/236, 33.9%) and the app was not in the local language (48/236, 20.3%). Among normal weight users, the main reason for noncontinuance was the app language (45/144, 31.3%) and difficulty of use (30/144, 20.8%). Conclusions: To better address the needs of both normal weight and overweight or obese adults, improved app designs that offer monitoring by a specialist are needed. Developers may consider ways of overcoming barriers to use, such as language, by developing local language apps, which can improve the efficacy of such apps and help spread their use. %M 30794205 %R 10.2196/12692 %U http://mhealth.jmir.org/2019/2/e12692/ %U https://doi.org/10.2196/12692 %U http://www.ncbi.nlm.nih.gov/pubmed/30794205 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 2 %P e12385 %T Toward Developing a Standardized Core Set of Outcome Measures in Mobile Health Interventions for Tuberculosis Management: Systematic Review %A Lee,Seohyun %A Lee,Youngji %A Lee,Sangmi %A Islam,Sheikh Mohammed Shariful %A Kim,Sun-Young %+ Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea, 82 880 2768, sykim22@snu.ac.kr %K mHealth %K tuberculosis %K outcome measures %K evidence synthesis %K low-and middle-income countries %D 2019 %7 19.02.2019 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Tuberculosis (TB) management can be challenging in low- and middle-income countries (LMICs) not only because of its high burden but also the prolonged treatment period involving multiple drugs. With rapid development in mobile technology, mobile health (mHealth) interventions or using a mobile device for TB management has gained popularity. Despite the potential usefulness of mHealth interventions for TB, few studies have quantitatively synthesized evidence on its effectiveness, presumably because of variability in outcome measures reported in the literature. Objective: The aim of this systematic review was to evaluate the outcome measures reported in TB mHealth literature in LMICs. Methods: MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched to identify mHealth intervention studies for TB (published up to May 2018) that reported any type of outcome measures. The extracted information included the study setting, types of mHealth technology used, target population, study design, and categories of outcome measures. Outcomes were classified into 13 categories including treatment outcome, adherence, process measure, perception, technical outcome, and so on. The qualitative synthesis of evidence focused on the categories of outcome measures reported by the type of mHealth interventions. Results: A total of 27 studies were included for the qualitative synthesis of evidence. The study designs varied widely, ranging from randomized controlled trials to economic evaluations. A total of 12 studies adopted short message service (SMS), whereas 5 studies used SMS in combination with additional technologies or mobile apps. The study populations were also diverse, including patients with TB, patients with TB/HIV, health care workers, and general patients attending a clinic. There was a wide range of variations in the definition of outcome measures across the studies. Among the diverse categories of outcome measures, treatment outcomes have been reported in 14 studies, but only 6 of them measured the outcome according to the standard TB treatment definitions by the World Health Organization. Conclusions: This critical evaluation of outcomes reported in mHealth studies for TB management suggests that substantial variability exists in reporting outcome measures. To overcome the challenges in evidence synthesis for mHealth interventions, this study can provide insights into the development of a core set of outcome measures by intervention type and study design. %M 30777847 %R 10.2196/12385 %U http://mhealth.jmir.org/2019/2/e12385/ %U https://doi.org/10.2196/12385 %U http://www.ncbi.nlm.nih.gov/pubmed/30777847 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 2 %P e11644 %T The MomConnect Nurses and Midwives Support Platform (NurseConnect): A Qualitative Process Evaluation %A Fischer,Alex Emilio %A Sebidi,Jane %A Barron,Peter %A Lalla-Edward,Samanta Tresha %+ Wits Reproductive Health and HIV Institute, University of Witwatersrand, Hillbrow Health Precinct, 22 Esselen Street, HIllbrow, Johannesburg, 2001, South Africa, 27 073 776 2705, afischer@wrhi.ac.za %K evaluation %K mHealth %K mobile phone %K MomConnect %K NurseConnect %K South Africa %D 2019 %7 13.02.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Over the past decade, mobile health has steadily increased in low-income and middle-income countries. However, few platforms have been able to sustainably scale up like the MomConnect program in South Africa. NurseConnect was created as a capacity building component of MomConnect, aimed at supporting nurses and midwives in maternal and child health. The National Department of Health has committed to expanding NurseConnect to all nurses across the country, and an evaluation of the current user experience was conducted to inform a successful scale up. Objective: This study aims to evaluate the perception and use of NurseConnect by nurses and midwives to produce feedback that can be used to optimize the user experience as the platform continues to scale up. Methods: We conducted focus group discussions and in-depth interviews with 110 nurses and midwives from 18 randomly selected health care facilities across South Africa. Questions focused on mobile phone use, access to medical information and their experience with NurseConnect registration, as well as the content and different platforms. Results: All participants had mobile phones and communication through calls and messaging was the main use in both personal and work settings. Of 110 participants, 108 (98.2%) had data-enabled phones, and the internet, Google, and apps (South African National Department of Health Guidelines, iTriage, Drugs.com) were commonly used, especially to find information in the work setting. Of 110 participants, 62 (56.4%) were registered NurseConnect users and liked the message content, especially listeriosis and motivational messages, which created behavioral change in some instances. The mobisite and helpdesk, however, were underutilized because of a lack of information surrounding these platforms. Some participants did not trust medical information from websites and had more confidence in apps, while others associated a “helpdesk” with a call-in service, not a messaging one. Many of the unregistered participants had not heard of NurseConnect, and some cited data and time constraints as barriers to both registration and uptake. Conclusions: Mobile and smartphone penetration was very high, and participants often used their phone to find medical information. The NurseConnect messages were well-liked by all registered participants; however, the mobisite and helpdesk were underutilized owing to a lack of information and training around these platforms. Enhanced marketing and training initiatives that optimize existing social networks, as well as the provision of data and Wi-Fi, should be explored to ensure that registration improves, and that users are active across all platforms. %M 30758298 %R 10.2196/11644 %U http://mhealth.jmir.org/2019/2/e11644/ %U https://doi.org/10.2196/11644 %U http://www.ncbi.nlm.nih.gov/pubmed/30758298 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 2 %P e10995 %T Evaluation of Electronic and Paper-Pen Data Capturing Tools for Data Quality in a Public Health Survey in a Health and Demographic Surveillance Site, Ethiopia: Randomized Controlled Crossover Health Care Information Technology Evaluation %A Zeleke,Atinkut Alamirrew %A Worku,Abebaw Gebeyehu %A Demissie,Adina %A Otto-Sobotka,Fabian %A Wilken,Marc %A Lipprandt,Myriam %A Tilahun,Binyam %A Röhrig,Rainer %+ Division of Medical Informatics, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Building V04-1-133, Ammerländer Heerstraße 140, Oldenburg, 26129, Germany, 49 1732587251, atinkut.alamirrew.zeleke@uni-oldenburg.de %K public health %K maternal health %K surveillance %K survey %K data collection %K data quality %K tablet computer %K mHealth %K Ethiopia %D 2019 %7 11.02.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Periodic demographic health surveillance and surveys are the main sources of health information in developing countries. Conducting a survey requires extensive use of paper-pen and manual work and lengthy processes to generate the required information. Despite the rise of popularity in using electronic data collection systems to alleviate the problems, sufficient evidence is not available to support the use of electronic data capture (EDC) tools in interviewer-administered data collection processes. Objective: This study aimed to compare data quality parameters in the data collected using mobile electronic and standard paper-based data capture tools in one of the health and demographic surveillance sites in northwest Ethiopia. Methods: A randomized controlled crossover health care information technology evaluation was conducted from May 10, 2016, to June 3, 2016, in a demographic and surveillance site. A total of 12 interviewers, as 2 individuals (one of them with a tablet computer and the other with a paper-based questionnaire) in 6 groups were assigned in the 6 towns of the surveillance premises. Data collectors switched the data collection method based on computer-generated random order. Data were cleaned using a MySQL program and transferred to SPSS (IBM SPSS Statistics for Windows, Version 24.0) and R statistical software (R version 3.4.3, the R Foundation for Statistical Computing Platform) for analysis. Descriptive and mixed ordinal logistic analyses were employed. The qualitative interview audio record from the system users was transcribed, coded, categorized, and linked to the International Organization for Standardization 9241-part 10 dialogue principles for system usability. The usability of this open data kit–based system was assessed using quantitative System Usability Scale (SUS) and matching of qualitative data with the isometric dialogue principles. Results: From the submitted 1246 complete records of questionnaires in each tool, 41.89% (522/1246) of the paper and pen data capture (PPDC) and 30.89% (385/1246) of the EDC tool questionnaires had one or more types of data quality errors. The overall error rates were 1.67% and 0.60% for PPDC and EDC, respectively. The chances of more errors on the PPDC tool were multiplied by 1.015 for each additional question in the interview compared with EDC. The SUS score of the data collectors was 85.6. In the qualitative data response mapping, EDC had more positive suitability of task responses with few error tolerance characteristics. Conclusions: EDC possessed significantly better data quality and efficiency compared with PPDC, explained with fewer errors, instant data submission, and easy handling. The EDC proved to be a usable data collection tool in the rural study setting. Implementation organization needs to consider consistent power source, decent internet connection, standby technical support, and security assurance for the mobile device users for planning full-fledged implementation and integration of the system in the surveillance site. %M 30741642 %R 10.2196/10995 %U http://mhealth.jmir.org/2019/2/e10995/ %U https://doi.org/10.2196/10995 %U http://www.ncbi.nlm.nih.gov/pubmed/30741642 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 2 %N 1 %P e12366 %T Procedures to Select Digital Sensing Technologies for Passive Data Collection With Children and Their Caregivers: Qualitative Cultural Assessment in South Africa and Nepal %A Kohrt,Brandon A %A Rai,Sauharda %A Vilakazi,Khanya %A Thapa,Kiran %A Bhardwaj,Anvita %A van Heerden,Alastair %+ Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington School of Medicine and Health Sciences, 2120 L Street NW, Suite 600, Washington, DC, 20037, United States, 1 4048951643, bkohrt@gwu.edu %K child development %K confidentiality %K culturally competent care %K developing countries %K global health %K mental health %K mobile phones %K wireless technology %D 2019 %7 16.01.2019 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Populations in low-resource settings with high childhood morbidity and mortality increasingly are being selected as beneficiaries for interventions using passive sensing data collection through digital technologies. However, these populations often have limited familiarity with the processes and implications of passive data collection. Therefore, methods are needed to identify cultural norms and family preferences influencing the uptake of new technologies. Objective: Before introducing a new device or a passive data collection approach, it is important to determine what will be culturally acceptable and feasible. The objective of this study was to develop a systematic approach to determine acceptability and perceived utility of potential passive data collection technologies to inform selection and piloting of a device. To achieve this, we developed the Qualitative Cultural Assessment of Passive Data collection Technology (QualCAPDT). This approach is built upon structured elicitation tasks used in cultural anthropology. Methods: We piloted QualCAPDT using focus group discussions (FGDs), video demonstrations of simulated technology use, attribute rating with anchoring vignettes, and card ranking procedures. The procedure was used to select passive sensing technologies to evaluate child development and caregiver mental health in KwaZulu-Natal, South Africa, and Kathmandu, Nepal. Videos were produced in South Africa and Nepal to demonstrate the technologies and their potential local application. Structured elicitation tasks were administered in FGDs after showing the videos. Using QualCAPDT, we evaluated the following 5 technologies: home-based video recording, mobile device capture of audio, a wearable time-lapse camera attached to the child, proximity detection through a wearable passive Bluetooth beacon attached to the child, and an indoor environmental sensor measuring air quality. Results: In South Africa, 38 community health workers, health organization leaders, and caregivers participated in interviews and FGDs with structured elicitation tasks. We refined the procedure after South Africa to make the process more accessible for low-literacy populations in Nepal. In addition, the refined procedure reduced misconceptions about the tools being evaluated. In Nepal, 69 community health workers and caregivers participated in a refined QualCAPDT. In both countries, the child’s wearable time-lapse camera achieved many of the target attributes. Participants in Nepal also highly ranked a home-based environmental sensor and a proximity beacon worn by the child. Conclusions: The QualCAPDT procedure can be used to identify community norms and preferences to facilitate the selection of potential passive data collection strategies and devices. QualCAPDT is an important first step before selecting devices and piloting passive data collection in a community. It is especially important for work with caregivers and young children for whom cultural beliefs and shared family environments strongly determine behavior and potential uptake of new technology. %M 31518316 %R 10.2196/12366 %U https://pediatrics.jmir.org/2019/1/e12366/ %U https://doi.org/10.2196/12366 %U http://www.ncbi.nlm.nih.gov/pubmed/31518316 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e12637 %T Perspectives of Nonphysician Clinical Students and Medical Lecturers on Tablet-Based Health Care Practice Support for Medical Education in Zambia, Africa: Qualitative Study %A Barteit,Sandra %A Neuhann,Florian %A Bärnighausen,Till %A Bowa,Annel %A Lüders,Sigrid %A Malunga,Gregory %A Chileshe,Geoffrey %A Marimo,Clemence %A Jahn,Albrecht %+ Heidelberg Institute of Global Health, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 06221 ext 5634030, barteit@uni-heidelberg.de %K educational technology %K computers, handheld %K computer-assisted decision making %K mobile apps %K information dissemination %K education %K allied health occupations %K Africa, Southern %K Zambia %D 2019 %7 15.1.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Zambia is faced with a severe shortage of health workers and challenges in national health financing. This burdens the medical licentiate practitioner (MLP) program for training nonphysician clinical students in Zambia because of the shortage of qualified medical lecturers and learning resources at training sites. To address this shortage and strengthen the MLP program, a self-directed electronic health (eHealth) platform was introduced, comprising technology-supported learning (e-learning) for medical education and support for health care practice. MLP students were provided with tablets that were preloaded with content for offline access. Objective: This study aimed to explore MLP students’ and medical lecturers’ perceptions of the self-directed eHealth platform with an offline-based tablet as a training and health care practice support tool during the first year of full implementation. Methods: We conducted in-depth qualitative interviews with 8 MLP students and 5 lecturers and 2 focus group discussions with 16 students to gain insights on perceptions of the usefulness, ease of use, and adequacy of self-directed e-learning and health care practice support accessible through the offline-based tablet. Participants were purposively sampled. Verbatim transcripts were analyzed following hypothesis coding. Results: The eHealth platform (e-platform), comprising e-learning for medical education and health care practice support, was positively received by students and medical lecturers and was seen as a step toward modernizing the MLP program. Tablets enabled equal access to offline learning contents, thus bridging the gap of slow or no internet connections. The study results indicated that the e-platform appears adequate to strengthen medical education within this low-resource setting. However, student self-reported usage was low, and medical lecturer usage was even lower. One stated reason was the lack of training in tablet usage and another was the quality of the tablets. The mediocre quality and quantity of most e-learning contents were perceived as a primary concern as materials were reported to be outdated, missing multimedia features, and addressing only part of the curriculum. Medical lecturers were noted to have little commitment to updating or creating new learning materials. Suggestions for improving the e-platform were given. Conclusions: To address identified major challenges, we plan to (1) introduce half-day training sessions at the beginning of each study year to better prepare users for tablet usage, (2) further update and expand e-learning content by fostering collaborations with MLP program stakeholders and nominating an e-platform coordinator, (3) set up an e-platform steering committee including medical lecturers, (4) incorporate e-learning and e-based health care practice support across the curriculum, as well as (5) implement processes to promote user-generated content. With these measures, we aim to sustainably strengthen the MLP program by implementing the tablet-based e-platform as a serious learning technology for medical education and health care practice support. %R 10.2196/12637 %U http://mhealth.jmir.org/2019/1/e12637/ %U https://doi.org/10.2196/12637 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 12 %P e11468 %T Unveiling the Black Box of Diagnostic and Clinical Decision Support Systems for Antenatal Care: Realist Evaluation %A Abejirinde,Ibukun-Oluwa Omolade %A Zweekhorst,Marjolein %A Bardají,Azucena %A Abugnaba-Abanga,Rudolf %A Apentibadek,Norbert %A De Brouwere,Vincent %A van Roosmalen,Jos %A Marchal,Bruno %+ Athena Institute, Faculty of Science, Vrije Universiteit, WN Building, S-544, De Boelelaan 1105, Amsterdam, 1081HV, Netherlands, 31 205983143, i.o.abejirinde@vu.nl %K systems analysis %K Ghana %K clinical decision support %K antenatal care %K mHealth %K program evaluation %D 2018 %7 21.12.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Digital innovations have shown promise for improving maternal health service delivery. However, low- and middle-income countries are still at the adoption-utilization stage. Evidence on mobile health has been described as a black box, with gaps in theoretical explanations that account for the ecosystem of health care and their effect on adoption mechanisms. Bliss4Midwives, a modular integrated diagnostic kit to support antenatal care service delivery, was piloted for 1 year in Northern Ghana. Although both users and beneficiaries valued Bliss4Midwives, results from the pilot showed wide variations in usage behavior and duration of use across project sites. Objective: To strengthen the design and implementation of an improved prototype, the study objectives were two-fold: to identify causal factors underlying the variation in Bliss4Midwives usage behavior and understand how to overcome or leverage these in subsequent implementation cycles. Methods: Using a multiple case study design, a realist evaluation of Bliss4Midwives was conducted. A total of 3 candidate program theories were developed and empirically tested in 6 health facilities grouped into low and moderate usage clusters. Quantitative and qualitative data were collected and analyzed using realist thinking to build configurations that link intervention, context, actors, and mechanisms to program outcomes, by employing inductive and deductive reasoning. Nonparametric t test was used to compare the perceived usefulness and perceived ease of use of Bliss4Midwives between usage clusters. Results: We found no statistically significant differences between the 2 usage clusters. Low to moderate adoption of Bliss4Midwives was better explained by fear, enthusiasm, and high expectations for service delivery, especially in the absence of alternatives. Recognition from pregnant women, peers, supervisors, and the program itself was a crucial mechanism for device utilization. Other supportive mechanisms included ownership, empowerment, motivation, and adaptive responses to the device, such as realignment and negotiation. Champion users displayed high adoption-utilization behavior in contexts of participative or authoritative supervision, yet used the device inconsistently. Intervention-related (technical challenges, device rotation, lack of performance feedback, and refresher training), context-related (staff turnover, competing priorities, and workload), and individual factors (low technological self-efficacy, baseline knowledge, and internal motivation) suppressed utilization mechanisms. Conclusions: This study shed light on optimal conditions necessary for Bliss4Midwives to thrive in a complex social and organizational setting. Beyond usability and viability studies, advocates of innovative technologies for maternal care need to consider how implementation strategies and contextual factors, such as existing collaborations and supervision styles, trigger mechanisms that influence program outcomes. In addition to informing scale-up of the Bliss4Midwives prototype, our results highlight the need for interventions that are guided by research methods that account for complexity. %M 30578177 %R 10.2196/11468 %U http://mhealth.jmir.org/2018/12/e11468/ %U https://doi.org/10.2196/11468 %U http://www.ncbi.nlm.nih.gov/pubmed/30578177 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 12 %P e11213 %T The Impact of a Maternal Education Program Through Text Messaging in Rural China: Cluster Randomized Controlled Trial %A Xie,Ri-Hua %A Tan,Hongzhuan %A Taljaard,Monica %A Liao,Yan %A Krewski,Daniel %A Du,Qingfeng %A Wen,Shi Wu %+ Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, ON, ON K1H 8L6, Canada, 1 6137378899 ext 73912, swwen@ohri.ca %K maternal education %K text messaging %K maternal health %K infant health %K cluster trial %D 2018 %7 19.12.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In recent years, attempts have been made to use mobile phone text messaging (short message service, SMS) to achieve positive results for a range of health issues. Reports on the impact of maternal education programs based on this widely available, inexpensive, and instant communication tool are sparse. Objective: This study aimed to explore the impact of a maternal education program through text messaging. Methods: We conducted a cluster randomized trial in a remote region in the Chinese province of Hunan between October 1, 2011, and December 31, 2012. We used county as the unit of randomization (a total of 10 counties), with half of the counties randomly allocated to the intervention arm (with maternal education material adapted from the World Health Organization being delivered by text messaging to village health workers and pregnant women alike) and the other half to the control arm (normal care without text messaging). Data on maternal and infant health outcomes and health behaviors were collected and compared between the 2 arms, with maternal and perinatal mortality as the primary outcomes. Results: A total of 13,937 pregnant women completed the follow-up and were included in the final analysis. Among them, 6771 were allocated to the intervention arm and 6966 were allocated to the control arm. At the county level, the mean (SD) of maternal mortality and perinatal mortality rate were 0.0% (0.1) and 1.3% (0.6), respectively, in the intervention arm and 0.1% (0.2) and 1.5% (0.4), respectively, in the control arm. However, these differences were not statistically significant. At the individual level, there were 3 maternal deaths (0.04%) and 84 perinatal deaths (1.24%) in the intervention arm and 6 maternal deaths (0.09%) and 101 perinatal deaths (1.45%) in the control arm. However, the differences were again not statistically significant. Conclusions: Adequate resources should be secured to launch large-scale cluster randomized trials with smaller cluster units and more intensive implementation to confirm the benefits of the text messaging–based maternal education program suggested by this trial. Trial Registration: ClinicalTrials.gov NCT01775150; https://clinicaltrials.gov/ct2/show/NCT01775150 (Archived by WebCite at http://www.webcitation.org/74cHmUexo) %M 30567693 %R 10.2196/11213 %U http://mhealth.jmir.org/2018/12/e11213/ %U https://doi.org/10.2196/11213 %U http://www.ncbi.nlm.nih.gov/pubmed/30567693 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e10239 %T Text Messages Sent to Household Tuberculosis Contacts in Kampala, Uganda: Process Evaluation %A Meyer,Amanda J %A Babirye,Diana %A Armstrong-Hough,Mari %A Mark,David %A Ayakaka,Irene %A Katamba,Achilles %A Haberer,Jessica E %A Davis,J Lucian %+ Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, 60 College Street, PO Box 208034, New Haven, CT, 06520, United States, 1 203 785 3665, lucian.davis@yale.edu %K Africa %K fidelity %K implementation %K intervention %K short message service %K tuberculosis %D 2018 %7 20.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Previous studies have reported the inconsistent effectiveness of text messaging (short message service, SMS) for improving health outcomes, but few have examined to what degree the quality, or “fidelity,” of implementation may explain study results. Objective: The aim of this study was to determine the fidelity of a one-time text messaging (SMS) intervention to promote the uptake of tuberculosis evaluation services among household contacts of index patients with tuberculosis. Methods: From February to June 2017, we nested a process evaluation of text message (SMS) delivery within the intervention arm of a randomized controlled trial of tuberculosis contact investigation in Kampala, Uganda. Because mobile service providers in Uganda do not provide delivery confirmations, we asked household tuberculosis contacts to confirm the receipt of a one-time tuberculosis-related text message (SMS) by sending a text message (SMS) reply through a toll-free “short code.” Two weeks later, a research officer followed up by telephone to confirm the receipt of the one-time text message (SMS) and administer a survey. We considered participants lost to follow-up after 3 unsuccessful call attempts on 3 separate days over a 1-week period. Results: Of 206 consecutive household contacts, 119 had a text message (SMS) initiated from the server. While 33% (39/119) were children aged 5-14 years, including 20% (24/119) girls and 13% (15/119) boys, 18 % (21/119) were adolescents or young adults, including 12% (14/119) young women and 6% (7/119) young men. 50% (59/119) were adults, including 26% (31/119) women and 24% (28/119) men. Of 107 (90%) participants for whom we could ascertain text message (SMS) receipt status, 67% (72/107) confirmed text message (SMS) receipt, including 22% (24/107) by reply text message (SMS) and 45% (48/107) during the follow-up telephone survey. No significant clinical or demographic differences were observed between those who did and did not report receiving the text message (SMS). Furthermore, 52% (56/107) reported ever reading the SMS. The cumulative likelihood of a text message (SMS) reaching its target and being read and retained by a participant was 19%. Conclusions: The fidelity of a one-time text message (SMS) intervention to increase the uptake of household tuberculosis contact investigation and linkage to care was extremely low, a fact only discoverable through detailed process evaluation. This study suggests the need for systematic process monitoring and reporting of implementation fidelity in both research studies and programmatic interventions using mobile communications to improve health. %M 30459147 %R 10.2196/10239 %U http://mhealth.jmir.org/2018/11/e10239/ %U https://doi.org/10.2196/10239 %U http://www.ncbi.nlm.nih.gov/pubmed/30459147 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e183 %T An mHealth Intervention to Improve Young Gay and Bisexual Men’s Sexual, Behavioral, and Mental Health in a Structurally Stigmatizing National Context %A Leluțiu-Weinberger,Corina %A Manu,Monica %A Ionescu,Florentina %A Dogaru,Bogdan %A Kovacs,Tudor %A Dorobănțescu,Cristian %A Predescu,Mioara %A Surace,Anthony %A Pachankis,John E %+ François-Xavier Bagnoud Center, School of Nursing, Rutgers Biomedical and Health Sciences, 65 Bergen Street, 8th Floor, Newark, NJ, 07101, United States, 1 9739722093, cl1148@sn.rutgers.edu %K alcohol use %K young gay and bisexual men %K HIV risk %K mental health %K mHealth intervention %D 2018 %7 14.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Young gay and bisexual men (YGBM) in some Eastern European countries, such as Romania, face high stigma and discrimination, including in health care. Increasing HIV transmission is a concern given inadequate prevention, travel to high-prevalence countries, and popularity of sexual networking technologies. Objective: This study aimed to adapt and pilot test, in Romania, a preliminarily efficacious mobile health (mHealth) HIV-prevention intervention, created in the United States, to reduce HIV risk among YGBM. Methods: After an intervention formative phase, we enrolled 43 YGBM, mean age 23.2 (SD 3.6) years, who reported condomless sex with a male partner and at least 5 days of heavy drinking in the past 3 months. These YGBM completed up to eight 60-minute text-based counseling sessions grounded in motivational interviewing and cognitive behavioral skills training with trained counselors on a private study mobile platform. We conducted one-group pre-post intervention assessments of sexual (eg, HIV-risk behavior), behavioral (eg, alcohol use), and mental health (eg, depression) outcomes to evaluate the intervention impact. Results: From baseline to follow-up, participants reported significant (1) increases in HIV-related knowledge (mean 4.6 vs mean 4.8; P=.001) and recent HIV testing (mean 2.8 vs mean 3.3; P=.05); (2) reductions in the number of days of heavy alcohol consumption (mean 12.8 vs mean 6.9; P=.005), and (3) increases in the self-efficacy of condom use (mean 3.3 vs mean 4.0; P=.01). Participants reported significant reductions in anxiety (mean 1.4 vs mean 1.0; P=.02) and depression (mean 1.5 vs mean 1.0; P=.003). The intervention yielded high acceptability and feasibility: 86% (38/44) of participants who began the intervention completed the minimum dose of 5 sessions, with an average of 7.1 sessions completed; evaluation interviews indicated that participation was rewarding and an “eye-opener” about HIV risk reduction, healthy identity development, and partner communication. Conclusions: This first mHealth HIV risk-reduction pilot intervention for YGBM in Eastern Europe indicates preliminary efficacy and strong acceptability and feasibility. This mobile prevention tool lends itself to broad dissemination across various similar settings pending future efficacy testing in a large trial, especially in contexts where stigma keeps YGBM out of reach of affirmative health interventions. %M 30429117 %R 10.2196/mhealth.9283 %U https://mhealth.jmir.org/2018/11/e183/ %U https://doi.org/10.2196/mhealth.9283 %U http://www.ncbi.nlm.nih.gov/pubmed/30429117 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e10190 %T Insights From a Text Messaging–Based Sexual and Reproductive Health Information Program in Tanzania (m4RH): Retrospective Analysis %A Olsen,Patrick S %A Plourde,Kate F %A Lasway,Christine %A van Praag,Eric %+ Health Services Research, Global Health, Population, and Nutrition, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, United States, 1 919 544 7040 ext 11713, polsen@fhi360.org %K data analysis %K mobile phone %K mHealth %K short message service %K user engagement %D 2018 %7 01.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Many mobile health (mHealth) interventions have the potential to generate and store vast amounts of system-generated participant interaction data that could provide insight into user engagement, programmatic strengths, and areas that need improvement to maximize efficacy. However, despite the popularity of mHealth interventions, there is little documentation on how to use these data to monitor and improve programming or to evaluate impact. Objective: This study aimed to better understand how users of the Mobile for Reproductive Health (m4RH) mHealth intervention engaged with the program in Tanzania from September 2013 to August 2016. Methods: We conducted secondary data analysis of longitudinal data captured by system logs of participant interactions with the m4RH program from 127 districts in Tanzania from September 2013 to August 2016. Data cleaning and analysis was conducted using Stata 13. The data were examined for completeness and “correctness.” No missing data was imputed; respondents with missing or incorrect values were dropped from the analyses. Results: The total population for analysis included 3,673,702 queries among 409,768 unique visitors. New users represented roughly 11.15% (409,768/3,673,702) of all queries. Among all system queries for new users, 46.10% (188,904/409,768) users accessed the m4RH main menu. Among these users, 89.58% (169,218/188,904) accessed specific m4RH content on family planning, contraceptive methods, adolescent-specific and youth-specific information, and clinic locations after first accessing the m4RH main menu. The majority of these users (216,422/409,768, 52.82%) requested information on contraceptive methods; fewer users (23,236/409,768, 5.67%) requested information on clinic location. The conversion rate was highest during the first and second years of the program when nearly all users (11,246/11,470, 98.05%, and 33,551/34,830, 96.33%, respectively) who accessed m4RH continued on to query more specific content from the system. The rate of users that accessed m4RH and became active users declined slightly from 98.05% (11,246/11,470) in 2013 to 87.54% (56,696/64,765) in 2016. Overall, slightly more than one-third of all new users accessing m4RH sent queries at least once per month for 2 or more months, and 67.86% (278,088/409,768) of new and returning users requested information multiple times per month. Promotional periods were present for 15 of 36 months during the study period. Conclusions: The analysis of the rich data captured provides a useful framework with which to measure the degree and nature of user engagement utilizing routine system-generated data. It also contributes to knowledge of how users engage with text messaging (short message service)-based health promotion interventions and demonstrates how data generated on user interactions could inform improvements to the design and delivery of a service, thereby enhancing its effectiveness. %M 30389651 %R 10.2196/10190 %U https://mhealth.jmir.org/2018/11/e10190/ %U https://doi.org/10.2196/10190 %U http://www.ncbi.nlm.nih.gov/pubmed/30389651 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 10 %P e11039 %T A Short Message Service Intervention for Improving Infant Feeding Practices in Shanghai, China: Planning, Implementation, and Process Evaluation %A Jiang,Hong %A Li,Mu %A Wen,Li Ming %A Baur,Louise A %A He,Gengsheng %A Ma,Xiaoying %A Qian,Xu %+ Global Health Institute, School of Public Health, Fudan University, Mailbox 175, No. 138 Yixueyuan Road, Shanghai, 200032, China, 86 21 64179976, h_jiang@fudan.edu.cn %K mHealth %K short message service %K breastfeeding %K infant feeding practices %K health services %K planning and development %K implementation %K process evaluation %D 2018 %7 29.10.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although mobile health (mHealth) has been widely applied in health care services, few studies have reported the detailed process of the development and implementation of text messaging (short message service, SMS) interventions. Objective: Our study aims to demonstrate the process and lessons learned from a community-based text messaging (SMS) intervention for improving infant feeding in Shanghai, China. Methods: The intervention included planning and development, implementation, and process evaluation. A 3-phase process was adopted during planning and development: (1) a formative study with expectant and new mothers to explore the barriers of appropriate infant feeding practices; (2) a baseline questionnaire survey to understand potential intervention approaches; and (3) development of the text message bank. The text messaging intervention was delivered via a computer-based platform. A message bank was established before the start of the intervention containing information on the benefits of breastfeeding, preparing for breastfeeding, early initiation of breastfeeding, timely introduction of complementary foods, and establishing appropriate feeding practices, etc. An expert advisory committee oversaw the content and quality of the message bank. Process evaluation was conducted through field records and qualitative interviews with participating mothers. Results: We found that the text messaging intervention was feasible and well received by mothers because of its easy and flexible access. The weekly based message frequency was thought to be appropriate, and the contents were anticipatory and trustworthy. Some mothers had high expectations for timely response to inquiries. Occasionally, the text messages were not delivered due to unstable telecommunication transmission. Mothers suggested that the messages could be more personalized. Conclusions: This study demonstrates the feasibility and value of text messaging intervention in filling gaps in delivering health care services and promoting healthy infant feeding practices in settings where personal contact is limited. %M 30373728 %R 10.2196/11039 %U http://mhealth.jmir.org/2018/10/e11039/ %U https://doi.org/10.2196/11039 %U http://www.ncbi.nlm.nih.gov/pubmed/30373728 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 4 %N 4 %P e68 %T Assessing the Concepts and Designs of 58 Mobile Apps for the Management of the 2014-2015 West Africa Ebola Outbreak: Systematic Review %A Tom-Aba,Daniel %A Nguku,Patrick Mboya %A Arinze,Chinedu Chukwujekwu %A Krause,Gerard %+ Department of Epidemiology, Helmholtz Centre for Infection Research (HZI), Inhoffen Strasse 7, Braunschweig, 38124, Germany, 49 01739136081, daniel.tom-aba@helmholtz-hzi.de %K case management %K contact tracing %K Ebola virus disease %K eHealth %K mHealth %K systematic review %K West Africa %D 2018 %7 29.10.2018 %9 Review %J JMIR Public Health Surveill %G English %X Background: The use of mobile phone information technology (IT) in the health sector has received much attention especially during the 2014-2015 Ebola virus disease (EVD) outbreak. mHealth can be attributed to a major improvement in EVD control, but there lacks an overview of what kinds of tools were available and used based on the functionalities they offer. Objective: We aimed to conduct a systematic review of mHealth tools in the context of the recent EVD outbreak to identify the most promising approaches and guide further mHealth developments for infectious disease control. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched for all reports on mHealth tools developed in the context of the 2014-2015 EVD outbreak published between January 1, 2014 and December 31, 2015 on Google Scholar, MEDLINE, CAB Abstracts (Global Health), POPLINE, and Web of Science in any language using the search strategy: (“outbreak” OR “epidemic”) AND (“mobile phone” OR “smartphone” OR “smart phone” OR “mobile phone” OR “tablet” OR “mHealth”) AND (“Ebola” OR ”EVD” OR “VHF” OR “Ebola virus disease” OR “viral hemorrhagic fever”) AND (“2014” OR “2015”). The relevant publications were selected by 2 independent reviewers who applied a standardized data extraction form on the tools’ functionalities. Results: We identified 1220 publications through the search strategy, of which 6.31% (77/1220) were original publications reporting on 58 specific mHealth tools in the context of the EVD outbreak. Of these, 62% (34/55) offered functionalities for surveillance, 22% (10/45) for case management, 18% (7/38) for contact tracing, and 6% (3/51) for laboratory data management. Only 3 tools, namely Community Care, Sense Ebola Followup, and Surveillance and Outbreak Response Management and Analysis System supported all four of these functionalities. Conclusions: Among the 58 identified tools related to EVD management in 2014 and 2015, only 3 appeared to contain all 4 key functionalities relevant for the response to EVD outbreaks and may be most promising for further development. %M 30373727 %R 10.2196/publichealth.9015 %U http://publichealth.jmir.org/2018/4/e68/ %U https://doi.org/10.2196/publichealth.9015 %U http://www.ncbi.nlm.nih.gov/pubmed/30373727 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 10 %P e11440 %T Current Status and Future Directions of mHealth Interventions for Health System Strengthening in India: Systematic Review %A Bassi,Abhinav %A John,Oommen %A Praveen,Devarsetty %A Maulik,Pallab K %A Panda,Rajmohan %A Jha,Vivekanand %+ George Institute for Global Health, India, 311-312, Third Floor, Elegance Tower, Plot Number 8, Jasola District Centre, New Delhi, 110025, India, 91 1141588091, vjha@georgeinstitute.org.in %K mHealth %K telemedicine %K health care system %K India %D 2018 %7 26.10.2018 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: With the exponential increase in mobile phone users in India, a large number of public health initiatives are leveraging information technology and mobile devices for health care delivery. Given the considerable financial and human resources being invested in these initiatives, it is important to ascertain their role in strengthening health care systems. Objective: We undertook this review to identify the published mobile health (mHealth) or telemedicine initiatives in India in terms of their current role in health systems strengthening. The review classifies these initiatives based on the disease areas, geographical distribution, and target users and assesses the quality of the available literature. Methods: A search of the literature was done to identify mHealth or telemedicine articles published between January 1997 and June 2017 from India. The electronic bibliographic databases and registries searched included MEDLINE, EMBASE, Joanna Briggs Institute Database, and Clinical Trial Registry of India. The World Health Organization health system building block framework was used to categorize the published initiatives as per their role in the health system. Quality assessment of the selected articles was done using the Cochrane risk of bias assessment and National Institutes of Health, US tools. Results: The combined search strategies yielded 2150 citations out of which 318 articles were included (primary research articles=125; reviews and system architectural, case studies, and opinion articles=193). A sharp increase was seen after 2012, driven primarily by noncommunicable disease–focused articles. Majority of the primary studies had their sites in the south Indian states, with no published articles from Jammu and Kashmir and north-eastern parts of India. Service delivery was the primary focus of 57.6% (72/125) of the selected articles. A majority of these articles had their focus on 1 (36.0%, 45/125) or 2 (45.6%, 57/125) domains of health system, most frequently service delivery and health workforce. Initiatives commonly used client education as a tool for improving the health system. More than 91.2% (114/125) of the studies, which lacked a sample size justification, had used convenience sampling. Methodological rigor of the selected trials (n=11) was assessed to be poor as majority of the studies had a high risk for bias in at least 2 categories. Conclusions: In conclusion, mHealth initiatives are being increasingly tested to improve health care delivery in India. Our review highlights the poor quality of the current evidence base and an urgent need for focused research aimed at generating high-quality evidence on the efficacy, user acceptability, and cost-effectiveness of mHealth interventions aimed toward health systems strengthening. A pragmatic approach would be to include an implementation research component into the existing and proposed digital health initiatives to support the generation of evidence for health systems strengthening on strategically important outcomes. %M 30368435 %R 10.2196/11440 %U http://mhealth.jmir.org/2018/10/e11440/ %U https://doi.org/10.2196/11440 %U http://www.ncbi.nlm.nih.gov/pubmed/30368435 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 10 %P e11076 %T Teleconsultation Using Mobile Phones for Diagnosis and Acute Care of Burn Injuries Among Emergency Physicians: Mixed-Methods Study %A Klingberg,Anders %A Wallis,Lee Alan %A Hasselberg,Marie %A Yen,Po-Yin %A Fritzell,Sara Caroline %+ Department of Public Health Sciences, Karolinska Institutet, Solnavägen 1, 171 77, Stockholm,, Sweden, 46 733357727, anders.klingberg@ki.se %K mobile phone %K referral and consultation %K emergency medicine %K mHealth %K teleconsultations %K burns %K usability evaluation %K think-aloud %K video analysis %K South Africa %D 2018 %7 19.10.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The referral process in acute care remains challenging in many areas including burn care. Mobile phone apps designed explicitly for medical referrals and consultations could streamline the referral process by using structured templates and integrating features specific to different specialties. However, as these apps are competing with commercial chat services, usability becomes a crucial factor for successful uptake. Objective: The aim of this study was to assess the usability of a mobile phone app for remote consultations and referrals of burn injuries. Methods: A total of 24 emergency doctors and 4 burns consultants were recruited for the study. A mixed-methods approach was used including a usability questionnaire and a think-aloud interview. Think-aloud sessions were video-recorded, and content analysis was undertaken with predefined codes relating to the following 3 themes: ease of use, usefulness of content, and technology-induced errors. Results: The users perceived the app to be easy to use and useful, but some problems were identified. Issues relating to usability were associated with navigation, such as scrolling and zooming. Users also had problems in understanding the meaning of some icons and terminologies. Sometimes, some users felt limited by predefined options, and they wanted to be able to freely express their clinical findings. Conclusions: We found that users faced problems mainly with navigation when the app did not work in the same way as the other apps that were frequently used. Our study also resonates with previous findings that when using standardized templates, the systems should also allow the user to express their clinical findings in their own words. %M 30341047 %R 10.2196/11076 %U http://mhealth.jmir.org/2018/10/e11076/ %U https://doi.org/10.2196/11076 %U http://www.ncbi.nlm.nih.gov/pubmed/30341047 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e169 %T Implementing eHealth Technology to Address Gaps in Early Infant Diagnosis Services: Qualitative Assessment of Kenyan Provider Experiences %A Wexler,Catherine %A Brown,Melinda %A Hurley,Emily A %A Ochieng,Martin %A Goggin,Kathy %A Gautney,Brad %A Maloba,May %A Lwembe,Raphael %A Khamadi,Samoel %A Finocchario-Kessler,Sarah %+ Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS,, United States, 1 913 945 7077, cwexler@kumc.edu %K early infant diagnosis (EID) %K HIV/AIDS %K eHealth %K mHealth %K implementation science %K Kenya %D 2018 %7 22.08.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Literature suggests that electronic health (eHealth) interventions can improve the efficiency and accuracy of health service delivery and improve health outcomes and are generally well received by patients; however, there are limited data on provider experiences using eHealth interventions in resource-limited settings. The HIV Infant Tracking System (HITSystem) is an eHealth intervention designed to improve early infant diagnosis (EID) outcomes among HIV-exposed infants. Objective: We aimed to compare provider experiences with standard EID and HITSystem implementation at 6 Kenyan hospitals and 3 laboratories. The objective of this study was to better understand provider experiences implementing and using the HITSystem in order to assess facilitators and barriers that may impact adoption and sustainability of this eHealth intervention. Methods: As part of a randomized controlled trial to evaluate the HITSystem, we conducted semistructured interviews with 17 EID providers at participating intervention and control hospitals and laboratories. Results: Providers emphasized the perceived usefulness of the HITSystem, including improved efficiency in sample tracking and patient follow-up, strengthened communication networks among key stakeholders, and improved capacity to meet patient needs compared to standard EID. These advantages were realized from an intervention that providers saw as easy to use and largely compatible with workflow. However, supply stock outs and patient psychosocial factors (including fear of HIV status disclosure and poverty) provided ongoing challenges to EID service provision. Furthermore, slow or sporadic internet access and heavy workload prevented real-time HITSystem data entry for some clinicians. Conclusions: Provider experiences with the HITSystem indicate that the usefulness of the HITSystem, along with the ease with which it is able to be incorporated into hospital workflows, contributes to its sustained adoption and use in Kenyan hospitals. To maximize implementation success, care should be taken in intervention design and implementation to ensure that end users see clear advantages to using the technology and to account for variations in workflows, patient populations, and resource levels by allowing flexibility to suit user needs. Trial Registration: ClinicalTrials.gov NCT02072603; https://clinicaltrials.gov/ct2/show/NCT02072603 (Archived by WebCite at http://www.webcitation.org/71NgMCrAm) %M 30135052 %R 10.2196/mhealth.9725 %U http://mhealth.jmir.org/2018/8/e169/ %U https://doi.org/10.2196/mhealth.9725 %U http://www.ncbi.nlm.nih.gov/pubmed/30135052 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 4 %N 3 %P e11203 %T Bringing Real-Time Geospatial Precision to HIV Surveillance Through Smartphones: Feasibility Study %A Nsabimana,Alain Placide %A Uzabakiriho,Bernard %A Kagabo,Daniel M %A Nduwayo,Jerome %A Fu,Qinyouen %A Eng,Allison %A Hughes,Joshua %A Sia,Samuel K %+ Junco Labs, 423 W 127th Street, Ground Floor, New York, NY,, United States, 1 518 880 9667, samuelsia@juncolabs.com %K HIV surveillance %K smartphones %K mobile phones %K geospatial data %D 2018 %7 07.08.2018 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Precise measurements of HIV incidences at community level can help mount a more effective public health response, but the most reliable methods currently require labor-intensive population surveys. Novel mobile phone technologies are being tested for adherence to medical appointments and antiretroviral therapy, but using them to track HIV test results with automatically generated geospatial coordinates has not been widely tested. Objective: We customized a portable reader for interpreting the results of HIV lateral flow tests and developed a mobile phone app to track HIV test results in urban and rural locations in Rwanda. The objective was to assess the feasibility of this technology to collect front line HIV test results in real time and with geospatial context to help measure HIV incidences and improve epidemiological surveillance. Methods: Twenty health care workers used the technology to track the test results of 2190 patients across 3 hospital sites (2 urban sites in Kigali and a rural site in the Western Province of Rwanda). Mobile phones for less than US $70 each were used. The mobile phone app to record HIV test results could take place without internet connectivity with uploading of results to the cloud taking place later with internet. Results: A total of 91.51% (2004/2190) of HIV test results could be tracked in real time on an online dashboard with geographical resolution down to street level. Out of the 20 health care workers, 14 (70%) would recommend the lateral flow reader, and 100% would recommend the mobile phone app. Conclusions: Smartphones have the potential to simplify the input of HIV test results with geospatial context and in real time to improve public health surveillance of HIV. %M 30087088 %R 10.2196/11203 %U http://publichealth.jmir.org/2018/3/e11203/ %U https://doi.org/10.2196/11203 %U http://www.ncbi.nlm.nih.gov/pubmed/30087088 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e10482 %T A Smartphone Game-Based Intervention (Tumaini) to Prevent HIV Among Young Africans: Pilot Randomized Controlled Trial %A Winskell,Kate %A Sabben,Gaëlle %A Akelo,Victor %A Ondeng'e,Ken %A Obong'o,Christopher %A Stephenson,Rob %A Warhol,David %A Mudhune,Victor %+ Rollins School of Public Health, Hubert Department of Global Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30322, United States, 1 (404)727 5286, swinske@emory.edu %K HIV %K youth %K Sub-Saharan Africa %K Kenya %K serious game %K narrative %K smartphone %K pilot study %K randomized controlled trial %K mhealth %K prevention %D 2018 %7 01.08.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: There is a pressing need to ensure that youth in high HIV prevalence settings are prepared for a safer sexual debut. Smartphone ownership is increasing dramatically in low-income and middle-income countries. Smartphone games that are appropriately grounded in behavioral theory and evidence-based practice have the potential to become valuable tools in youth HIV prevention efforts in Sub-Saharan Africa. Objective: To pilot-test a theory-based, empirically grounded smartphone game for young Kenyans designed to increase age and condom use at first sex, aiming to establish directionality of effects on behavior change. Methods: Tumaini (“hope for the future” in Swahili) is an interactive, narrative-based game grounded in social cognitive theory. A randomized controlled pilot study was conducted in Kisumu, Western Kenya, from April to June 2017 with 60 participants aged 11-14 (mean 12.7) years. Intervention arm participants (n=30) were provided with an Android smartphone with Tumaini installed on it and were instructed to play the game for at least 1 hour a day for 16 days; control arm participants (n=30) received no intervention. All participants completed a survey on behavioral mediators, delivered via an audio computer-assisted self-interview system at baseline (T1), post intervention (T2), and at 6 weeks postintervention (T3). The postintervention survey for intervention arm participants included questions eliciting feedback on the game. Intervention arm participants and their parents participated in 8 postintervention focus group discussions. Game log files were analyzed to calculate the length of exposure to the game. Behavioral survey data were analyzed using two-sample t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. Descriptive statistics on game feedback questions were computed. Focus group transcripts were uploaded to MAXQDA software, where they were labeled with deductive and inductive codes. Data were analyzed thematically and compared across demographics. Results: Intervention arm participants played Tumaini for a mean of approximately 27 hours. The intervention arm showed significant gains in sexual health-related knowledge and self-efficacy (both P<.001), behavioral intention for risk-avoidance strategies and sexual risk communication (P=.006), and overall survey scores (P<.001) compared with the control arm at T3. The postintervention survey revealed high subjective measures of the game’s value, relevance, and appeal. Focus groups identified a wide range of knowledge and skills the participants had gained, including setting goals and planning how to achieve them, which was perceived as a key motivator for avoiding or reducing risk. Conclusions: The study supports the need for further research to assess the efficacy of the game-based intervention. If proven efficacious, smartphone games have the potential to dramatically increase the reach of culturally adapted behavioral interventions while ensuring fidelity to intervention design. Trial Registration: ClinicalTrials.gov NCT03054051; http://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW) %M 30068501 %R 10.2196/10482 %U http://mhealth.jmir.org/2018/8/e10482/ %U https://doi.org/10.2196/10482 %U http://www.ncbi.nlm.nih.gov/pubmed/30068501 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 7 %P e158 %T The Complexity of Mental Health App Privacy Policies: A Potential Barrier to Privacy %A Powell,Adam C %A Singh,Preeti %A Torous,John %+ Payer+Provider Syndicate, 111 Beach Street Suite 4e, Boston, MA 02111, United States, 1 617 939 9168, powell@payerprovider.com %K apps %K privacy %K ethics %K mobile phone %D 2018 %7 30.7.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In 2017, the Supreme Court of India ruled that privacy is a fundamental right of every citizen. Although mobile phone apps have the potential to help people with noncommunicable diseases, such as diabetes and mental illness, they often contain complex privacy policies, which consumers may not understand. This complexity may impede the ability of consumers to make decisions regarding privacy, a critical issue due to the stigma of mental illness. Objective: Our objective is to determine whether mental health apps have more complex privacy policies than diabetes apps. Methods: The study used privacy policies extracted from apps. The apps pertained to diabetes or mental health, and were all of Indian origin. Privacy policy reading complexity was compared between the two types of apps using a series of 15 readability measures. The universe of applicable apps on the Google Play store, as viewed between May and June 2017, was considered. The measures of readability were compared using chi-square tests. Results: No significant difference was found between the privacy policy readability of the diabetes apps versus the mental health apps for each of the measures considered. The mean Flesch-Kincaid Grade Level was 13.9 for diabetes apps and 13.6 for mental health apps; therefore, the mean policy grade level for both types of apps was written at a college level. Privacy policies in the 25th percentile of complexity were also written at a college level for both types of apps. Conclusions: Privacy policy complexity may be a barrier for informed decision making. %M 30061090 %R 10.2196/mhealth.9871 %U http://mhealth.jmir.org/2018/7/e158/ %U https://doi.org/10.2196/mhealth.9871 %U http://www.ncbi.nlm.nih.gov/pubmed/30061090 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 7 %P e156 %T Mobile-Based Nutrition Counseling and Unconditional Cash Transfers for Improving Maternal and Child Nutrition in Bangladesh: Pilot Study %A Huda,Tanvir M %A Alam,Ashraful %A Tahsina,Tazeen %A Hasan,Mohammad Mehedi %A Khan,Jasmin %A Rahman,Mohammad Masudur %A Siddique,Abu Bakkar %A Arifeen,Shams El %A Dibley,Michael J %+ Sydney School of Public Health, University of Sydney, Edward Ford Building (A27), Sydney,, Australia, 61 412735284, huda.tanvir@gmail.com %K unconditional cash transfer %K mHealth %K voice message %K undernutrition %D 2018 %7 18.07.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Inappropriate feeding practices, inadequate nutrition knowledge, and insufficient access to food are major risk factors for maternal and child undernutrition. There is evidence to suggest that the combination of cash transfer and nutrition education improves child growth. However, a cost-effective delivery platform is needed to achieve complete, population-wide coverage of these interventions. Objective: This study aimed to assess the feasibility, acceptability, and perceived appropriateness of an intervention package consisting of voice messaging, direct counseling, and unconditional cash transfers all on a mobile platform for changing perceptions on nutrition during pregnancy and the first year of a child’s life in a poor rural community in Bangladesh. Methods: We conducted a mixed-methods pilot study. We recruited 340 pregnant or recently delivered, lactating women from rural Bangladesh. The intervention consisted of an unconditional cash transfer combined with nutrition counseling, both delivered on a mobile platform. The participants received a mobile phone and BDT 787 per month (US $10). We used a voice messaging service to deliver nutrition-related messages. We provided additional nutrition counseling through a nutrition counselor from a call center. We carried out cross-sectional surveys at baseline and at the end of the study, focus group discussions, and in-depth interviews with participants and their family members. Results: Approximately 89% (245/275) of participants reported that they were able to operate the mobile phones without much trouble. Charging of the mobile handsets posed some challenges since only approximately 45% (124/275) households in our study had electricity at home. Approximately 26% (72/275) women reported they had charged their mobile phones at their neighbor’s house, while 34% (94/275) reported that they charged it at a marketplace. Less than 10% (22/275) of women reported difficulties understanding the voice messages or direct counseling through mobile phones, while only 3% (8/275) of women reported they had some problems withdrawing cash from the mobile bank agent. Approximately 87% (236/275) women reported spending the cash to purchase food for themselves and their children. Conclusions: The nature of our study precludes any conclusion about the effectiveness of the intervention package. However, the high coverage of our intervention and the positive feedback from the mothers were encouraging and support the feasibility, acceptability, and appropriateness of this program. Further research is needed to determine the efficacy and cost-effectiveness of mobile-based nutrition counseling and unconditional cash transfers in improving maternal and child nutrition in Bangladesh. %M 30021707 %R 10.2196/mhealth.8832 %U http://mhealth.jmir.org/2018/7/e156/ %U https://doi.org/10.2196/mhealth.8832 %U http://www.ncbi.nlm.nih.gov/pubmed/30021707 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 7 %P e155 %T Improving Linkage to HIV Care Through Mobile Phone Apps: Randomized Controlled Trial %A Venter,Willem %A Coleman,Jesse %A Chan,Vincent Lau %A Shubber,Zara %A Phatsoane,Mothepane %A Gorgens,Marelize %A Stewart-Isherwood,Lynsey %A Carmona,Sergio %A Fraser-Hurt,Nicole %+ Wits Reproductive Health and HIV Institute, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Hugh Soloman Building, 22 Esselen Street, Johannesburg, 2000, South Africa, 27 833991066, venter.francois@gmail.com %K cell phones %K app %K Africa %K linkage to care %K HIV %K patient information %D 2018 %7 17.07.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In HIV treatment program, gaps in the “cascade of care” where patients are lost between diagnosis, laboratory evaluation, treatment initiation, and retention in HIV care, is a well-described challenge. Growing access to internet-enabled mobile phones has led to an interest in using the technology to improve patient engagement with health care. Objective: The objectives of this trial were: (1) to assess whether a mobile phone–enabled app could provide HIV patients with laboratory test results, (2) to better understand the implementation of such an intervention, and (3) to determine app effectiveness in improving linkage to HIV care after diagnosis. Methods: We developed and tested an app through a randomized controlled trial carried out in several primary health care facilities in Johannesburg. Newly diagnosed HIV-positive patients were screened, recruited, and randomized into the trial as they were giving a blood sample for initial CD4 staging. Trial eligibility included ownership of a phone compatible with the app and access to the internet. Trial participants were followed for a minimum of eight months to determine linkage to HIV care indicated by an HIV-related laboratory test result. Results: The trial outcome results are being prepared for publication, but here we describe the significant operational and technological lessons provided by the implementation. Android was identified as the most suitable operating system for the app, due to Android functionality and communication characteristics. Android also had the most significant market share of all smartphone operating systems in South Africa. The app was successfully developed with laboratory results sent to personal smartphones. However, given the trial requirements and the app itself, only 10% of screened HIV patients successfully enrolled. We report on issues such as patient eligibility, app testing in a dynamic phone market, software installation and compatibility, safe identification of patients, linkage of laboratory results to patients lacking unique identifiers, and present lessons and potential solutions. Conclusions: The implementation challenges and lessons of this trial may assist future similar mHealth interventions to avoid some of the pitfalls. Ensuring sufficient expertise and understanding of the programmatic needs by the software developer, as well as in the implementation team, with adequate and rapid piloting within the target groups, could have led to better trial recruitment. However, the majority of screened patients were interested in the study, and the app was installed successfully in patients with suitable smartphones, suggesting that this may be a way to engage patients with their health care data in future. Trial Registration: ClinicalTrials.gov NCT02756949; https://clinicaltrials.gov/ct2/show/NCT02756949 (Archived by WebCite at http://www.webcitation.org/6z1GTJCNW) %M 30021706 %R 10.2196/mhealth.8376 %U http://mhealth.jmir.org/2018/7/e155/ %U https://doi.org/10.2196/mhealth.8376 %U http://www.ncbi.nlm.nih.gov/pubmed/30021706 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 7 %P e137 %T Using Mobile Health to Enhance Outcomes of Noncommunicable Diseases Care in Rural Settings and Refugee Camps: Randomized Controlled Trial %A Saleh,Shadi %A Farah,Angie %A Dimassi,Hani %A El Arnaout,Nour %A Constantin,Joanne %A Osman,Mona %A El Morr,Christo %A Alameddine,Mohamad %+ Health Management and Policy, College of Medicine, Mohammed bin Rashid University of Medicine and Health Sciences, Dubai Healthcare City, Building 14, Dubai, 505055, United Arab Emirates, 971 +971521023423, ma164@aub.edu.lb %K noncommunicable diseases %K hypertension %K diabetes mellitus %K telemedicine %K mobile health %K rural health %K refugees %D 2018 %7 13.07.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Rural areas and refugee camps are characterized by poor access of patients to needed noncommunicable disease (NCD)–related health services, including diabetes and hypertension. Employing low-cost innovative eHealth interventions, such as mobile health (mHealth), may help improve NCDs prevention and control among disadvantaged populations. Objective: The aim of this study was to assess the effect of employing low-cost mHealth tools on the accessibility to health services and improvement of health indicators of individuals with NCDs in rural areas and refugee camps in Lebanon. Methods: This is a randomized controlled trial study in which centers were allocated randomly into control and intervention sites. The effect of an employed mHealth intervention is assessed through selected quality indicators examined in both control and intervention groups. Sixteen primary health care centers (eight controls, eight interventions) located in rural areas and Palestinian refugee camps across Lebanon were included in this study. Data on diabetic and hypertensive patients—1433 in the intervention group and 926 in the control group—was extracted from patient files in the pre and postintervention periods. The intervention entailed weekly short message service messages, including medical information, importance of compliance, and reminders of appointments or regular physician follow-up. Internationally established care indicators were utilized in this study. Descriptive analysis of baseline characteristics of participants, bivariate analysis, logistic and linear regression were conducted using SPSS (IBM Corp). Results: Bivariate analysis of quality indicators indicated that the intervention group had a significant increase in blood pressure control (P=.03), as well as a significant decrease in the mean systolic blood pressure (P=.02), mean glycated hemoglobin (HbA1c; P<.01), and in the proportion of HbA1c poor control (P=.02). Separate regression models controlling for age, gender, and setting showed a 28% increase in the odds of blood pressure control (P=.05) and a 38% decrease in the odds of HbA1c poor control (P=.04) among the intervention group in the posttest period. Females were at lower odds of HbA1c poor control (P=.01), and age was statistically associated with annual HbA1c testing (P<.01). Regression models for mean systolic blood pressure, mean diastolic blood pressure, and mean HbA1c showed that a mean decrease in HbA1c of 0.87% (P<.01) pretest to posttest period was observed among the intervention group. Patients in rural areas belonging to the intervention group had a lower HbA1c score as compared with those in refugee camps (P<.01). Conclusions: This study underlines the importance of employing integrative approaches of diseases prevention and control in which existing NCD programs in underserved communities (ie, rural and refugee camps settings) are coupled with innovative, low-cost approaches such as mHealth to provide an effective and amplified effect of traditional NCD-targeted care that can be reflected by improved NCD-related health indicators among the population. Trial Registration: ClinicalTrials.gov NCT03580330; https://clinicaltrials.gov/ct2/show/NCT03580330 (Archived by WebCite at http://www.webcitation.org/70mhVEUwQ) %M 30006326 %R 10.2196/mhealth.8146 %U http://mhealth.jmir.org/2018/7/e137/ %U https://doi.org/10.2196/mhealth.8146 %U http://www.ncbi.nlm.nih.gov/pubmed/30006326 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 7 %P e162 %T Identifying Barriers and Facilitators of 13 mHealth Projects in North America and Africa: Protocol for a 5-Year Implementation Science Study %A Tilahun,Binyam %A Smillie,Kirsten %A Bardosh,Kevin Louis %A Murray,Melanie %A Fitzgerald,Mark %A Cook,Victoria %A Poureslami,Iraj %A Forrest,Jamie %A Lester,Richard %+ Division of Infectious Disease, Faculty of Medicine, University of British Columbia, 10th Avenue West, Vancouver, BC, V5Z0C1, Canada, 1 604 875 4588, tilahunb@mail.ubc.ca %K mobile health %K mHealth %K text messaging %K digital health %K implementation science %K Africa %K North America %D 2018 %7 03.07.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Although many mHealth interventions have shown efficacy in research, few have been effectively implemented and sustained in real-world health system settings. Despite this programmatic gap, there is limited conclusive evidence identifying the factors that affect the implementation and successful integration of mHealth into a health system. Objective: The aim of this study is to examine the individual, organizational, and external level factors associated with the effective implementation of WelTel, an mHealth intervention designed to support outpatient medication adherence and engagement in care in Africa and North America. Methods: We will adopt the Consolidated Framework for Implementation Research (CFIR) constructs for evaluation of mHealth implementation including a scoring and monitoring system. We will apply the adapted tool to identify facilitators and barriers to implementation of the WelTel mHealth intervention in order to determine how the technology platform is perceived, diffused, adapted, and used by different mHealth project teams and health system actors in Africa and North America. We will use a mixed-methods approach to quantitatively test whether the factors identified in the CFIR framework are associated with the successful uptake of the mHealth intervention toward implementation goals. We will triangulate these data through interviews and focus group discussion with project stakeholders, exploring factors associated with successful implementation and sustainment of these interventions. Results: The development of the customized CFIR is finalized and currently is in pilot testing. The initial results of the use of the tool in those 13 implementations will be available in 2019. Continuous conference and peer- reviewed publications will be published in the coming years. Conclusions: The results of this study will provide an in-depth understanding of individual, organizational, and external level factors that influence the successful implementation of mHealth in different health systems and geographic contexts over time. Via the tool’s unique scoring system connected to qualitative descriptors, these data will inform the most critical implementation targets and contribute to the tailoring of strategies that will assist the health system in overcoming barriers to implementation, and ultimately, improve treatment adherence and engagement in care. Registered Report Identifier: RR1-10.2196/9633 %M 29970360 %R 10.2196/resprot.9633 %U http://www.researchprotocols.org/2018/7/e162/ %U https://doi.org/10.2196/resprot.9633 %U http://www.ncbi.nlm.nih.gov/pubmed/29970360 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 5 %P e126 %T The Use of Mobile Health Applications to Improve Patient Experience: Cross-Sectional Study in Chinese Public Hospitals %A Lu,Chuntao %A Hu,Yinhuan %A Xie,Jinzhu %A Fu,Qiang %A Leigh,Isabella %A Governor,Samuel %A Wang,Guanping %+ School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan,, China, 86 13554285879, hyh288@hotmail.com %K mobile applications %K technology %K outpatients %K patient satisfaction %K surveys and questionnaire %D 2018 %7 23.05.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The proliferation of mobile health apps has greatly changed the way society accesses the health care industry. However, despite the widespread use of mobile health apps by patients in China, there has been little research that evaluates the effect of mobile health apps on patient experience during hospital visits. Objective: The purpose of our study was to examine whether the use of mobile health apps improves patient experience and to find out the difference in patient experience between users and nonusers and the characteristics associated with the users of these apps. Methods: We used the Chinese Outpatient Experience Questionnaire to survey patient experience. A sample of 300 outpatients was randomly selected from 3 comprehensive public hospitals (3 tertiary hospitals) in Hubei province, China. Each hospital randomly selected 50 respondents from mobile health app users and 50 from nonusers. A chi-square test was employed to compare the different categorical characteristics between mobile health app users and nonusers. A t test was used to test the significance in continuous variables between user scores and nonuser scores. Multiple linear regression was conducted to determine whether the use of mobile health apps during hospital visits was associated with patient experience. Results: The users and nonusers differed in age (χ22=12.2, P=.002), education (χ23=9.3, P=.03), living place (χ21=7.7, P=.006), and the need for specialists (χ24=11.0, P=.03). Compared with nonusers, mobile health app users in China were younger, better educated, living in urban areas, and had higher demands for specialists. In addition, mobile health app users gave significantly higher scores than nonusers in total patient experience scores (t298=3.919, P<.001), the 18 items and the 5 dimensions of physician-patient communication (t298=2.93, P=.004), health information (t298=3.556, P<.001), medical service fees (t298=3.991, P<.001), short-term outcome (t298=4.533, P<.001), and general satisfaction (t298=4.304, P<.001). Multiple linear regression results showed that the use of mobile health apps during hospital visits influenced patient experience (t289=3.143, P=.002). After controlling for other factors, it was shown that the use of mobile health apps increased the outpatient experience scores by 17.7%. Additional results from the study found that the self-rated health status (t289=3.746, P<.001) and monthly income of patients (t289=2.416, P=.02) influenced the patient experience as well. Conclusions: The use of mobile health apps could improve patient experience, especially with regard to accessing health information, making physician-patient communication more convenient, ensuring transparency in medical charge, and ameliorating short-term outcomes. All of these may contribute to positive health outcomes. Therefore, we should encourage the adoption of mobile health apps in health care settings so as to improve patient experience. %M 29792290 %R 10.2196/mhealth.9145 %U http://mhealth.jmir.org/2018/5/e126/ %U https://doi.org/10.2196/mhealth.9145 %U http://www.ncbi.nlm.nih.gov/pubmed/29792290 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 5 %P e122 %T Acceptability and Feasibility of Real-Time Antiretroviral Therapy Adherence Interventions in Rural Uganda: Mixed-Method Pilot Randomized Controlled Trial %A Musiimenta,Angella %A Atukunda,Esther C %A Tumuhimbise,Wilson %A Pisarski,Emily E %A Tam,Melanie %A Wyatt,Monique A %A Ware,Norma C %A Haberer,Jessica E %+ Mbarara University of Science and Technology, Angella Musiimenta, PhD, Mbarara, PO Box 653, Uganda, 256 776820598, amusiimenta@must.ac.ug %K real-time adherence monitoring %K SMS %K mobile health technologies %K antiretroviral therapy %K acceptability %K feasibility study %D 2018 %7 17.05.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Wireless electronic adherence monitors can detect antiretroviral therapy (ART) adherence lapses and trigger interventions in real time, thus potentially avoiding unnecessary HIV viremia. Evidence about the acceptability and feasibility of these monitors and associated interventions, however, is limited. Objective: The aim of this study was to assess the acceptability and feasibility of real-time adherence monitoring linked to text messaging (short message service, SMS) reminders and notifications to support adherence among individuals living with HIV who are taking ART in rural southwestern Uganda. Methods: Individuals living with HIV who were initiating ART were enrolled in a pilot randomized controlled trial and followed up for 9 months. Participants received a real-time adherence monitor and were randomized to one of the following study arms: (1) scheduled SMS, (2) SMS triggered by missed or delayed doses, or (3) no SMS. SMS notifications were also sent to 45 patient-identified social supporters for sustained adherence lapses in the scheduled SMS and triggered SMS arms. Study participants and social supporters participated in qualitative semistructured in-depth interviews on acceptability and feasibility of this technology. An inductive, content analytic approach, framed by the unified theory of acceptance and use of technology model, was used to analyze qualitative data. Quantitative feasibility data, including device functionality and SMS tracking data, were recorded based upon device metrics collected electronically and summarized descriptively. Results: A total of 63 participants participated in the study. Participants reported that real-time monitoring intervention linked to SMS reminders and notifications are generally acceptable; the predominant feedback was perceived utility—the intervention was beneficial in motivating and reminding patients to take medication, as well as enabling provision of social support. The intervention was found to be technically feasible, as data were obtained from most participants as expected most of the time. Potential challenges included the impact of the technology on confidentiality, shared phone ownership, usability skills, and availability of electricity. Conclusions: Real-time adherence monitoring integrated with SMS reminders and social support notifications is a generally acceptable (based primarily on perceived utility) and feasible intervention in a resource-limited country. Future efforts should focus on optimized device design, user training to overcome the challenges we encountered, cost effectiveness studies, as well as studying the monitoring aspect of the device without accompanying interventions. Trial Registration: ClinicalTrials.gov NCT01957865; https://clinicaltrials.gov/ct2/show/NCT01957865 (Archived by WebCite at http://www.webcitation.org/6zFiDlXDa) %M 29773527 %R 10.2196/mhealth.9031 %U http://mhealth.jmir.org/2018/5/e122/ %U https://doi.org/10.2196/mhealth.9031 %U http://www.ncbi.nlm.nih.gov/pubmed/29773527 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 5 %P e119 %T Multistakeholder Perspectives on Maternal Text Messaging Intervention in Uganda: Qualitative Study %A Ilozumba,Onaedo %A Dieleman,Marjolein %A Van Belle,Sara %A Mukuru,Moses %A Bardají,Azucena %A Broerse,Jacqueline EW %+ Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, Amsterdam, 1081 HV, Netherlands, 31 205983143, ona.ilozumba@vu.nl %K maternal health %K telemedicine %K community health workers %K Uganda %K evaluation studies %D 2018 %7 10.05.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite continued interest in the use of mobile health for improving maternal health outcomes, there have been limited attempts to identify relevant program theories. Objectives: This study had two aims: first, to explicate the assumptions of program designers, which we call the program theory and second, to contrast this program theory with empirical data to gain a better understanding of mechanisms, facilitators, and barriers related to the program outcomes. Methods: To achieve the aforementioned objectives, we conducted a retrospective qualitative study of a text messaging (short message service) platform geared at improving individual maternal health outcomes in Uganda. Through interviews with program designers (n=3), we elicited 3 main designers’ assumptions and explored these against data from qualitative interviews with primary beneficiaries (n=26; 15 women and 11 men) and health service providers (n=6), as well as 6 focus group discussions with village health team members (n=50) who were all involved in the program. Results: Our study results highlighted that while the program designers’ assumptions were appropriate, additional mechanisms and contextual factors, such as the importance of incentives for village health team members, mobile phone ownership, and health system factors should have been considered. Conclusions: Our results indicate that text messages could be an effective part of a more comprehensive maternal health program when context and system barriers are identified and addressed in the program theories. %M 29748159 %R 10.2196/mhealth.9565 %U http://mhealth.jmir.org/2018/5/e119/ %U https://doi.org/10.2196/mhealth.9565 %U http://www.ncbi.nlm.nih.gov/pubmed/29748159 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 5 %P e117 %T Determinants of Intention to Use Mobile Phone Caller Tunes to Promote Voluntary Blood Donation: Cross-Sectional Study %A Appiah,Bernard %A Burdine,James N %A Aftab,Ammar %A Asamoah-Akuoko,Lucy %A Anum,David A %A Kretchy,Irene A %A Samman,Elfreda W %A Appiah,Patience B %A Bates,Imelda %+ Research Program on Public and International Engagement for Health, Department of Environmental and Occupational Health, Texas A&M School of Public Health, Texas A&M University, 1266 TAMU, College Station, Texas, TX, 77843, United States, 1 9794369456, appiah@sph.tamhsc.edu %K caller tunes %K blood donation %K sub-Saharan Africa %K technology acceptance model %K mobile health %D 2018 %7 04.05.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Voluntary blood donation rates are low in sub-Saharan Africa. Sociobehavioral factors such as a belief that donated blood would be used for performing rituals deter people from donating blood. There is a need for culturally appropriate communication interventions to encourage individuals to donate blood. Health care interventions that use mobile phones have increased in developing countries, although many of them focus on SMS text messaging (short message service, SMS). A unique feature of mobile phones that has so far not been used for aiding blood donation is caller tunes. Caller tunes replace the ringing sound heard by a caller to a mobile phone before the called party answers the call. In African countries such as Ghana, instead of the typical ringing sound, a caller may hear a message or song. Despite the popularity of such caller tunes, there is a lack of empirical studies on their potential use for promoting blood donation. Objective: The aim of this study was to use the technology acceptance model to explore the influence of the factors—perceived ease of use, perceived usefulness, attitude, and free of cost—on intentions of blood or nonblood donors to download blood donation-themed caller tunes to promote blood donation, if available. Methods: A total of 478 blood donors and 477 nonblood donors were purposively sampled for an interviewer-administered questionnaire survey at blood donation sites in Accra, Ghana. Data were analyzed using descriptive statistics, exploratory factor analysis, and confirmatory factory analysis or structural equation modeling, leading to hypothesis testing to examine factors that determine intention to use caller tunes for blood donation among blood or nonblood donors who use or do not use mobile phone caller tunes. Results: Perceived usefulness had a significant effect on intention to use caller tunes among blood donors with caller tunes (beta=.293, P<.001), blood donors without caller tunes (beta=.165, P=.02, nonblood donors with caller tunes (beta=.278, P<.001), and nonblood donors without caller tunes (beta=.164, P=.01). Attitudes had significant effect on intention to use caller tunes among blood donors without caller tunes (beta=.351, P<.001), nonblood donors with caller tunes (beta=.384, P<.001), nonblood donors without caller tunes (beta=.539, P<.001) but not among blood donors with caller tunes (beta=.056, P=.44). The effect of free-of-cost caller tunes on the intention to use for blood donation was statistically significant (beta=.169, P<.001) only in the case of nonblood donors without caller tunes, whereas this path was statistically not significant in other models. Conclusions: Our results provide empirical evidence for designing caller tunes to promote blood donation in Ghana. The study found that making caller tunes free is particularly relevant for nonblood donors with no caller tunes. %M 29728343 %R 10.2196/mhealth.9752 %U http://mhealth.jmir.org/2018/5/e117/ %U https://doi.org/10.2196/mhealth.9752 %U http://www.ncbi.nlm.nih.gov/pubmed/29728343 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 4 %N 2 %P e46 %T Recommendations for the Development of a Mobile HIV Prevention Intervention for Men Who Have Sex With Men and Hijras in Mumbai: Qualitative Study %A Rawat,Shruta %A Wilkerson,J Michael %A Lawler,Sylvia M %A Patankar,Pallav %A Rosser,BR Simon %A Shukla,Kanjani %A Butame,Seyram %A Ekstrand,Maria L %+ School of Public Health, University of Texas Health Science Center at Houston, 7000 Fannin St, Ste 2620, Houston, TX,, United States, 1 713 500 9974, Johnny.M.Wilkerson@uth.tmc.edu %K health promotion %K health seeking %K gays and lesbians %K Internet %K HIV/AIDS %D 2018 %7 03.05.2018 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: As Internet and mobile phone use expands in India, there is an opportunity to develop mobile health (mHealth) interventions for marginalized populations, including men who have sex with men (MSM) and hijras (transgender women), hesitant to access traditional health care systems. Objective: The purpose of this study was to determine if an mHealth intervention was acceptable to MSM and hijras living in Mumbai, and if so, what features would be useful in targeting the prevention of HIV acquisition and to increase the quality of life among persons living with HIV/AIDS. Methods: Data from 4 focus groups with MSM and interviews with 4 hijras, 10 health service providers, and 8 mHealth developers were thematically analyzed. Results: Once the need for an mHealth intervention was confirmed, comments about features were organized into 3 themes: content, interface, and retention. Content subthemes included providing sex education for younger community members, providing information about STIs, and providing information and social support for persons living with HIV. Interface subthemes included presenting content using pictures; using videos to present stories of role models; using push notifications for testing, appointment, and medication reminders; using geolocation to link to just-in-time services; and using telemedicine to increase access to health service providers and community services. The 5 retention subthemes included keeping it fun, using gaming mechanics, developing content in regional languages, protecting confidentiality, and linking to social networking apps. Conclusions: These findings may help inform mHealth development in India. %M 29724705 %R 10.2196/publichealth.9088 %U http://publichealth.jmir.org/2018/2/e46/ %U https://doi.org/10.2196/publichealth.9088 %U http://www.ncbi.nlm.nih.gov/pubmed/29724705 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 4 %P e106 %T Mobile Health Initiatives in Vietnam: Scoping Study %A Lam,Jeffrey A %A Dang,Linh Thuy %A Phan,Ngoc Tran %A Trinh,Hue Thi %A Vu,Nguyen Cong %A Nguyen,Cuong Kieu %+ Institute of Population, Health and Development, 14th Floor, ICON 4 Building, 243A De La Thanh, Lang Thuong, Dong Da, Hanoi,, Viet Nam, 84 2473000988 ext 341, cuong.kieu.nguyen@phad.org %K mHealth %K eHealth %K mobile health %K telemedicine %K Vietnam %K scoping review %D 2018 %7 24.04.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) offers a promising solution to the multitude of challenges the Vietnamese health system faces, but there is a scarcity of published information on mHealth in Vietnam. Objective: The objectives of this scoping study were (1) to summarize the extent, range, and nature of mHealth initiatives in Vietnam and (2) to examine the opportunities and threats of mHealth utilization in the Vietnamese context. Methods: This scoping study systematically identified and extracted relevant information from 20 past and current mHealth initiatives in Vietnam. The study includes multimodal information sources, including published literature, gray literature (ie, government reports and unpublished literature), conference presentations, Web-based documents, and key informant interviews. Results: We extracted information from 27 records from the electronic search and conducted 14 key informant interviews, allowing us to identify 20 mHealth initiatives in Vietnam. Most of the initiatives were primarily funded by external donors (n=15), while other initiatives were government funded (n=1) or self-funded (n=4). A majority of the initiatives targeted vulnerable and hard-to-reach populations (n=11), aimed to prevent the occurrence of disease (n=12), and used text messaging (short message service, SMS) as part of their intervention (n=14). The study revealed that Vietnamese mHealth implementation has been challenged by factors including features unique to the Vietnamese language (n=4) and sociocultural factors (n=3). Conclusions: The largest threats to the popularity of mHealth initiatives are the absence of government policy, lack of government interest, heavy dependence on foreign funding, and lack of technological infrastructure. Finally, while current mHealth initiatives have already demonstrated promising opportunities for alternative models of funding, such as social entrepreneurship or private business models, sustainable mHealth initiatives outside of those funded by external donors have not yet been undertaken. %M 29691214 %R 10.2196/mhealth.8639 %U http://mhealth.jmir.org/2018/4/e106/ %U https://doi.org/10.2196/mhealth.8639 %U http://www.ncbi.nlm.nih.gov/pubmed/29691214 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 5 %N 2 %P e16 %T Relationship Between Evidence Requirements, User Expectations, and Actual Experiences: Usability Evaluation of the Twazon Arabic Weight Loss App %A Alnasser,Aroub %A Kyle,Janet %A Alkhalifah,Abdulrahman %A Marais,Debbi %+ Food Science and Nutrition Department, College of Food and Agriculture Sciences, King Saud University, PO Box 86683, Riyadh, 11632, Saudi Arabia, 966 118056476, aroub@ksu.edu.sa %K mHealth %K weight loss %K obesity %K smartphones %K mobile applications %K Saudi Arabia %K women's health %D 2018 %7 17.04.2018 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Saudi Arabia has faced a steady growth in the prevalence of obesity. The concurrent and ubiquitous use of mobile technology, such as smartphones and apps, provides an opportunity for the implementation of mHealth technology, a method for delivering behavioral interventions. Despite their effectiveness in promoting lifestyle and diet modification, culturally adapted weight loss apps and related interventions are lacking in Gulf Cooperation Council countries. Objective: The objective of our study was to identify the relationship between adherence to evidence-informed practices, potential user expectations, and actual user experiences in order to enhance the understanding of the overall usability of the Twazon Arabic weight loss app. Methods: In 2 previous studies, 39 Saudi women were recruited for focus group discussions and 240 Saudi women were recruited for an app-based weight loss intervention. Usability of the Twazon Arabic weight loss app was evaluated by analyzing the opinions and experiences of 26 participants who engaged with the Twazon app for 4 months; the System Usability Scale (SUS) and word clouds were used. The results were triangulated with potential user expectations obtained in the focus group discussion and with the findings from an Arabic app screening for evidence-informed practices. Results: The average reported SUS score was 69.3. The most favored features were the calorie counter, step counter, and physical activity calorie counter. The features in need of improvement were the social network, notifications, and the Twazon Saudi Food Database. Twazon users preferred and found useful 7 of the 13 evidence-informed weight loss practices that were integrated into the features of the app. Conclusions: Triangulation identified the most notable relationship to be the disparity between user experience and 2 of the evidence-informed practices, namely a minimum weight loss goal of 0.5 to 1 kg/week and social support; no relationship was found between user expectations and evidence-informed weight loss practices. The overall usability of the Twazon Arabic weight loss app ranged between high marginal and acceptable, indicating that some improvements to the app should be considered for implementation in future app-based weight loss interventions of this kind. %M 29666042 %R 10.2196/humanfactors.9765 %U http://humanfactors.jmir.org/2018/2/e16/ %U https://doi.org/10.2196/humanfactors.9765 %U http://www.ncbi.nlm.nih.gov/pubmed/29666042 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 4 %P e76 %T Women’s Perceptions of Using Mobile Phones for Maternal and Child Health Support in Afghanistan: Cross-Sectional Survey %A Yamin,Fazal %A Kaewkungwal,Jaranit %A Singhasivanon,Pratap %A Lawpoolsri,Saranath %+ Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithee Road, Ratchathewi, Bangkok,, Thailand, 66 2 306 9188, saranath.law@mahidol.ac.th %K Afghanistan %K mobile health %K maternal health, child health %K perception %K mobile phone %D 2018 %7 10.04.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Growing rates of global mobile subscriptions pave the way for implementation of mobile health (mHealth) initiatives, especially among hard-to-reach populations. Objective: This study aimed to determine the perceptions of Afghan women regarding the use of mobile phones for maternal and child health services. Methods: A cross-sectional survey was conducted in both rural and urban districts of Nangarhar Province, Afghanistan. The interviewer-administered questionnaire was used to assess participants’ demographic profile, mobile phone usage, and perception of respondents toward different aspects of health care delivery via mobile phones. Results: Of the 240 participants, 142 (59.2%) owned mobile phones and 220 (91.7%) routinely used mobile phones. Approximately 209 (87.1%) of participants were willing to receive health messages via a mobile phone. Automated voice call was the most preferred method for sending health messages. More than 90% of the women reported that they would like to receive reminders for their children’s vaccinations and antenatal care visits. Conclusions: Users’ perception was associated with mobile phone ownership, literacy level, and experience using mobile phones. In the study area, where the literacy rate is low, mHealth was well perceived. %M 29636317 %R 10.2196/mhealth.9504 %U http://mhealth.jmir.org/2018/4/e76/ %U https://doi.org/10.2196/mhealth.9504 %U http://www.ncbi.nlm.nih.gov/pubmed/29636317 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 6 %N 2 %P e18 %T Patient-Physician Communication in the Era of Mobile Phones and Social Media Apps: Cross-Sectional Observational Study on Lebanese Physicians’ Perceptions and Attitudes %A Daniel,Fady %A Jabak,Suha %A Sasso,Roula %A Chamoun,Yara %A Tamim,Hani %+ Department of Internal Medicine, American University of Beirut Medical Center, American University of Beirut, Hamra, Cairo Street, Beirut,, Lebanon, 961 3614660, fd21@aub.edu.lb %K social media %K communication %K patient-physician communication %K technology use %D 2018 %7 06.04.2018 %9 Original Paper %J JMIR Med Inform %G English %X Background: The increased prevalence of virtual communication technology, particularly social media, has shifted the physician-patient relationship away from the well-established face-to-face interaction. The views and habits of physicians in Lebanon toward the use of online apps and social media as forms of patient communication have not been previously described. Objective: The aim of this study is to describe the views of Lebanese physicians toward the use of social media and other online apps as means of patient communication. Methods: This was a cross-sectional observational study using an online survey that addressed physicians’ perceptions on the use of virtual communication in their clinical practice. The study took place between April and June 2016, and was directed toward physicians at the American University of Beirut Medical Center. Results: A total of 834 doctors received the online survey, with 238 physicians completing the survey. Most of the participants were from medical specialties. Most responders were attending physicians. Less than half of the respondents believed that Web-based apps and social media could be a useful tool for communicating with patients. Email was the most common form of professional online app, followed by WhatsApp (an instant messaging service). The majority of participants felt that this mode of communication can result in medicolegal issues and that it was a breach of privacy. Participants strictly against the use of virtual forms of communication made up 47.5% (113/238) of the study sample. Conclusions: The majority of physicians at the American University of Beirut Medical Center are reluctant to use virtual communication technology as a form of patient communication. Appropriate policy making and strategies can allow both physicians and patients to communicate virtually in a more secure setting without fear of breaching privacy and confidentiality. %M 29625955 %R 10.2196/medinform.8895 %U http://medinform.jmir.org/2018/2/e18/ %U https://doi.org/10.2196/medinform.8895 %U http://www.ncbi.nlm.nih.gov/pubmed/29625955 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 4 %N 1 %P e25 %T A Participatory System for Preventing Pandemics of Animal Origins: Pilot Study of the Participatory One Health Disease Detection (PODD) System %A Yano,Terdsak %A Phornwisetsirikun,Somphorn %A Susumpow,Patipat %A Visrutaratna,Surasing %A Chanachai,Karoon %A Phetra,Polawat %A Chaisowwong,Warangkhana %A Trakarnsirinont,Pairat %A Hemwan,Phonpat %A Kaewpinta,Boontuan %A Singhapreecha,Charuk %A Kreausukon,Khwanchai %A Charoenpanyanet,Arisara  %A Robert,Chongchit Sripun %A Robert,Lamar %A Rodtian,Pranee %A Mahasing,Suteerat %A Laiya,Ekkachai %A Pattamakaew,Sakulrat %A Tankitiyanon,Taweesart %A Sansamur,Chalutwan %A Srikitjakarn,Lertrak %+ Faculty of Veterinary Medicine, Chiang Mai University, Chonlapratan Road, Maehia, Muang, Chiang Mai, 50100, Thailand, 66 871850280, lertrak.s@gmail.com %K community-owned disease surveillance system %K PODD %K mobile app %K one health %K participatory approach %K backyard chicken %K pandemic prevention %D 2018 %7 21.03.2018 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Aiming for early disease detection and prompt outbreak control, digital technology with a participatory One Health approach was used to create a novel disease surveillance system called Participatory One Health Disease Detection (PODD). PODD is a community-owned surveillance system that collects data from volunteer reporters; identifies disease outbreak automatically; and notifies the local governments (LGs), surrounding villages, and relevant authorities. This system provides a direct and immediate benefit to the communities by empowering them to protect themselves. Objective: The objective of this study was to determine the effectiveness of the PODD system for the rapid detection and control of disease outbreaks. Methods: The system was piloted in 74 LGs in Chiang Mai, Thailand, with the participation of 296 volunteer reporters. The volunteers and LGs were key participants in the piloting of the PODD system. Volunteers monitored animal and human diseases, as well as environmental problems, in their communities and reported these events via the PODD mobile phone app. LGs were responsible for outbreak control and provided support to the volunteers. Outcome mapping was used to evaluate the performance of the LGs and volunteers. Results: LGs were categorized into one of the 3 groups based on performance: A (good), B (fair), and C (poor), with the majority (46%,34/74) categorized into group B. Volunteers were similarly categorized into 4 performance groups (A-D), again with group A showing the best performance, with the majority categorized into groups B and C. After 16 months of implementation, 1029 abnormal events had been reported and confirmed to be true reports. The majority of abnormal reports were sick or dead animals (404/1029, 39.26%), followed by zoonoses and other human diseases (129/1029, 12.54%). Many potentially devastating animal disease outbreaks were detected and successfully controlled, including 26 chicken high mortality outbreaks, 4 cattle disease outbreaks, 3 pig disease outbreaks, and 3 fish disease outbreaks. In all cases, the communities and animal authorities cooperated to apply community contingency plans to control these outbreaks, and community volunteers continued to monitor the abnormal events for 3 weeks after each outbreak was controlled. Conclusions: By design, PODD initially targeted only animal diseases that potentially could emerge into human pandemics (eg, avian influenza) and then, in response to community needs, expanded to cover human health and environmental health issues. %M 29563079 %R 10.2196/publichealth.7375 %U http://publichealth.jmir.org/2018/1/e25/ %U https://doi.org/10.2196/publichealth.7375 %U http://www.ncbi.nlm.nih.gov/pubmed/29563079 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 4 %N 1 %P e20 %T Effect of Mobile Phone Text Message Reminders on Routine Immunization Uptake in Pakistan: Randomized Controlled Trial %A Kazi,Abdul Momin %A Ali,Murtaza %A Zubair,Khurram %A Kalimuddin,Hussain %A Kazi,Abdul Nafey %A Iqbal,Saleem Perwaiz %A Collet,Jean-Paul %A Ali,Syed Asad %+ Department of Paediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan, 92 34864232, momin.kazi@aku.edu %K SMS %K mobile phone %K reminders %K low- and middle-income countries %K routine immunization %K children %D 2018 %7 07.03.2018 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Improved routine immunization (RI) coverage is recommended as the priority public health strategy to decrease vaccine-preventable diseases and eradicate polio in Pakistan and worldwide. Objective: The objective of this study was to ascertain whether customized, automated, one-way text messaging (short message service, SMS) reminders delivered to caregivers via mobile phones when a child is due for an RI visit can improve vaccination uptake and timelines in Pakistan. Methods: This was a randomized controlled trial, conducted in an urban squatter settlement area of Karachi, Pakistan. Infants less than 2 weeks of age with at least one family member who had a valid mobile phone connection and was comfortable receiving and reading SMS text messages were included. Participants were randomized to the intervention (standard care + one-way SMS reminder) or control (standard care) groups. The primary outcome was to compare the proportion of children immunized up to date at 18 weeks of age. Vaccine given at 6, 10, and 14 weeks schedule includes DPT-Hep-B-Hib vaccine (ie, diphtheria, pertussis, and tetanus; hepatitis B; and Haemophilus influenza type b) and oral poliovirus vaccine (OPV). Data were analyzed using chi-square tests of independence and tested for both per protocol (PP) and intention-to-treat (ITT) analyses. Results: Out of those approached, 84.3% (300/356) of the participants were eligible for enrollment and 94.1% (318/338) of the participants had a working mobile phone. Only children in the PP analyses, who received an SMS reminder for vaccine uptake at 6 weeks visit, showed a statistically significant difference (96.0%, 86/90 vs 86.4%, 102/118; P=.03).The immunization coverage was consistently higher in the intervention group according to ITT analyses at the 6 weeks scheduled visit (76.0% vs 71.3%, P=.36). The 10 weeks scheduled visit (58.7% vs 52.7%, P=.30) and the 14 weeks scheduled visit (31.3% vs 26.0%, P=.31), however, were not statistically significant. Conclusions: Automated simple one-way SMS reminders in local languages might be feasible for improving routine vaccination coverage. Whether one-way SMS reminders alone can have a strong impact on parental attitudes and behavior for improvement of RI coverage and timeliness needs to be further evaluated by better-powered studies and by comparing different types and content of text messages in low-and middle-income countries (LMICs). Trial Registration: ClinicalTrials.gov NCT01859546; https://clinicaltrials.gov/ct2/show/NCT01859546 (Archived by WebCite at http://www.webcitation.org/6xFr57AOc) %M 29514773 %R 10.2196/publichealth.7026 %U http://publichealth.jmir.org/2018/1/e20/ %U https://doi.org/10.2196/publichealth.7026 %U http://www.ncbi.nlm.nih.gov/pubmed/29514773 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 3 %P e50 %T Reliability of Self-Reported Mobile Phone Ownership in Rural North-Central Nigeria: Cross-Sectional Study %A Menson,William Nii Ayitey %A Olawepo,John Olajide %A Bruno,Tamara %A Gbadamosi,Semiu Olatunde %A Nalda,Nannim Fazing %A Anyebe,Victor %A Ogidi,Amaka %A Onoka,Chima %A Oko,John Okpanachi %A Ezeanolue,Echezona Edozie %+ Global Health Initiative, School of Community Health Sciences, University of Nevada, Las Vegas, 4505 S Maryland Pkwy, Las Vegas, Las Vegas, NV, 89154, United States, 1 443 682 5034, william.menson@unlv.edu %K reliability %K phone ownership %K resource-limited setting %K cell phone use %K rural population %K developing countries %K self report %K Nigeria %K telemedicine %D 2018 %7 01.03.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: mHealth practitioners seek to leverage the ubiquity of the mobile phone to increase the impact and robustness of their interventions, particularly in resource-limited settings. However, data on the reliability of self-reported mobile phone access is minimal. Objective: We sought to ascertain the reliability of self-reported ownership of and access to mobile phones among a population of rural dwellers in north-central Nigeria. Methods: We contacted participants in a community-based HIV testing program by phone to determine actual as opposed to self-reported mobile phone access. A phone script was designed to conduct these calls and descriptive analyses conducted on the findings. Results: We dialed 349 numbers: 110 (31.5%) were answered by participants who self-reported ownership of the mobile phone; 123 (35.2%) of the phone numbers did not ring at all; 28 (8.0%) rang but were not answered; and 88 (25.2%) were answered by someone other than the participant. We reached a higher proportion of male participants (68/133, 51.1%) than female participants (42/216, 19.4%; P<.001). Conclusions: Self-reported access to mobile phones in rural and low-income areas in north-central Nigeria is higher than actual access. This has implications for mHealth programming, particularly for women’s health. mHealth program implementers and researchers need to be cognizant of the low reliability of self-reported mobile phone access. These observations should therefore affect sample-size calculations and, where possible, alternative means of reaching research participants and program beneficiaries should be established. %M 29496656 %R 10.2196/mhealth.8760 %U https://mhealth.jmir.org/2018/3/e50/ %U https://doi.org/10.2196/mhealth.8760 %U http://www.ncbi.nlm.nih.gov/pubmed/29496656 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 2 %P e46 %T Feasibility of a Mobile Phone App to Support Recovery From Addiction in China: Secondary Analysis of a Pilot Study %A Han,Hui %A Zhang,Jing Ying %A Hser,Yih-Ing %A Liang,Di %A Li,Xu %A Wang,Shan Shan %A Du,Jiang %A Zhao,Min %+ Collaborative Innovation Center for Brain Science, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 600 Wan Ping Nan Road, Xu Hui District, Shanghai, 200030, China, 86 18017311220, dujiangdou@163.com %K mHealth %K substance use %K heroin dependence %K amphetamine-type stimulant (ATS) dependence %K mobile app %K China %D 2018 %7 27.02.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health technologies have been found to improve the self-management of chronic diseases. However, there is limited research regarding their feasibility in supporting recovery from substance use disorders (SUDs) in China. Objective: The objective of this study was to examine the feasibility of a mobile phone-based ecological momentary assessment (EMA) app by testing the concordance of drug use assessed by the EMA, urine testing, and a life experience timeline (LET) assessment. Methods: A total of 75 participants dependent on heroin or amphetamine-type stimulant (ATS) in Shanghai were recruited to participate in a 4-week pilot study. Of the participants, 50 (67% [50/75]) were randomly assigned to the experimental group and 25 (33% [25/75]) were assigned to the control group. The experimental group used mobile health (mHealth) based EMA technology to assess their daily drug use in natural environments and received 2 short health messages each day, whereas the control group only received 2 short health messages each day from the app. Urine tests and LET assessments were conducted each week and a post-intervention survey was administered to both groups. The correlations among the EMA, the LET assessment, and the urine test were investigated. Results: The mean age of the participants was 41.6 (SD 8.0) years, and 71% (53/75) were male. During the 4 weeks of observation, 690 daily EMA survey data were recorded, with a response rate of 49.29% (690/1400). With respect to drug use, the percent of agreement between the EMA and the LET was 66.7%, 79.2%, 72.4%, and 85.8%, respectively, for each of the 4 weeks, whereas the percent of agreement between the EMA and the urine test was 51.2%, 65.1%, 61.9%, and 71.5%, respectively. The post-intervention survey indicated that 46% (32/70) of the participants preferred face-to-face interviews rather than the mHealth app. Conclusions: This study demonstrated poor agreement between the EMA data and the LET and found that the acceptance of mHealth among individuals with SUDs in China was not positive. Hence, greater efforts are needed to improve the feasibility of mHealth in China. %M 29487040 %R 10.2196/mhealth.8388 %U http://mhealth.jmir.org/2018/2/e46/ %U https://doi.org/10.2196/mhealth.8388 %U http://www.ncbi.nlm.nih.gov/pubmed/29487040 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 1 %P e27 %T A Breastfeed-Promoting Mobile App Intervention: Usability and Usefulness Study %A Wang,Chih-Jau %A Chaovalit,Pimwadee %A Pongnumkul,Suporn %+ National Electronics and Computer Technology Center, 112 Phahonyothin Road, Khlong Nueng, Khlong Luang District, Pathum Thani, 12120, Thailand, 66 2 564 6900 ext 72293, wang.chihjau@gmail.com %K mobile health %K breast feeding %K mobile applications %K health promotion %K usability %K usefulness %D 2018 %7 26.01.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Breastfeeding is proven to have lasting health benefits for both mothers and infants; however, 6-month exclusive breastfeeding rate remains below 20% in Thailand. Although the number of research literature and commercial apps for breastfeeding women is significantly growing, they are country-specific and restricted to English-speaking users. There exists a major knowledge gap on how mobile health apps could support breastfeeding in Thailand. To address these gaps, MoomMae has been developed with the intention to support Thai women in breastfeeding outside of their homes and in keeping their feeding records. Objective: The aim of this study was to evaluate the usability and usefulness of MoomMae, a mobile phone app designed to support breastfeeding women. Methods: Our study was reviewed and approved by Thailand’s National Science and Technology Development Agency (NSTDA) ethics committee. A total of 21 breastfeeding women with at least one Android phone or tablet were recruited via convenience and snowball sampling. The study process for each participant was as follows: the participant was requested to attend a preuse interview and given the app to use for 4 weeks. Following this period, a postuse interview was conducted to examine the usability and usefulness of the app. Both sessions were held individually and audiorecorded for qualitative analysis. Results: The mean scores of usability and usefulness from the postuse survey were 4.33 (SD 0.87; range 1-5) and 4.60 (SD 0.74; range 2-5). Our qualitative analysis revealed a total of 137 feedbacks: 71 related to usability and 66 associated with usefulness. A further sentimental analysis showed that comments on usability were generally negative (59 negative, 11 positive, and 1 neutral), and comments on usefulness were relatively positive (56 positive, 9 negative, and 1 neutral). We discovered 26 unique design issues and proposed recommendations for future improvement. Conclusions: Our usability and usefulness assessment of MoomMae demonstrated that MoomMae has a great potential to be a useful self-management tool for breastfeeding mothers in Thailand. The qualitative analysis suggested that the app is supportive of breastfeeding on demand, but the flow and inputs of the app should be redesigned to be more intuitive. For future implementations, the most desirable feature is a pump-reminding notification system. %M 29374000 %R 10.2196/mhealth.8337 %U http://mhealth.jmir.org/2018/1/e27/ %U https://doi.org/10.2196/mhealth.8337 %U http://www.ncbi.nlm.nih.gov/pubmed/29374000 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 1 %P e18 %T A Patient-Held Smartcard With a Unique Identifier and an mHealth Platform to Improve the Availability of Prenatal Test Results in Rural Nigeria: Demonstration Study %A Gbadamosi,Semiu Olatunde %A Eze,Chuka %A Olawepo,John Olajide %A Iwelunmor,Juliet %A Sarpong,Daniel F %A Ogidi,Amaka Grace %A Patel,Dina %A Oko,John Okpanachi %A Onoka,Chima %A Ezeanolue,Echezona Edozie %+ Global Health Initiative, School of Community Health Sciences, University of Nevada, Las Vegas, 4505 S. Maryland Parkway, Las Vegas, NV, 89154-1026, United States, 1 702 895 4950, semiu.gbadamosi@unlv.edu %K mHealth %K prenatal screening %K HIV %K hepatitis B %K sickle cell disease %K Nigeria %K telemedicine %K prenatal diagnosis %K infectious disease transmission, vertical %D 2018 %7 15.01.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Community-based strategies to test for HIV, hepatitis B virus (HBV), and sickle cell disease (SCD) have expanded opportunities to increase the proportion of pregnant women who are aware of their diagnosis. In order to use this information to implement evidence-based interventions, these results have to be available to skilled health providers at the point of delivery. Most electronic health platforms are dependent on the availability of reliable Internet connectivity and, thus, have limited use in many rural and resource-limited settings. Objective: Here we describe our work on the development and deployment of an integrated mHealth platform that is able to capture medical information, including test results, and encrypt it into a patient-held smartcard that can be read at the point of delivery without the need for an Internet connection. Methods: We engaged a team of implementation scientists, public health experts, and information technology specialists in a requirement-gathering process to inform the design of a prototype for a platform that uses smartcard technology, database deployment, and mobile phone app development. Key design decisions focused on usability, scalability, and security. Results: We successfully designed an integrated mHealth platform and deployed it in 4 health facilities across Benue State, Nigeria. We developed the Vitira Health platform to store test results of HIV, HBV, and SCD in a database, and securely encrypt the results on a Quick Response code embedded on a smartcard. We used a mobile app to read the contents on the smartcard without the need for Internet connectivity. Conclusions: Our findings indicate that it is possible to develop a patient-held smartcard and an mHealth platform that contains vital health information that can be read at the point of delivery using a mobile phone-based app without an Internet connection. Trial Registration: ClinicalTrials.gov NCT03027258; https://clinicaltrials.gov/ct2/show/NCT03027258 (Archived by WebCite at http://www.webcitation.org/6owR2D0kE) %M 29335234 %R 10.2196/jmir.8716 %U http://www.jmir.org/2018/1/e18/ %U https://doi.org/10.2196/jmir.8716 %U http://www.ncbi.nlm.nih.gov/pubmed/29335234 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 1 %P e16 %T Tanzania Health Information Technology (T-HIT) System: Pilot Test of a Tablet-Based System to Improve Prevention of Mother-to-Child Transmission of HIV %A Bull,Sheana %A Thomas,Deborah SK %A Nyanza,Elias C %A Ngallaba,Sospatro E %+ Department of Geography & Environmental Sciences, University of Colorado Denver, PO Box 173364, CB 172, Denver, CO, 80217-3364, United States, 1 303 315 7557, deborah.thomas@ucdenver.edu %K mHealth %K decision aids %K HIV %K healthcare workers %D 2018 %7 15.01.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The prevention of mother-to-child transmission (PMTCT) of HIV requires innovative solutions. Although routine monitoring is effective in some areas, standardized and easy-to-scale solutions to identify and monitor pregnant women, test them for HIV, and treat them and their children is still lacking. Mobile health (mHealth) offers opportunities for surveillance and reporting in rural areas of low- and middle-income countries. Objective: The aim of this study was to document the preliminary impacts of the Tanzania Health Information Technology (T-HIT) system mHealth intervention aimed at health workers for PMTCT care delivery and capacity building in a rural area of Tanzania. Methods: We developed T-HIT as a tablet-based system for an electronic data collection system designed to capture and report PMTCT data during antenatal, delivery, and postnatal visits in Misungwi, Tanzania. T-HIT was tested by health workers in a pilot randomized trial comparing seven sites using T-HIT assigned at random to seven control sites; all sites maintained standard paper record-keeping during the pilot intervention period. We compared numbers of antenatal visits, number of HIV tests administered, and women testing positive across all sites. Results: Health workers recorded data from antenatal visits for 1530 women; of these, 695 (45.42%) were tested for HIV and 3.59% (55/1530) tested positive. Health workers were unable to conduct an HIV test for 103 women (6.73%, 103/1530) because of lack of reagent, which is not captured on paper logs. There was no difference in the activity level for testing when comparing sites T-HIT to non-T-HIT sites. We observed a significant postintervention increase in the numbers of women testing positive for HIV compared with the preintervention period (P=.04), but this was likely not attributable to the T-HIT system. Conclusions: T-HIT had a high degree of acceptability and feasibility and is perceived as useful by health workers, who documented more antenatal visits during the pilot intervention compared with a traditional system of paper logs, suggesting potential for improvements in antenatal care for women at risk for HIV. %M 29335236 %R 10.2196/mhealth.8513 %U https://mhealth.jmir.org/2018/1/e16/ %U https://doi.org/10.2196/mhealth.8513 %U http://www.ncbi.nlm.nih.gov/pubmed/29335236 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 1 %P e6 %T Development of a Maternal, Newborn and Child mHealth Intervention in Thai Nguyen Province, Vietnam: Protocol for the mMom Project %A McBride,Bronwyn %A Nguyen,Liem Thanh %A Wiljer,David %A Vu,Nguyen C %A Nguyen,Cuong K %A O'Neil,John %+ Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A1S6, Canada, 1 778 782 5361, joneil@sfu.ca %K mobile health %K Vietnam %K maternal health %K reproductive health %K health equity %D 2018 %7 11.01.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Ethnic minority women (EMW) living in mountainous areas of northern Vietnam have disproportionately high infant and maternal mortality rates as a result of low maternal health knowledge, poverty, and remoteness from low-capacity health centers. Objective: The objective of this study was to describe the protocol for the development and evaluation of the mMom intervention, which is an integrated mobile health (mHealth) system designed to improve maternal and infant health knowledge, and behavior among women in remote areas of Thai Nguyen, Vietnam. Methods: This project featured the following four phases: (1) development of an mHealth platform integrated into the existing health management information system in partnership with the provincial health department; (2) ethnographic fieldwork and intervention content development; (3) intervention piloting and implementation; and (4) evaluation of the intervention’s impact on participants’ maternal health knowledge, behavior, and interactions with the health system. Results: The mMom project development process resulted in the following: (1) the successful development of the mMom system, including the mHealth platform hardware and integration, the intervention plan and content, and the monitoring and evaluation framework; (2) the piloting and implementation of the intervention as planned; and (3) the implementation of the monitoring and evaluation framework components. Conclusions: This protocol outlines the development of the mMom intervention and describes critical next steps in understanding the impact of the intervention on participants and the wider health system in Thai Nguyen province, Vietnam. %M 29326095 %R 10.2196/resprot.7912 %U http://www.researchprotocols.org/2018/1/e6/ %U https://doi.org/10.2196/resprot.7912 %U http://www.ncbi.nlm.nih.gov/pubmed/29326095 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 1 %P e5 %T A Mobile App to Screen for Neurocognitive Impairment: Preliminary Validation of NeuroScreen Among HIV-Infected South African Adults %A Robbins,Reuben N %A Gouse,Hetta %A Brown,Henry G %A Ehlers,Andries %A Scott,Travis M %A Leu,Cheng-Shiun %A Remien,Robert H %A Mellins,Claude A %A Joska,John A %+ HIV Center for Clinical and Behavioral Studies, Department of Psychiatry, New York State Psychiatric Institute & Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, United States, 1 6467746968, rnr2110@cumc.columbia.edu %K HIV %K neurocognitive %K impairment %K lay health workers %K resource-limited settings %K South Africa %K tablet %K app %K neuropsychology %D 2018 %7 05.01.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Neurocognitive impairment (NCI) is one of the most common complications of HIV infection, and has serious medical and functional consequences. South Africa has 7 million people living with HIV (PLHIV) with up to three-quarters of antiretroviral therapy (ART)-naïve individuals having NCI. South Africa’s health system struggles to meet the care needs of its millions of PLHIV; screening for NCI is typically neglected due to limited clinical staff trained to administer, score, and interpret neuropsychological tests, as well as long test batteries and limited screening tools for South African populations. Without accurate, clinically useful, and relatively brief NCI screening tests that can be administered by all levels of clinical staff, critical opportunities to provide psychoeducation, behavioral planning, additional ART adherence support, and adjuvant therapies for NCI (when they become available) are missed. To address these challenges and gap in care, we developed an mHealth app screening tool, NeuroScreen, to detect NCI that can be administered by all levels of clinical staff, including lay health workers. Objective: The purpose of this study was to examine sensitivity and specificity of an adapted version of NeuroScreen to detect NCI (as determined by a gold standard neuropsychological test battery administered by a trained research psychometrist) among HIV-infected South Africans when administered by a lay health worker. Methods: A total of 102 HIV-infected black South African adults who had initiated ART at least 12 months prior were administered NeuroScreen and a gold standard neuropsychological test battery in the participants’ choice of language (ie, English or isiXhosa). Three composite z scores were calculated for NeuroScreen: (1) sum of all individual test scores, (2) sum of all individual test scores and error scores from four tests, and (3) sum of four tests (abbreviated version). Global deficit scores were calculated for the gold standard battery where a score of 0.5 or greater indicated the presence of NCI. Results: The mean age of participants was 33.31 (SD 7.46) years, most (59.8%, 61/102) had at least 12 years of education, and 81.4% (83/102) of the sample was female. Gold standard test battery results indicated that 26.5% (27/102) of the sample had NCI. Sensitivity and specificity of age-, education-, and sex-adjusted NeuroScreen scores were 81.48% and 74.67% for composite score 1, 81.48% and 81.33% for composite score 2, and 92.59% and 70.67% for composite score 3, respectively. Conclusions: NeuroScreen, a highly automated, easy-to-use, tablet-based screening test to detect NCI among English- and isiXhosa-speaking South African HIV patients demonstrated robust sensitivity and specificity to detect NCI when administered by lay health workers. NeuroScreen could help make screening for NCI more feasible. However, additional research is needed with larger samples and normative test performance data are needed. %M 29305338 %R 10.2196/mhealth.9148 %U http://mhealth.jmir.org/2018/1/e5/ %U https://doi.org/10.2196/mhealth.9148 %U http://www.ncbi.nlm.nih.gov/pubmed/29305338 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 12 %P e174 %T Developing mHealth Messages to Promote Postmenstrual Regulation Contraceptive Use in Bangladesh: Participatory Interview Study %A Eckersberger,Elisabeth %A Pearson,Erin %A Andersen,Kathryn %A Hossain,Altaf %A Footman,Katharine %A Biswas,Kamal Kanti %A Nuremowla,Sadid %A Reiss,Kate %+ Ipas, PO Box 9990, Chapel Hill, NC, 27515, United States, 1 9199677052, eckersbergere@ipas.org %K abortion %K reproductive health services %K contraception %K family planning %K mHealth %K Bangladesh %D 2017 %7 14.12.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Abortions are restricted in Bangladesh, but menstrual regulation is an approved alternative, defined as a procedure of regulating the menstrual cycle when menstruation is absent for a short duration. Use of contraception after menstrual regulation can reduce subsequent unintended pregnancy, but in Bangladesh, the contraceptive method mix is dominated by short-term methods, which have higher discontinuation and failure rates. Mobile phones are a channel via which menstrual regulation clients could be offered contraceptive support after leaving the clinic. Objective: This study aimed to support the development of a mobile phone intervention to support postmenstrual regulation family planning use in Bangladesh. It explored what family planning information women want to receive after having a menstrual regulation procedure, whether they would like to receive this information via their mobile phone, and if so, what their preferences are for the way in which it is delivered. Methods: We conducted participatory interviews with 24 menstrual regulation clients in Dhaka and Sylhet divisions in Bangladesh. Women were recruited from facilities in urban and peri-urban areas, which included public sector clinics supported by Ipas, an international nongovernmental organization (NGO), and NGO clinics run by Marie Stopes. Main themes covered in the interviews were factors affecting the use of contraception, what information and support women want after their menstrual regulation procedure, how respondents would prefer to receive information about contraception, and other key issues for mobile health (mHealth) interventions, such as language and privacy. As part of the in-depth interviews, women were shown and played 6 different messages about contraception on the research assistant’s phone, which they were given to operate, and were then asked to give feedback. Results: Women were open to both receiving messages about family planning methods on their mobile phones and talking to a counselor about family planning methods over the phone after their menstrual regulation. Women most commonly wanted information about the contraceptive method they were currently using and wanted this information to be tailored to their particular needs. Women preferred voice messages to text and liked the interactive voice message format. When asked to repeat and identify the main points of the messages, women demonstrated good understanding of the content. Women did not seem too concerned with privacy or with others reading the messages and welcomed including their husbands in speaking to a counselor. Conclusions: This study found that menstrual regulation clients are very interested in receiving information on their phones to support family planning use and wanted more information about the method of contraception they were using. Participatory voicemail was the preferred modality. %M 29242175 %R 10.2196/mhealth.6969 %U http://mhealth.jmir.org/2017/12/e174/ %U https://doi.org/10.2196/mhealth.6969 %U http://www.ncbi.nlm.nih.gov/pubmed/29242175 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 12 %P e186 %T How Do Infant Feeding Apps in China Measure Up? A Content Quality Assessment %A Zhao,Jing %A Freeman,Becky %A Li,Mu %+ School of Public Health, University of Sydney, Edward Ford Building, A27, Camperdown, New South Wales, 2006, Australia, 61 406502156, jzha5010@uni.sydney.edu.au %K apps %K mobile phone %K Chinese %D 2017 %7 06.12.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Globally, with the popularization of mobile phones, the number of health-related mobile phone apps has skyrocketed to 259,000 in 2016. In the digital era, people are accessing health information through their fingertips. In China, there are several apps that claim to provide infant feeding and nutrition guidance. However, the quality of information in those apps has not been extensively assessed. Objective: We aimed to assess the quality of Chinese infant feeding apps using comprehensive quality assessment criteria and to explore Chinese mothers’ perceptions on apps’ quality and usability. Methods: We searched for free-to-download Chinese infant feeding apps in the iTunes and Android App Stores. We conducted a comprehensive assessment of the accountability, scientific basis, accuracy of information relevant to infant feeding, advertising policy, and functionality and carried out a preliminary screening of infant formula advertisements in the apps. In addition, we also conducted exploratory qualitative research through semistructured interviews with Chinese mothers in Shanghai to elicit their views about the quality of apps. Results: A total of 4925 apps were screened, and 26 apps that met the selection criteria were evaluated. All 26 apps were developed by commercial entities, and the majority of them were rated poorly. The highest total score was 62.2 (out of approximately 100) and the lowest was 16.7. In the four quality domains assessed, none of them fulfilled all the accountability criteria. Three out of 26 apps provided information covering the three practices from the World Health Organization’s infant feeding recommendations. Only one app described its advertising policy in its terms of usage. The most common app functionality was a built-in social forum (19/26). Provision of a website link was the least common functionality (2/26). A total of 20 out of 26 apps promoted infant formula banner advertisements on their homepages. In addition, 12 apps included both e-commerce stores and featured infant formula advertisements. In total, 21 mothers were interviewed face-to-face. Mothers highly valued immediate access to parenting information and multifunctionality provided by apps. However, concerns regarding incredible information and commercial activities in apps, as well as the desire for information and support offered by health care professionals were expressed. Conclusions: The findings provide valuable information on Chinese infant feeding apps. The results are concerning, particularly with the relative absence of scientific basis and credibility and the large number of commercial advertisements that are displayed. Apps do seem to be able to provide an opportunity for mothers to access health information and support; it is time for tighter controls on content and advertisements. Ongoing app research and development should focus on implementation of a standard framework, which would drive the development of high-quality apps to support healthy infant feeding through cooperation among academics, health professionals, app users, app developers, and government bodies. %M 29212627 %R 10.2196/mhealth.8764 %U http://mhealth.jmir.org/2017/12/e186/ %U https://doi.org/10.2196/mhealth.8764 %U http://www.ncbi.nlm.nih.gov/pubmed/29212627 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 12 %P e182 %T App-Supported Promotion of Child Growth and Development by Community Health Workers in Kenya: Feasibility and Acceptability Study %A van Heerden,Alastair %A Sen,Debjeet %A Desmond,Chris %A Louw,Julia %A Richter,Linda %+ Human Sciences Research Council, Sweetwaters, Pietermaritzburg,, South Africa, 27 33 324 5015 ext 5015, avanheerden@hsrc.ac.za %K child health %K child development %K monitoring and evaluation %K parent support %K mHealth %D 2017 %7 05.12.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Early childhood is a critical phase of development. In low resource settings, monitoring this stage of development and providing appropriate and timely feedback is a challenge. Community-based service providers play a key role in promoting early childhood development in areas where government services are weak. These community-based service providers are also tasked with the collection of monitoring and evaluation data for donors and local government. Usually, collection of these data aims to provide accountability, learning, and correction leading to improvement. However, such data is rarely used beyond the accountability stage. Objective: The purpose of this study was to test the feasibility and acceptability of the Information for Action (IFA) mobile phone app. The IFA app was designed for use by community health volunteers (CHVs), and repackages routinely collected data about children into useful, offline decision support for caregivers and program managers. Methods: The IFA app was tested with a convenience sample of 10 CHVs in West Katweng’a, a sublocation of Rarieda subcounty in western Kenya. CHVs used the IFA app for 5 months as part of their regular home visits to households containing children aged 0 to 5 years, after which a qualitative assessment of the app was conducted. A total of 16 caregivers who received services from the CHVs were randomly selected to participate in 1 of 2 focus group discussions about their experience. Results: The app was reported to help facilitate interactive dialog between CHVs and caregivers, leading to improved quality of home visits. Caregivers described the app as shifting the relationship from feeling harassed by CHVs to experiencing genuine interest from CHVs. CHVs reported feasibility challenges primarily related to infrastructure. The limited battery life of mobile phones combined with the lack of readily available electricity made it difficult to keep the phones charged. CHVs reported initial anxiety as first-time mobile phones users, including concerns about using the IFA app. With time, increased levels of confidence were seen. Conclusions: Acceptability was high with both CHVs and caregivers, who reported an improvement in their client-provider relationship. A number of feasibility challenges were experienced. %M 29208588 %R 10.2196/mhealth.6911 %U http://mhealth.jmir.org/2017/12/e182/ %U https://doi.org/10.2196/mhealth.6911 %U http://www.ncbi.nlm.nih.gov/pubmed/29208588 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 11 %P e171 %T Using Android and Open Data Kit Technology in Data Management for Research in Resource-Limited Settings in the Niger Delta Region of Nigeria: Cross-Sectional Household Survey %A Maduka,Omosivie %A Akpan,Godwin %A Maleghemi,Sylvester %+ Department of Preventive and Social Medicine, College of Health Sciences, University of Port Harcourt, Alakahia, Choba, Port Harcourt, 50001, Nigeria, 234 8033298096, omosivie.maduka@uniport.edu.ng %K mobile phones %K technology %K Africa %D 2017 %7 30.11.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Data collection in Sub-Saharan Africa has traditionally been paper-based. However, the popularization of Android mobile devices and data capture software has brought paperless data management within reach. We used Open Data Kit (ODK) technology on Android mobile devices during a household survey in the Niger Delta region of Nigeria. Objective: The aim of this study was to describe the pros and cons of deploying ODK for data management. Methods: A descriptive cross-sectional household survey was carried out by 6 data collectors between April and May 2016. Data were obtained from 1706 persons in 601 households across 6 communities in 3 states in the Niger Delta. The use of Android mobile devices and ODK technology involved form building, testing, collection, aggregation, and download for data analysis. The median duration for data collection per household and per individual was 25.7 and 9.3 min, respectively. Results: Data entries per device ranged from 33 (33/1706, 1.93%) to 482 (482/1706, 28.25%) individuals between 9 (9/601, 1.5%) and 122 (122/601, 20.3%) households. The most entries (470) were made by data collector 5. Only 2 respondents had data entry errors (2/1706, 0.12%). However, 73 (73/601, 12.1%) households had inaccurate date and time entries for when data collection started and ended. The cost of deploying ODK was estimated at US $206.7 in comparison with the estimated cost of US $466.7 for paper-based data management. Conclusions: We found the use of mobile data capture technology to be efficient and cost-effective. As Internet services improve in Africa, we advocate their use as effective tools for health information management. %M 29191798 %R 10.2196/mhealth.7827 %U http://mhealth.jmir.org/2017/11/e171/ %U https://doi.org/10.2196/mhealth.7827 %U http://www.ncbi.nlm.nih.gov/pubmed/29191798 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 11 %P e368 %T Performance of a Mobile Phone App-Based Participatory Syndromic Surveillance System for Acute Febrile Illness and Acute Gastroenteritis in Rural Guatemala %A Olson,Daniel %A Lamb,Molly %A Lopez,Maria Renee %A Colborn,Kathryn %A Paniagua-Avila,Alejandra %A Zacarias,Alma %A Zambrano-Perilla,Ricardo %A Rodríguez-Castro,Sergio Ricardo %A Cordon-Rosales,Celia %A Asturias,Edwin Jose %+ University of Colorado School of Medicine, Section of Pediatric Infectious Diseases, 13123 East 16th Avenue, Box 055, Aurora, CO, 80045, United States, 1 7207772838, daniel.olson@ucdenver.edu %K mobile phone %K app %K participatory %K syndromic surveillance %K norovirus %K dengue %K acute febrile illness %K diarrhea %K Guatemala %D 2017 %7 09.11.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: With their increasing availability in resource-limited settings, mobile phones may provide an important tool for participatory syndromic surveillance, in which users provide symptom data directly into a centralized database. Objective: We studied the performance of a mobile phone app-based participatory syndromic surveillance system for collecting syndromic data (acute febrile illness and acute gastroenteritis) to detect dengue virus and norovirus on a cohort of children living in a low-resource and rural area of Guatemala. Methods: Randomized households were provided with a mobile phone and asked to submit weekly reports using a symptom diary app (Vigilant-e). Participants reporting acute febrile illness or acute gastroenteritis answered additional questions using a decision-tree algorithm and were subsequently visited at home by a study nurse who performed a second interview and collected samples for dengue virus if confirmed acute febrile illness and norovirus if acute gastroenteritis. We analyzed risk factors associated with decreased self-reporting of syndromic data using the Vigilant-e app and evaluated strategies to improve self-reporting. We also assessed agreement between self-report and nurse-collected data obtained during home visits. Results: From April 2015 to June 2016, 469 children in 207 households provided 471 person-years of observation. Mean weekly symptom reporting rate was 78% (range 58%-89%). Households with a poor (<70%) weekly reporting rate using the Vigilant-e app during the first 25 weeks of observation (n=57) had a greater number of children (mean 2.8, SD 1.5 vs mean 2.5, SD 1.3; risk ratio [RR] 1.2, 95% CI 1.1-1.4), were less likely to have used mobile phones for text messaging at study enrollment (61%, 35/57 vs 76.7%, 115/150; RR 0.6, 95% CI 0.4-0.9), and were less likely to access care at the local public clinic (35%, 20/57 vs 67.3%, 101/150; RR 0.4, 95% CI 0.2-0.6). Parents of female enrolled participants were more likely to have low response rate (57.1%, 84/147 vs 43.8%, 141/322; RR 1.4, 95% CI 1.1-1.9). Several external factors (cellular tower collapse, contentious elections) were associated with periods of decreased reporting. Poor response rate (<70%) was associated with lower case reporting of acute gastroenteritis, norovirus-associated acute gastroenteritis, acute febrile illness, and dengue virus-associated acute febrile illness (P<.001). Parent-reported syndromic data on the Vigilant-e app demonstrated agreement with nurse-collected data for fever (kappa=.57, P<.001), vomiting (kappa=.63, P<.001), and diarrhea (kappa=.61, P<.001), with decreased agreement as the time interval between parental report and nurse home visit increased (<1 day: kappa=.65-.70; ≥2 days: kappa=.08-.29). Conclusions: In a resource-limited area of rural Guatemala, a mobile phone app-based participatory syndromic surveillance system demonstrated a high reporting rate and good agreement between parental reported data and nurse-reported data during home visits. Several household-level and external factors were associated with decreased syndromic reporting. Poor reporting rate was associated with decreased syndromic and pathogen-specific case ascertainment. %M 29122738 %R 10.2196/jmir.8041 %U http://www.jmir.org/2017/11/e368/ %U https://doi.org/10.2196/jmir.8041 %U http://www.ncbi.nlm.nih.gov/pubmed/29122738 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 10 %P e158 %T Guidelines and mHealth to Improve Quality of Hypertension and Type 2 Diabetes Care for Vulnerable Populations in Lebanon: Longitudinal Cohort Study %A Doocy,Shannon %A Paik,Kenneth E %A Lyles,Emily %A Hei Tam,Hok %A Fahed,Zeina %A Winkler,Eric %A Kontunen,Kaisa %A Mkanna,Abdalla %A Burnham,Gilbert %+ Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States, 1 4105022628, doocy1@jhu.edu %K mHealth %K hypertension %K diabetes mellitus %K chronic disease %K Lebanon, Syria %K refugees %D 2017 %7 18.10.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Given the protracted nature of the crisis in Syria, the large noncommunicable disease (NCD) caseload of Syrian refugees and host Lebanese, and the high costs of providing NCD care, the implications for Lebanon’s health system are vast. Objective: The aim of this study was to evaluate the effectiveness of treatment guidelines and a mobile health (mHealth) app on quality of care and health outcomes in primary care settings in Lebanon. Methods: A longitudinal cohort study was implemented from January 2015 to August 2016 to evaluate the effectiveness of treatment guidelines and an mHealth app on quality of care and health outcomes for Syrian and Lebanese patients in Lebanese primary health care (PHC) facilities. Results: Compared with baseline record extraction, recording of blood pressure (BP) readings (−11.4%, P<.001) and blood sugar measurements (−6.9%, P=.03) significantly decreased following the implementation of treatment guidelines. Recording of BP readings also decreased after the mHealth phase as compared with baseline (−8.4%, P=.001); however, recording of body mass index (BMI) reporting increased at the end of the mHealth phase from baseline (8.1%, P<.001) and the guidelines phase (7.7%, P<.001). There were a great proportion of patients for whom blood sugar, BP, weight, height, and BMI were recorded using the tablet compared with in paper records; however, only differences in BMI were statistically significant (31.6% higher in app data as compared with paper records; P<.001). Data extracted from the mHealth app showed that a higher proportion of providers offered lifestyle counseling compared with the counseling reported in patients’ paper records (health diet counseling; 77.3% in app data vs 8.8% in paper records, P<.001 and physical activity counseling and 59.7% in app vs 7.1% in paper records, P<.001). There were statistically significant increases in all four measures of patient-provider interaction across study phases. Provider inquiry of medical history increased by 16.6% from baseline following guideline implementation and by 28.2% from baseline to mHealth implementation (P<.001). From baseline, patient report of provider inquiry regarding medication complications increased in the guidelines and mHealth phases by 12.9% and 59.6%, respectively, (P<.001). The proportion of patients reporting that providers asked other questions relevant to their illness increased from baseline through guidelines implementation by 27.8% and to mHealth implementation by 66.3% (P<.001). Follow-up scheduling increased from baseline to the guidelines phase by 20.6% and the mHealth phase by 39.8% (P<.001). Conclusions: Results from this study of an mHealth app in 10 PHC facilities in Lebanon indicate that the app has potential to improve adherence to guidelines and quality of care. Further studies are necessary to determine the effects of patient-controlled health record apps on provider adherence to treatment guidelines, as well as patients’ long-term medication and treatment adherence and disease control. %M 29046266 %R 10.2196/mhealth.7745 %U http://mhealth.jmir.org/2017/10/e158/ %U https://doi.org/10.2196/mhealth.7745 %U http://www.ncbi.nlm.nih.gov/pubmed/29046266 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 10 %P e155 %T Tackling Regional Public Health Issues Using Mobile Health Technology: Event Report of an mHealth Hackathon in Thailand %A Pathanasethpong,Atipong %A Soomlek,Chitsutha %A Morley,Katharine %A Morley,Michael %A Polpinit,Pattarawit %A Dagan,Alon %A Weis,James W %A Celi,Leo Anthony %+ Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mittraphab Road, Khon Kaen,, Thailand, 66 891758278, atipat@kku.ac.th %K hackathon %K mHealth %K interdisciplinary collaboration %D 2017 %7 16.10.2017 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X Hackathons are intense, short, collaborative events focusing on solving real world problems through interdisciplinary teams. This is a report of the mHealth hackathon hosted by Khon Kaen University in collaboration with MIT Sana and faculty members from Harvard Medical School with the aim to improve health care delivery in the Northeast region of Thailand. Key health challenges, such as improving population health literacy, tracking disease trajectory and outcomes among rural communities, and supporting the workflow of overburdened frontline providers, were addressed using mHealth. Many modifications from the usual format of hackathon were made to tailor the event to the local context and culture, such as the process of recruiting participants and how teams were matched and formed. These modifications serve as good learning points for hosting future hackathons. There are also many lessons learned about how to achieve a fruitful collaboration despite cultural barriers, how to best provide mentorship to the participants, how to instill in the participants a sense of mission, and how to match the participants in a fair and efficient manner. This event showcases how interdisciplinary collaboration can produce results that are unattainable by any discipline alone and demonstrates that innovations are the fruits of collective wisdom of people from different fields of expertise who work together toward the same goals. %M 29038098 %R 10.2196/mhealth.8259 %U http://mhealth.jmir.org/2017/10/e155/ %U https://doi.org/10.2196/mhealth.8259 %U http://www.ncbi.nlm.nih.gov/pubmed/29038098 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 10 %P e148 %T Using Mobile Phones to Improve Vaccination Uptake in 21 Low- and Middle-Income Countries: Systematic Review %A Oliver-Williams,Clare %A Brown,Elizabeth %A Devereux,Sara %A Fairhead,Cassandra %A Holeman,Isaac %+ Cardiovascular Epidemiology Unit, Department of Public Health & Primary Care, University of Cambridge, Wort's Causeway, Cambridge,, United Kingdom, 44 1223 748650, cto21@medschl.cam.ac.uk %K cell phones %K vaccination %K communication %K telemedicine %K mHealth %K global health %D 2017 %7 04.10.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The benefits of vaccination have been comprehensively proven; however, disparities in coverage persist because of poor health system management, limited resources, and parental knowledge and attitudes. Evidence suggests that health interventions that engage local parties in communication strategies improve vaccination uptake. As mobile technology is widely used to improve health communication, mobile health (mHealth) interventions might be used to increase coverage. Objective: The aim of this study was to conduct a systematic review of the available literature on the use of mHealth to improve vaccination in low- and middle-income countries with large numbers of unvaccinated children. Methods: In February 2017, MEDLINE (Medical Literature Analysis and Retrieval System Online), Scopus, and Web of Science, as well as three health organization websites—Communication Initiative Network, TechNet-21, and PATH—were searched to identify mHealth intervention studies on vaccination uptake in 21 countries. Results: Ten peer-reviewed studies and 11 studies from white or gray literature were included. Nine took place in India, three in Pakistan, two each in Malawi and Nigeria, and one each in Bangladesh, Zambia, Zimbabwe, and Kenya. Ten peer-reviewed studies and 7 white or gray studies demonstrated improved vaccination uptake after interventions, including appointment reminders, mobile phone apps, and prerecorded messages. Conclusions: Although the potential for mHealth interventions to improve vaccination coverage seems clear, the evidence for such interventions is not. The dearth of studies in countries facing the greatest barriers to immunization impedes the prospects for evidence-based policy and practice in these settings. %M 28978495 %R 10.2196/mhealth.7792 %U http://mhealth.jmir.org/2017/10/e148/ %U https://doi.org/10.2196/mhealth.7792 %U http://www.ncbi.nlm.nih.gov/pubmed/28978495 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 3 %N 4 %P e65 %T Lessons From the Implementation of Mo-Buzz, a Mobile Pandemic Surveillance System for Dengue %A Lwin,May Oo %A Jayasundar,Karthikayen %A Sheldenkar,Anita %A Wijayamuni,Ruwan %A Wimalaratne,Prasad %A Ernst,Kacey C %A Foo,Schubert %+ Wee Kim Wee School of Communication and Information, Nanyang Technological University, 31 Nanyang Link, Singapore, 637718, Singapore, 65 67906669, tmaylwin@ntu.edu.sg %K pandemics %K dengue %K health communication %K telemedicine %K epidemiology %K participatory surveillance %K participatory epidemiology %D 2017 %7 02.10.2017 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Approximately 128 countries and 3.9 billion people are at risk of dengue infection. Incidence of dengue has increased over the past decades, becoming a growing public health concern for countries with populations that are increasingly susceptible to this vector-borne disease, such as Sri Lanka. Almost 55,150 dengue cases were reported in Sri Lanka in 2016, with more than 30.40% of cases (n=16,767) originating from Colombo, which struggles with an outdated manual paper-based dengue outbreak management system. Community education and outreach about dengue are also executed using paper-based media channels such as pamphlets and brochures. Yet, Sri Lanka is one of the countries with the most affordable rates of mobile services in the world, with penetration rates higher than most developing countries. Objectives: To combat the issues of an exhausted dengue management system and to make use of new technology, in 2015, a mobile participatory system for dengue surveillance called Mo-Buzz was developed and launched in Colombo, Sri Lanka. This paper describes the system’s components and uptake, along with other similar disease surveillance systems. Methods: We developed Mo-Buzz and tested its feasibility for dengue. Two versions of the app were developed. The first was for use by public health inspectors (PHIs) to digitize form filling and recording of site visit information, and track dengue outbreaks on a real-time dengue hotspot map using the global positioning system technology. The system also provides updated dengue infographics and educational materials for the PHIs to educate the general public. The second version of Mo-Buzz was created for use by the general public. This system uses dynamic mapping to help educate and inform the general public about potential outbreak regions and allow them to report dengue symptoms and post pictures of potential dengue mosquito–breeding sites, which are automatically sent to the health authorities. Targeted alerts can be sent to users depending on their geographical location. Results: We assessed the usage and the usability of the app and its impact on overall dengue transmission in Colombo. Initial uptake of Mo-Buzz for PHIs was low; however, after more training and incentivizing of usage, the uptake of the app in PHIs increased from less than 10% (n=3) to 76% (n=38). The general public user evaluation feedback was fruitful in providing improvements to the app, and at present, a number of solutions are being reviewed as viable options to boost user uptake. Conclusions: From our Mo-Buzz study, we have learned that initial acceptance of such systems can be slow but eventually positive. Mobile and social media interventions, such as Mo-Buzz, are poised to play a greater role in shaping risk perceptions and managing seasonal and sporadic outbreaks of infectious diseases in Asia and around the world. %M 28970191 %R 10.2196/publichealth.7376 %U https://publichealth.jmir.org/2017/4/e65/ %U https://doi.org/10.2196/publichealth.7376 %U http://www.ncbi.nlm.nih.gov/pubmed/28970191 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 8 %P e116 %T Feasibility and Acceptability of a Text Message-Based Smoking Cessation Program for Young Adults in Lima, Peru: Pilot Study %A Blitchtein-Winicki,Dora %A Zevallos,Karine %A Samolski,M Reuven %A Requena,David %A Velarde,Chaska %A Briceño,Patricia %A Piazza,Marina %A Ybarra,Michele L %+ Executive Office of Research, Peruvian National Institute of Health, Cápac Yupanqui 1400, Jesus María, Lima, CP 11, Peru, 51 999 090917, dblit2007@gmail.com %K Pilot Projects, Text Messaging, Smoking Cessation, Young Adult, Cognitive Therapy, Feasibility Studies, Latinos %D 2017 %7 04.08.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In Peru’s urban communities, tobacco smoking generally starts during adolescence and smoking prevalence is highest among young adults. Each year, many attempt to quit, but access to smoking cessation programs is limited. Evidence-based text messaging smoking cessation programs are an alternative that has been successfully implemented in high-income countries, but not yet in middle- and low-income countries with limited tobacco control policies. Objective: The objective was to assess the feasibility and acceptability of an short message service (SMS) text message-based cognitive behavioral smoking cessation program for young adults in Lima, Peru. Methods: Recruitment included using flyers and social media ads to direct young adults interested in quitting smoking to a website where interested participants completed a Google Drive survey. Inclusion criteria were being between ages 18 and 25 years, smoking at least four cigarettes per day at least 6 days per week, willing to quit in the next 30 days, owning a mobile phone, using SMS text messaging at least once in past year, and residing in Lima. Participants joined one of three phases: (1) focus groups and in-depth interviews whose feedback was used to develop the SMS text messages, (2) validating the SMS text messages, and (3) a pilot of the SMS text message-based smoking cessation program to test its feasibility and acceptability among young adults in Lima. The outcome measures included adherence to the SMS text message-based program, acceptability of content, and smoking abstinence self-report on days 2, 7, and 30 after quitting. Results: Of 639 participants who completed initial online surveys, 42 met the inclusion criteria and 35 agreed to participate (focus groups and interviews: n=12; validate SMS text messages: n=8; program pilot: n=15). Common quit practices and beliefs emerged from participants in the focus groups and interviews informed the content, tone, and delivery schedule of the messages used in the SMS text message smoking cessation program. A small randomized controlled pilot trial was performed to test the program’s feasibility and acceptability; nine smokers were assigned to the SMS text message smoking cessation program and six to a SMS text message nutrition program. Participant retention was high: 93% (14/15) remained until day 30 after quit day. In all, 56% of participants (5/9) in the SMS text message smoking cessation program reported remaining smoke-free until day 30 after quit day and 17% of participants (1/6) in the SMS text message nutrition program reported remaining smoke-free during the entire program. The 14 participants who completed the pilot reported that they received valuable health information and approved the delivery schedule of the SMS text messages. Conclusions: This study provides initial evidence that a SMS text message smoking cessation program is feasible and acceptable for young adults residing in Lima. %M 28778850 %R 10.2196/mhealth.7532 %U http://mhealth.jmir.org/2017/8/e116/ %U https://doi.org/10.2196/mhealth.7532 %U http://www.ncbi.nlm.nih.gov/pubmed/28778850 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 7 %P e93 %T Content Analysis of Smartphone Apps for Smoking Cessation in China: Empirical Study %A Cheng,Feng %A Xu,Junfang %A Su,Chunyan %A Fu,Xiaoxing %A Bricker,Jonathan %+ Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, WA,, United States, 1 206 667 5074, jbricker@fredhutch.org %K smoking cessation %K smartphone apps %K China %D 2017 %7 11.07.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: With 360 million smokers, China consumes more cigarettes than any other country in the world. Given that 620 million Chinese own smartphones, smartphone apps for smoking cessation are increasingly used in China to help smokers quit. Objective: This study analyzed and evaluated the contents of all smoking cessation apps (iOS and Android) available in China, applying the China Clinical Smoking Cessation Guideline (CCSCG; identical to the US Clinical Practice Guideline for Treating Tobacco Use and Dependence) as a framework for analysis. Methods: We conducted a content analysis of Chinese Android and iOS smoking cessation apps (N=64) designed to assist users in quitting smoking. Each app was independently coded by two raters for its approach to smoking cessation and adherence to the CCSCG. We also recorded the features of smoking cessation apps (eg, release date, size, frequency of downloads, user ratings, type, quality scores by raters, and designers). Linear regression was used to test predictors of popularity and user-rated quality. Results: Chinese smoking cessation apps have low levels of adherence to guidelines, with an average score of 11.1 for Android and 14.6 for iOS apps on a scale of 0 to 46. There was no significant association between popularity, user rating, and the characteristics of apps. However, there was a positive relationship between popularity, user rating, and adherence score. Conclusions: Chinese apps for smoking cessation have low levels of adherence to standard clinical practice guidelines. New apps need be developed and existing apps be revised following evidence-based principles in China. %M 28698170 %R 10.2196/mhealth.7462 %U http://mhealth.jmir.org/2017/7/e93/ %U https://doi.org/10.2196/mhealth.7462 %U http://www.ncbi.nlm.nih.gov/pubmed/28698170 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 6 %P e126 %T Mobile Phone Short Messages to Improve Exclusive Breastfeeding and Reduce Adverse Infant Feeding Practices: Protocol for a Randomized Controlled Trial in Yangon, Myanmar %A Hmone,Myat Pan %A Li,Mu %A Alam,Ashraful %A Dibley,Michael J %+ Sydney Medical School, School of Public Health, The University of Sydney, A27, Edward Ford Building, Sydney,, Australia, 61 4 2470 8124, myat.panhmone@sydney.edu.au %K randomized controlled trial %K mHealth %K text messaging (SMS) %K intervention studies %K exclusive breastfeeding %K infant and young child feeding %K nutrition %K Myanmar %K pregnant women %K child health %D 2017 %7 28.06.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Myanmar has a high burden of mortality for children aged younger than 5 years in which undernutrition plays a major role. Despite current efforts, the exclusive breastfeeding rate for children under 6 months is only 24%. To date there have been no interventions using mobile phones to improve breastfeeding and other feeding practices in Myanmar. Objective: This study aims to implement a breastfeeding promotion intervention using mobile phone text messages in Yangon, Myanmar, and evaluate its impact on breastfeeding practices. Methods: M528 is a 2-group parallel-arm randomized controlled trial with 9 months follow-up from recruitment until 6 months post-delivery. A total of 353 pregnant women between 28 and 34 weeks’ gestation who had access to a mobile phone and were able to read and write have been recruited from the Central Women’s Hospital, Yangon, and allocated randomly to an intervention or control group in a 1:1 ratio. The intervention group received breastfeeding promotional SMS messages 3 times a week while the control group received maternal and child health care messages (excluding breastfeeding-related messages) once a week. The SMS messages were tailored for the women’s stage of gestation or the child’s age. A formative qualitative study was conducted prior to the trial to inform the study design and text message content. We hypothesize that the exclusive breastfeeding rate in the intervention group will be double that in the control group. The primary outcome is exclusive breastfeeding from birth to 6 months and secondary outcomes are median durations of exclusive breastfeeding and other infant feeding practices. Both primary and secondary outcomes were assessed by monthly phone calls at 1 to 6 months postdelivery in both groups. Participants’ delivery status was tracked through text messages, phone calls, and hospital records, and delivery characteristics were assessed 1 month after delivery. Child morbidity and breastfeeding self-efficacy scores were assessed at 1, 3, and 5 months postdelivery. Social desirability was measured at 5 months, and text messages expressing delivery success and user experience were assessed at the end of the study. Results: The targeted 353 pregnant women were recruited between January and March 2015. Baseline data have been collected; SMS messages have been developed and pretested and sent to the women from both groups. Follow-up data collection via phone calls has been completed. Data analysis is being done and results are expected soon. This is the first RCT study examining the effects of mobile text messaging for promoting exclusive breastfeeding. Conclusions: This trial is timely in Myanmar following the telecommunications market opening in 2014. Our results will help determine whether text messaging is an effective and feasible method for promoting appropriate feeding practices and will inform further research to assess how this model could be replicated in the broader community. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12615000063516; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367704 (Archived by WebCite at http://www.webcitation.org/ 6rGif3l81) %M 28659252 %R 10.2196/resprot.7679 %U http://www.researchprotocols.org/2017/6/e126/ %U https://doi.org/10.2196/resprot.7679 %U http://www.ncbi.nlm.nih.gov/pubmed/28659252 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 6 %P e216 %T What Predicts Online Health Information-Seeking Behavior Among Egyptian Adults? A Cross-Sectional Study %A Ghweeba,Mayada %A Lindenmeyer,Antje %A Shishi,Sobhi %A Abbas,Mostafa %A Waheed,Amani %A Amer,Shaymaa %+ Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom, 44 0 121 4145390, a.lindenmeyer@bham.ac.uk %K Internet %K information-seeking behavior %K computer literacy %K surveys and questionnaires %K Egypt %D 2017 %7 22.06.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Over the last decade, the Internet has become an important source of health-related information for a wide range of users worldwide. Yet, little is known about the personal characteristics of Egyptian Internet users who search for online health information (OHI). Objective: The aim of the study was to identify the personal characteristics of Egyptian OHI seekers and to determine any associations between their personal characteristics and their health information-seeking behavior. Methods:  This cross-sectional questionnaire study was conducted from June to October 2015. A Web-based questionnaire was sent to Egyptian users aged 18 years and older (N=1400) of a popular Arabic-language health information website. The questionnaire included (1) demographic characteristics; (2) self-reported general health status; and (3) OHI-seeking behavior that included frequency of use, different topics sought, and self-reported impact of obtained OHI on health behaviors. Data were analyzed using descriptive statistics and multiple regression analysis. Results: A total of 490 participants completed the electronic questionnaire with a response rate equivalent to 35.0% (490/1400). Regarding personal characteristics, 57.1% (280/490) of participants were females, 63.4% (311/490) had a university level qualification, and 37.1% (182/490) had a chronic health problem. The most commonly sought OHI by the participants was nutrition-related. Results of the multiple regression analysis showed that 31.0% of the variance in frequency of seeking OHI among Egyptian adults can be predicted by personal characteristics. Participants who sought OHI more frequently were likely to be female, of younger age, had higher education levels, and good self-reported general health. Conclusions: Our results provide insights into personal characteristics and OHI-seeking behaviors of Egyptian OHI users. This will contribute to better recognize their needs, highlight ways to increase the availability of appropriate OHI, and may lead to the provision of tools allowing Egyptian OHI users to navigate to the highest-quality health information. %M 28642216 %R 10.2196/jmir.6855 %U http://www.jmir.org/2017/6/e216/ %U https://doi.org/10.2196/jmir.6855 %U http://www.ncbi.nlm.nih.gov/pubmed/28642216 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 5 %P e72 %T A Smartphone-Based Approach for Triage of Human Papillomavirus-Positive Sub-Saharan African Women: A Prospective Study %A Urner,Esther %A Delavy,Martine %A Catarino,Rosa %A Viviano,Manuela %A Meyer-Hamme,Ulrike %A Benski,Anne-Caroline %A Jinoro,Jeromine %A Heriniainasolo,Josea Lea %A Undurraga,Manuela %A De Vuyst,Hugo %A Combescure,Christophe %A Vassilakos,Pierre %A Petignat,Patrick %+ Gynecology Division, Department of Gynecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, Geneva, 1206, Switzerland, 41 22 372 68 16, martinegilliane@gmail.com %K cervical cancer %K squamous intraepithelial lesions of the cervix %K HPV %K acetic acid %K lugol’s iodine %K smartphone %K mobile phone %D 2017 %7 29.05.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Sub-Saharan African countries are marked by a high incidence of cervical cancer. Madagascar ranks 11th among the countries with the highest cervical cancer incidence worldwide. Objective: The aim of the study was to evaluate the performances of digital smartphone-based visual inspection with acetic acid (D-VIA) and Lugol’s iodine (D-VILI) for diagnosing cervical precancer and cancer. Methods: Human papillomavirus (HPV)-positive women recruited through a cervical screening campaign had D-VIA and D-VILI examinations with endocervical curettage (ECC) and cervical biopsy. Three images were captured for each woman (native, D-VIA, D-VILI) using a smartphone camera. The images were randomly coded and distributed on 2 online databases (Google Forms). The D-VIA form included native and D-VIA images, and the D-VILI form included native and D-VILI images. Pathological cases were defined as cervical intraepithelial neoplasia grade 2 or worse (CIN2+). Physicians rated the images as non-pathological or pathological. Using the ECC and cervical biopsy results as references, the sensitivity and specificity of D-VIA and D-VILI examinations for each and all physicians were calculated. Results: Altogether, 15 clinicians assessed 240 images. Sensitivity was higher for the D-VIA interpretations (94.1%; 95% CI 81.6-98.3) than for the D-VILI interpretations (78.8%; 95% CI 54.1-92.1; P=.009). In contrast, the specificity was higher for the D-VILI interpretations (56.4%; 95% CI 38.3-72.9) than for the D-VIA interpretations (50.4%; 95% CI 35.9-64.8; P=.005). Conclusion: Smartphone-based image for triage of HPV-positive women is more accurate for detecting CIN2+ lesions with D-VIA than D-VILI, although with a small loss of specificity. %M 28554879 %R 10.2196/mhealth.6697 %U http://mhealth.jmir.org/2017/5/e72/ %U https://doi.org/10.2196/mhealth.6697 %U http://www.ncbi.nlm.nih.gov/pubmed/28554879 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 5 %P e100 %T An mHealth Framework to Improve Birth Outcomes in Benue State, Nigeria: A Study Protocol %A Ezeanolue,Echezona Edozie %A Gbadamosi,Semiu Olatunde %A Olawepo,John Olajide %A Iwelunmor,Juliet %A Sarpong,Daniel %A Eze,Chuka %A Ogidi,Amaka %A Patel,Dina %A Onoka,Chima %+ Global Health Initiative, School of Community Health Sciences, University of Nevada, 4505 S Maryland Parkway, Las Vegas, NV, 89154-4009, United States, 1 702 895 2687, echezona.ezeanolue@unlv.edu %K mHealth %K smart card %K HIV %K hepatitis B %K sickle cell disease %K mobile health technology %K Nigeria %D 2017 %7 26.05.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: The unprecedented coverage of mobile technology across the globe has led to an increase in the use of mobile health apps and related strategies to make health information available at the point of care. These strategies have the potential to improve birth outcomes, but are limited by the availability of Internet services, especially in resource-limited settings such as Nigeria. Objective: Our primary objective is to determine the feasibility of developing an integrated mobile health platform that is able to collect data from community-based programs, embed collected data into a smart card, and read the smart card using a mobile phone-based app without the need for Internet access. Our secondary objectives are to determine (1) the acceptability of the smart card among pregnant women and (2) the usability of the smart card by pregnant women and health facilities in rural Nigeria. Methods: We will leverage existing technology to develop a platform that integrates a database, smart card technology, and a mobile phone-based app to read the smart cards. We will recruit 300 pregnant women with one of the three conditions—HIV, hepatitis B virus infection, and sickle cell trait or disease—and four health facilities in their community. We will use Glasgow’s Reach, Effectiveness, Adoption, Implementation, and Maintenance framework as a guide to assess the implementation, acceptability, and usability of the mHealth platform. Results: We have recruited four health facilities and 300 pregnant women with at least one of the eligible conditions. Over the course of 3 months, we will complete the development of the mobile health platform and each participant will be offered a smart card; staff in each health facility will receive training on the use of the mobile health platform. Conclusions: Findings from this study could offer a new approach to making health data from pregnant women available at the point of delivery without the need for an Internet connection. This would allow clinicians to implement evidence-based interventions in real time to improve health outcomes. Trial Registration: ClinicalTrials.gov NCT03027258; https://clinicaltrials.gov/ct2/show/NCT03027258 (Archived by WebCite at http://www.webcitation.org/6owR2D0kE) %M 28550003 %R 10.2196/resprot.7743 %U http://www.researchprotocols.org/2017/5/e100/ %U https://doi.org/10.2196/resprot.7743 %U http://www.ncbi.nlm.nih.gov/pubmed/28550003 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e140 %T Building the Evidence Base for Remote Data Collection in Low- and Middle-Income Countries: Comparing Reliability and Accuracy Across Survey Modalities %A Greenleaf,Abigail R %A Gibson,Dustin G %A Khattar,Christelle %A Labrique,Alain B %A Pariyo,George W %+ Johns Hopkins Bloomberg School of Public Health, Department of Population, Family and Reproductive Health, 615 N Wolfe Street, Baltimore, MD, 21205, United States, 1 410 955 3543, agreenleaf@jhu.edu %K mHealth %K developing countries %K Africa South of the Sahara %K cell phones %K health surveys %K reproducibility of results %K surveys and questionnaires %K text messaging %K interviews as topic %K humans %K research design %K data collection methods %D 2017 %7 05.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Given the growing interest in mobile data collection due to the proliferation of mobile phone ownership and network coverage in low- and middle-income countries (LMICs), we synthesized the evidence comparing estimates of health outcomes from multiple modes of data collection. In particular, we reviewed studies that compared a mode of remote data collection with at least one other mode of data collection to identify mode effects and areas for further research. Objective: The study systematically reviewed and summarized the findings from articles and reports that compare a mode of remote data collection to at least one other mode. The aim of this synthesis was to assess the reliability and accuracy of results. Methods: Seven online databases were systematically searched for primary and grey literature pertaining to remote data collection in LMICs. Remote data collection included interactive voice response (IVR), computer-assisted telephone interviews (CATI), short message service (SMS), self-administered questionnaires (SAQ), and Web surveys. Two authors of this study reviewed the abstracts to identify articles which met the primary inclusion criteria. These criteria required that the survey collected the data from the respondent via mobile phone or landline. Articles that met the primary screening criteria were read in full and were screened using secondary inclusion criteria. The four secondary inclusion criteria were that two or more modes of data collection were compared, at least one mode of data collection in the study was a mobile phone survey, the study had to be conducted in a LMIC, and finally, the study should include a health component. Results: Of the 11,568 articles screened, 10 articles were included in this study. Seven distinct modes of remote data collection were identified: CATI, SMS (singular sitting and modular design), IVR, SAQ, and Web surveys (mobile phone and personal computer). CATI was the most frequent remote mode (n=5 articles). Of the three in-person modes (face-to-face [FTF], in-person SAQ, and in-person IVR), FTF was the most common (n=11) mode. The 10 articles made 25 mode comparisons, of which 12 comparisons were from a single article. Six of the 10 articles included sensitive questions. Conclusions: This literature review summarizes the existing research about remote data collection in LMICs. Due to both heterogeneity of outcomes and the limited number of comparisons, this literature review is best positioned to present the current evidence and knowledge gaps rather than attempt to draw conclusions. In order to advance the field of remote data collection, studies that employ standardized sampling methodologies and study designs are necessary to evaluate the potential for differences by survey modality. %M 28476728 %R 10.2196/jmir.7331 %U http://www.jmir.org/2017/5/e140/ %U https://doi.org/10.2196/jmir.7331 %U http://www.ncbi.nlm.nih.gov/pubmed/28476728 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e137 %T Leveraging Mobile Phones for Monitoring Risks for Noncommunicable Diseases in the Future %A Ellis,Jennifer A %+ Bloomberg Philanthropies, 25 E 78th St., New York, NY,, United States, 1 212 205 0129, Jennifer@bloomberg.org %K mHealth %K low- and middle-income countries %K noncommunicable diseases %K health systems strengthening %D 2017 %7 05.05.2017 %9 Guest Editorial %J J Med Internet Res %G English %X %M 28476721 %R 10.2196/jmir.7622 %U http://www.jmir.org/2017/5/e137/ %U https://doi.org/10.2196/jmir.7622 %U http://www.ncbi.nlm.nih.gov/pubmed/28476721 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e139 %T Mobile Phone Surveys for Collecting Population-Level Estimates in Low- and Middle-Income Countries: A Literature Review %A Gibson,Dustin G %A Pereira,Amanda %A Farrenkopf,Brooke A %A Labrique,Alain B %A Pariyo,George W %A Hyder,Adnan A %+ Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States, 1 443 287 8763, dgibso28@jhu.edu %K survey methodology %K cellular phone %K interactive voice response %K short messages service %K computer-assisted telephone interview %K mobile phone surveys %D 2017 %7 05.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: National and subnational level surveys are important for monitoring disease burden, prioritizing resource allocation, and evaluating public health policies. As mobile phone access and ownership become more common globally, mobile phone surveys (MPSs) offer an opportunity to supplement traditional public health household surveys. Objective: The objective of this study was to systematically review the current landscape of MPSs to collect population-level estimates in low- and middle-income countries (LMICs). Methods: Primary and gray literature from 7 online databases were systematically searched for studies that deployed MPSs to collect population-level estimates. Titles and abstracts were screened on primary inclusion and exclusion criteria by two research assistants. Articles that met primary screening requirements were read in full and screened for secondary eligibility criteria. Articles included in review were grouped into the following three categories by their survey modality: (1) interactive voice response (IVR), (2) short message service (SMS), and (3) human operator or computer-assisted telephone interviews (CATI). Data were abstracted by two research assistants. The conduct and reporting of the review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: A total of 6625 articles were identified through the literature review. Overall, 11 articles were identified that contained 19 MPS (CATI, IVR, or SMS) surveys to collect population-level estimates across a range of topics. MPSs were used in Latin America (n=8), the Middle East (n=1), South Asia (n=2), and sub-Saharan Africa (n=8). Nine articles presented results for 10 CATI surveys (10/19, 53%). Two articles discussed the findings of 6 IVR surveys (6/19, 32%). Three SMS surveys were identified from 2 articles (3/19, 16%). Approximately 63% (12/19) of MPS were delivered to mobile phone numbers collected from previously administered household surveys. The majority of MPS (11/19, 58%) were panel surveys where a cohort of participants, who often were provided a mobile phone upon a face-to-face enrollment, were surveyed multiple times. Conclusions: Very few reports of population-level MPS were identified. Of the MPS that were identified, the majority of surveys were conducted using CATI. Due to the limited number of identified IVR and SMS surveys, the relative advantages and disadvantages among the three survey modalities cannot be adequately assessed. The majority of MPS were sent to mobile phone numbers that were collected from a previously administered household survey. There is limited evidence on whether a random digit dialing (RDD) approach or a simple random sample of mobile network provided list of numbers can produce a population representative survey. %M 28476725 %R 10.2196/jmir.7428 %U http://www.jmir.org/2017/5/e139/ %U https://doi.org/10.2196/jmir.7428 %U http://www.ncbi.nlm.nih.gov/pubmed/28476725 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e112 %T The Development of an Interactive Voice Response Survey for Noncommunicable Disease Risk Factor Estimation: Technical Assessment and Cognitive Testing %A Gibson,Dustin G %A Farrenkopf,Brooke A %A Pereira,Amanda %A Labrique,Alain B %A Pariyo,George William %+ Johns Hopkins Bloomberg School of Public Health, Department of International Health, 615 N Wolfe St, Baltimore, MD, 21231, United States, 1 4432878763, dgibso28@jhu.edu %K interactive voice response %K noncommunicable disease %K survey methodology %K public health surveillance %K cellular phone %K risk factors %D 2017 %7 05.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: The rise in mobile phone ownership in low- and middle-income countries (LMICs) presents an opportunity to transform existing data collection and surveillance methods. Administering surveys via interactive voice response (IVR) technology—a mobile phone survey (MPS) method—has potential to expand the current surveillance coverage and data collection, but formative work to contextualize the survey for LMIC deployment is needed. Objective: The primary objectives of this study were to (1) cognitively test and identify challenging questions in a noncommunicable disease (NCD) risk factor questionnaire administered via an IVR platform and (2) assess the usability of the IVR platform. Methods: We conducted two rounds of pilot testing the IVR survey in Baltimore, MD. Participants were included in the study if they identified as being from an LMIC. The first round included individual interviews to cognitively test the participant’s understanding of the questions. In the second round, participants unique from those in round 1 were placed in focus groups and were asked to comment on the usability of the IVR platform. Results: A total of 12 participants from LMICs were cognitively tested in round 1 to assess their understanding and comprehension of questions in an IVR-administered survey. Overall, the participants found that the majority of the questions were easy to understand and did not have difficulty recording most answers. The most frequent recommendation was to use country-specific examples and units of measurement. In round 2, a separate set of 12 participants assessed the usability of the IVR platform. Overall, participants felt that the length of the survey was appropriate (average: 18 min and 31 s), but the majority reported fatigue in answering questions that had a similar question structure. Almost all participants commented that they thought an IVR survey would lead to more honest, accurate responses than face-to-face questionnaires, especially for sensitive topics. Conclusions: Overall, the participants indicated a clear comprehension of the IVR-administered questionnaire and that the IVR platform was user-friendly. Formative research and cognitive testing of the questionnaire is needed for further adaptation before deploying in an LMIC. %M 28476724 %R 10.2196/jmir.7340 %U http://www.jmir.org/2017/5/e112/ %U https://doi.org/10.2196/jmir.7340 %U http://www.ncbi.nlm.nih.gov/pubmed/28476724 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e121 %T Health Surveys Using Mobile Phones in Developing Countries: Automated Active Strata Monitoring and Other Statistical Considerations for Improving Precision and Reducing Biases %A Labrique,Alain %A Blynn,Emily %A Ahmed,Saifuddin %A Gibson,Dustin %A Pariyo,George %A Hyder,Adnan A %+ Johns Hopkins Bloomberg School of Public Health, Department of International Health, W5501, Johns Hopkins Bloomberg SPH, 615 N Wolfe St, Baltimore, MD, 21205, United States, 1 4102361568, alabriqu@jhsph.edu %K surveys and questionnaires %K sampling studies %K mobile health %K mobile phone %K research methodology %D 2017 %7 05.05.2017 %9 Policy Proposal %J J Med Internet Res %G English %X In low- and middle-income countries (LMICs), historically, household surveys have been carried out by face-to-face interviews to collect survey data related to risk factors for noncommunicable diseases. The proliferation of mobile phone ownership and the access it provides in these countries offers a new opportunity to remotely conduct surveys with increased efficiency and reduced cost. However, the near-ubiquitous ownership of phones, high population mobility, and low cost require a re-examination of statistical recommendations for mobile phone surveys (MPS), especially when surveys are automated. As with landline surveys, random digit dialing remains the most appropriate approach to develop an ideal survey-sampling frame. Once the survey is complete, poststratification weights are generally applied to reduce estimate bias and to adjust for selectivity due to mobile ownership. Since weights increase design effects and reduce sampling efficiency, we introduce the concept of automated active strata monitoring to improve representativeness of the sample distribution to that of the source population. Although some statistical challenges remain, MPS represent a promising emerging means for population-level data collection in LMICs. %M 28476726 %R 10.2196/jmir.7329 %U http://www.jmir.org/2017/5/e121/ %U https://doi.org/10.2196/jmir.7329 %U http://www.ncbi.nlm.nih.gov/pubmed/28476726 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 5 %P e81 %T Evaluation of Mechanisms to Improve Performance of Mobile Phone Surveys in Low- and Middle-Income Countries: Research Protocol %A Gibson,Dustin G %A Pariyo,George William %A Wosu,Adaeze C %A Greenleaf,Abigail R %A Ali,Joseph %A Ahmed,Saifuddin %A Labrique,Alain B %A Islam,Khaleda %A Masanja,Honorati %A Rutebemberwa,Elizeus %A Hyder,Adnan A %+ Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States, 1 443 287 8763, dgibso28@jhu.edu %K IVR %K CATI %K Bangladesh %K Tanzania %K Uganda %K mHealth %K mobile phone survey %K noncommunicable diseases %K survey methodology %D 2017 %7 05.05.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mobile phone ownership and access have increased rapidly across low- and middle-income countries (LMICs) within the last decade. Concomitantly, LMICs are experiencing demographic and epidemiologic transitions, where non-communicable diseases (NCDs) are increasingly becoming leading causes of morbidity and mortality. Mobile phone surveys could aid data collection for prevention and control of these NCDs but limited evidence of their feasibility exists. Objective: The objective of this paper is to describe a series of sub-studies aimed at optimizing the delivery of interactive voice response (IVR) and computer-assisted telephone interviews (CATI) for NCD risk factor data collection in LMICs. These sub-studies are designed to assess the effect of factors such as airtime incentive timing, amount, and structure, survey introduction characteristics, different sampling frames, and survey modality on key survey metrics, such as survey response, completion, and attrition rates. Methods: In a series of sub-studies, participants will be randomly assigned to receive different airtime incentive amounts (eg, 10 minutes of airtime versus 20 minutes of airtime), different incentive delivery timings (airtime delivered before survey begins versus delivery upon completion of survey), different survey introductions (informational versus motivational), different narrative voices (male versus female), and different sampling frames (random digit dialing versus mobile network operator-provided numbers) to examine which study arms will yield the highest response and completion rates. Furthermore, response and completion rates and the inter-modal reliability of the IVR and CATI delivery methods will be compared. Results: Research activities are expected to be completed in Bangladesh, Tanzania, and Uganda in 2017. Conclusions: This is one of the first studies to examine the feasibility of using IVR and CATI for systematic collection of NCD risk factor information in LMICs. Our findings will inform the future design and implementation of mobile phone surveys in LMICs. %M 28476729 %R 10.2196/resprot.7534 %U http://www.researchprotocols.org/2017/5/e81/ %U https://doi.org/10.2196/resprot.7534 %U http://www.ncbi.nlm.nih.gov/pubmed/28476729 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e115 %T Moving the Agenda on Noncommunicable Diseases: Policy Implications of Mobile Phone Surveys in Low and Middle-Income Countries %A Pariyo,George W %A Wosu,Adaeze C %A Gibson,Dustin G %A Labrique,Alain B %A Ali,Joseph %A Hyder,Adnan A %+ Johns Hopkins Bloomberg School of Public Health, Department of International Health, 615 North Wolfe Street E 8648, Baltimore, MD, 21205, United States, 1 410 502 5790, gpariyo1@jhu.edu %K NCDs %K policy %K mHealth %K policy analysis %K surveys %D 2017 %7 05.05.2017 %9 Viewpoint %J J Med Internet Res %G English %X The growing burden of noncommunicable diseases (NCDs), for example, cardiovascular diseases and chronic respiratory diseases, in low- and middle-income countries (LMICs) presents special challenges for policy makers, due to resource constraints and lack of timely data for decision-making. Concurrently, the increasing ubiquity of mobile phones in LMICs presents possibilities for rapid collection of population-based data to inform the policy process. The objective of this paper is to highlight potential benefits of mobile phone surveys (MPS) for developing, implementing, and evaluating NCD prevention and control policies. To achieve this aim, we first provide a brief overview of major global commitments to NCD prevention and control, and subsequently explore how countries can translate these commitments into policy action at the national level. Using the policy cycle as our frame of reference, we highlight potential benefits of MPS which include (1) potential cost-effectiveness of using MPS to inform NCD policy actions compared with using traditional household surveys; (2) timeliness of assessments to feed into policy and planning cycles; (3) tracking progress of interventions, hence assessment of reach, coverage, and distribution; (4) better targeting of interventions, for example, to high-risk groups; (5) timely course correction for suboptimal or non-effective interventions; (6) assessing fairness in financial contribution and financial risk protection for those affected by NCDs in the spirit of universal health coverage (UHC); and (7) monitoring progress in reducing catastrophic medical expenditure due to chronic health conditions in general, and NCDs in particular. We conclude that MPS have potential to become a powerful data collection tool to inform policies that address public health challenges such as NCDs. Additional forthcoming assessments of MPS in LMICs will inform opportunities to maximize this technology. %M 28476720 %R 10.2196/jmir.7302 %U http://www.jmir.org/2017/5/e115/ %U https://doi.org/10.2196/jmir.7302 %U http://www.ncbi.nlm.nih.gov/pubmed/28476720 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e133 %T Noncommunicable Disease Risk Factors and Mobile Phones: A Proposed Research Agenda %A Hyder,Adnan A %A Wosu,Adaeze C %A Gibson,Dustin G %A Labrique,Alain B %A Ali,Joseph %A Pariyo,George W %+ Johns Hopkins Bloomberg School of Public Health, Department of International Health, 615 North Wolfe Street, Suite E8132, Baltimore, MD, 21205, United States, 1 410 502 8947, ahyder1@jhu.edu %K mHealth %K noncommunicable disease %K mobile phone %K research agenda %K survey %D 2017 %7 05.05.2017 %9 Viewpoint %J J Med Internet Res %G English %X Noncommunicable diseases (NCDs) account for two-thirds of all deaths globally, with 75% of these occurring in low- and middle-income countries (LMICs). Many LMICs seek cost-effective methods to obtain timely and quality NCD risk factor data that could inform resource allocation, policy development, and assist evaluation of NCD trends over time. Over the last decade, there has been a proliferation of mobile phone ownership and access in LMICs, which, if properly harnessed, has great potential to support risk factor data collection. As a supplement to traditional face-to-face surveys, the ubiquity of phone ownership has made large proportions of most populations reachable through cellular networks. However, critical gaps remain in understanding the ways by which mobile phone surveys (MPS) could aid in collection of NCD data in LMICs. Specifically, limited information exists on the optimization of these surveys with regard to incentives and structure, comparative effectiveness of different MPS modalities, and key ethical, legal, and societal issues (ELSI) in the development, conduct, and analysis of these surveys in LMIC settings. We propose a research agenda that could address important knowledge gaps in optimizing MPS for the collection of NCD risk factor data in LMICs and provide an example of a multicountry project where elements of that agenda aim to be integrated over the next two years. %M 28476722 %R 10.2196/jmir.7246 %U http://www.jmir.org/2017/5/e133/ %U https://doi.org/10.2196/jmir.7246 %U http://www.ncbi.nlm.nih.gov/pubmed/28476722 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 4 %P e70 %T The Malaria System MicroApp: A New, Mobile Device-Based Tool for Malaria Diagnosis %A Oliveira,Allisson Dantas %A Prats,Clara %A Espasa,Mateu %A Zarzuela Serrat,Francesc %A Montañola Sales,Cristina %A Silgado,Aroa %A Codina,Daniel Lopez %A Arruda,Mercia Eliane %A i Prat,Jordi Gomez %A Albuquerque,Jones %+ Federal Rural University of Pernambuco, Department of Statistics and Informatics, Rua Dom Manoel de Medeiros, s/n, Dois Irmãos, Recife, 52171900, Brazil, 55 8133206491, allissondantas@gmail.com %K artificial intelligence %K applied computing %K automated diagnosis %K malaria %K mobile devices %D 2017 %7 25.04.2017 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Malaria is a public health problem that affects remote areas worldwide. Climate change has contributed to the problem by allowing for the survival of Anopheles in previously uninhabited areas. As such, several groups have made developing news systems for the automated diagnosis of malaria a priority. Objective: The objective of this study was to develop a new, automated, mobile device-based diagnostic system for malaria. The system uses Giemsa-stained peripheral blood samples combined with light microscopy to identify the Plasmodium falciparum species in the ring stage of development. Methods: The system uses image processing and artificial intelligence techniques as well as a known face detection algorithm to identify Plasmodium parasites. The algorithm is based on integral image and haar-like features concepts, and makes use of weak classifiers with adaptive boosting learning. The search scope of the learning algorithm is reduced in the preprocessing step by removing the background around blood cells. Results: As a proof of concept experiment, the tool was used on 555 malaria-positive and 777 malaria-negative previously-made slides. The accuracy of the system was, on average, 91%, meaning that for every 100 parasite-infected samples, 91 were identified correctly. Conclusions: Accessibility barriers of low-resource countries can be addressed with low-cost diagnostic tools. Our system, developed for mobile devices (mobile phones and tablets), addresses this by enabling access to health centers in remote communities, and importantly, not depending on extensive malaria expertise or expensive diagnostic detection equipment. %M 28442456 %R 10.2196/resprot.6758 %U http://www.researchprotocols.org/2017/4/e70/ %U https://doi.org/10.2196/resprot.6758 %U http://www.ncbi.nlm.nih.gov/pubmed/28442456 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 4 %P e47 %T A Framework for the Study of Complex mHealth Interventions in Diverse Cultural Settings %A Maar,Marion A %A Yeates,Karen %A Perkins,Nancy %A Boesch,Lisa %A Hua-Stewart,Diane %A Liu,Peter %A Sleeth,Jessica %A Tobe,Sheldon W %+ Faculty of Medicine, Northern Ontario School of Medicine, Laurentian University, 935 Ramsey Lake Rd, Sudbury, ON, P3E 2C6, Canada, 1 705 662 7233, mmaar@nosm.ca %K mobile health %K health care texting %K SMS %K protocol %K process evaluation %K process assessment (health care) %K health services, Indigenous %K Tanzania %K community-based participatory research %K DREAM-GLOBAL %D 2017 %7 20.04.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: To facilitate decision-making capacity between options of care under real-life service conditions, clinical trials must be pragmatic to evaluate mobile health (mHealth) interventions under the variable conditions of health care settings with a wide range of participants. The mHealth interventions require changes in the behavior of patients and providers, creating considerable complexity and ambiguity related to causal chains. Process evaluations of the implementation are necessary to shed light on the range of unanticipated effects an intervention may have, what the active ingredients in everyday practice are, how they exert their effect, and how these may vary among recipients or between sites. Objective: Building on the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile HEalth Applications and onLine TeleHealth) statement and participatory evaluation theory, we present a framework for the process evaluations for mHealth interventions in multiple cultural settings. We also describe the application of this evaluation framework to the implementation of DREAM-GLOBAL (Diagnosing hypertension—Engaging Action and Management in Getting Lower BP in Indigenous and LMIC [low- and middle-income countries]), a pragmatic randomized controlled trial (RCT), and mHealth intervention designed to improve hypertension management in low-resource environments. We describe the evaluation questions and the data collection processes developed by us. Methods: Our literature review revealed that there is a significant knowledge gap related to the development of a process evaluation framework for mHealth interventions. We used community-based participatory research (CBPR) methods and formative research data to develop a process evaluation framework nested within a pragmatic RCT. Results: Four human organizational levels of participants impacted by the mHealth intervention were identified that included patients, providers, community and organizations actors, and health systems and settings. These four levels represent evaluation domains and became the core focus of the evaluation. In addition, primary implementation themes to explore in each of the domains were identified as follows: (1) the major active components of the intervention, (2) technology of the intervention, (3) cultural congruence, (4) task shifting, and (5) unintended consequences. Using the four organizational domains and their interaction with primary implementation themes, we developed detailed evaluation research questions and identified the data or information sources to best answer our questions. Conclusions: Using DREAM-GLOBAL to illustrate our approach, we succeeded in developing an uncomplicated process evaluation framework for mHealth interventions that provide key information to stakeholders, which can optimize implementation of a pragmatic trial as well as inform scale up. The human organizational level domains used to focus the primary implementation themes in the DREAM-GLOBAL process evaluation framework are sufficiently supported in our research, and the literature and can serve as a valuable tool for other mHealth process evaluations. Trial Registration: ClinicalTrials.gov NCT02111226; https://clinicaltrials.gov/ct2/show/NCT02111226 (Archived by WebCite at http://www.webcitation.org/6oxfHXege) %M 28428165 %R 10.2196/mhealth.7044 %U http://mhealth.jmir.org/2017/4/e47/ %U https://doi.org/10.2196/mhealth.7044 %U http://www.ncbi.nlm.nih.gov/pubmed/28428165 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 2 %N 1 %P e6 %T How’s Your Sugar? Evaluation of a Website for Aboriginal People With Diabetes %A Adams,Karen %A Liebzeit,Anna %A Browne,Jennifer %A Atkinson,Petah %+ Gukwonderuk, Faculty of Medicine Nursing and Health Science, Monash University, 27 Rainforest Walk, Clayton, 3800, Australia, 61 3 9902 4328, karen.adams@monash.edu %K Aboriginal and Torres Strait Islander peoples %K type 2 diabetes mellitus %K Indigenous populations %K Internet %D 2017 %7 04.04.2017 %9 Original Paper %J JMIR Diabetes %G English %X Background: Australia’s Aboriginal and Torres Strait Islander peoples (hereafter referred to as “Aboriginal people”) have the longest continuing culture in the world, living sustainably for at least 65,000 years on the Australian continent. In relatively recent times, colonization processes have resulted in Aboriginal people experiencing unacceptable health inequalities compared with other Australians. One disease introduced due to colonization is diabetes, the second leading cause of death for Aboriginal peoples. Objectives: The objective of this study was to describe the construction and utilization of the website “How’s Your Sugar, ” a website for Aboriginal people with type 2 diabetes (herein after referred to as diabetes). The questions for the evaluation were as follows: how was the website constructed; did target groups utilize the website; and did engagement with the website improve diabetes management. Methods: A mixed-method study design was employed. A content analysis of project documents provided information about the website construction. Data from Google analytics provided information about website utilization. To describe patterns of website sessions, percentages and numbers were calculated. A voluntary survey provided more information on website utilization and diabetes self-management. Percentage, numbers, and 95% CIs were calculated for each variable. A chi-square test was performed for Aboriginal status, age, gender, and Aboriginal diabetic status using Australian population estimates and Aboriginal diabetes rates. Results: The website development drew on Aboriginal health, social marketing, interactive health promotion frameworks, as well as evidence for diabetes self-management. The website build involved a multidisciplinary team and participation of Aboriginal diabetics, Aboriginal diabetic family members, and Aboriginal health workers. This participation allowed for inclusion of Aboriginal ways of knowing and being. The highest number of website sessions came from Australia, 98.15% (47,717/48,617) and within Australia, Victoria 50.97% (24,323/47,717). There were 129 survey respondents, and the distribution had more female, 82.9% (107/129, 95% CI 76-88), Aboriginal, 21.7% (28/129, 95% CI 16-30), and Aboriginal diabetic, 48% (13/27, 95% CI 31-66) respondents than expected with P<.001 for these three groups. Most common reasons for visits were university assignment research, 40.6% (41/101), and health workers looking for information, 20.8% (21/101). The sample size was too small to calculate diabetes self-management change. Conclusions: Inclusion of Aboriginal ways of knowing and being alongside other theoretical and evidence models in Web design is possible. Aboriginal people do utilize Web-based health promotion, and further understanding about reaching to this population would be of use. Provision of an education resource would likely have enhanced educational engagement. Web-based technologies are rapidly evolving, and these can potentially measure behavior change in engaging ways that also have benefits for the participant. A challenge for designers is inclusivity of cultural diversity for self-determination. %M 30291066 %R 10.2196/diabetes.6930 %U http://diabetes.jmir.org/2017/1/e6/ %U https://doi.org/10.2196/diabetes.6930 %U http://www.ncbi.nlm.nih.gov/pubmed/30291066 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 4 %P e41 %T Processes and Recommendations for Creating mHealth Apps for Low-Income Populations %A Stephan,Laura Siga %A Dytz Almeida,Eduardo %A Guimaraes,Raphael Boesche %A Ley,Antonio Gaudie %A Mathias,Rodrigo Gonçalves %A Assis,Maria Valéria %A Leiria,Tiago Luiz Luz %+ Instituto de Cardiologia, Fundação Universitária de Cardiologia, Av Princesa Isabel, 370 - Santana, Porto Alegre, RS, 90620-001, Brazil, 55 51 32303600, emaildalaura@gmail.com %K mHealth %K atrial fibrillation %K low-income population %D 2017 %7 03.04.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) apps have shown to improve health indicators, but concerns remain about the inclusion of populations from low- and medium-income countries (LMIC) in these new technologies. Atrial fibrillation (AF) is a chronic condition with a challenging management. Previous studies have shown socioeconomic differences in the prescription of anticoagulant treatment and shared decision strategies are encouraged to achieve better outcomes. mHealth can aid both doctors and patients in this matter. Objective: We describe the development of an mHealth app (aFib) idealized to aid shared decision between doctor and patient about anticoagulation prophylaxis in AF in a low-income and low-literacy population in Brazil. On the basis of our research, we suggest the processes to be followed when developing mHealth apps in this context. Methods: A multidisciplinary team collected information about the target population and its needs and detected the best opportunity to insert the app in their current health care. Literature about the subject was reviewed and important data were selected to be delivered through good navigability, easy terminology, and friendly design. The app was evaluated in a multimethod setting. Results: The steps suggested to develop an mHealth app target to LMIC are: (1) characterize the problem and the target user, (2) review the literature, (3) translate information to knowledge, (4) protect information, and (5) evaluate usability and efficacy. Conclusions: We expect that these recommendations can guide the development of new mHealth apps in LMIC, on a scientific basis. %M 28373155 %R 10.2196/mhealth.6510 %U http://mhealth.jmir.org/2017/4/e41/ %U https://doi.org/10.2196/mhealth.6510 %U http://www.ncbi.nlm.nih.gov/pubmed/28373155 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 3 %P e38 %T mHealth for Clinical Decision-Making in Sub-Saharan Africa: A Scoping Review %A Adepoju,Ibukun-Oluwa Omolade %A Albersen,Bregje Joanna Antonia %A De Brouwere,Vincent %A van Roosmalen,Jos %A Zweekhorst,Marjolein %+ Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1105, WN Building, Room S-544, Amsterdam, 1081HV, Netherlands, 31 205983143, i.o.adepoju@vu.nl %K mHealth %K decision support systems, clinical %K sub-Saharan Africa %K clinical decision-making %D 2017 %7 23.03.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In a bid to deliver quality health services in resource-poor settings, mobile health (mHealth) is increasingly being adopted. The role of mHealth in facilitating evidence-based clinical decision-making through data collection, decision algorithms, and evidence-based guidelines, for example, is established in resource-rich settings. However, the extent to which mobile clinical decision support systems (mCDSS) have been adopted specifically in resource-poor settings such as Africa and the lessons learned about their use in such settings are yet to be established. Objective: The aim of this study was to synthesize evidence on the use of mHealth for point-of-care decision support and improved quality of care by health care workers in Africa. Methods: A scoping review of 4 peer-reviewed and 1 grey literature databases was conducted. No date limits were applied, but only articles in English language were selected. Using pre-established criteria, 2 reviewers screened articles and extracted data. Articles were analyzed using Microsoft Excel and MAXQDA. Results: We retained 22 articles representing 11 different studies in 7 sub-Saharan African countries. Interventions were mainly in the domain of maternal health and ranged from simple text messaging (short message service, SMS) to complex multicomponent interventions. Although health workers are generally supportive of mCDSS and perceive them as useful, concerns about increased workload and altered workflow hinder sustainability. Facilitators and barriers to use of mCDSS include technical and infrastructural support, ownership, health system challenges, and training. Conclusions: The use of mCDSS in sub-Saharan Africa is an indication of progress in mHealth, although their effect on quality of service delivery is yet to be fully explored. Lessons learned are useful for informing future research, policy, and practice for technologically supported health care delivery, especially in resource-poor settings. %M 28336504 %R 10.2196/mhealth.7185 %U http://mhealth.jmir.org/2017/3/e38/ %U https://doi.org/10.2196/mhealth.7185 %U http://www.ncbi.nlm.nih.gov/pubmed/28336504 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 5 %N 3 %P e32 %T mHealth Interventions for Health System Strengthening in China: A Systematic Review %A Tian,Maoyi %A Zhang,Jing %A Luo,Rong %A Chen,Shi %A Petrovic,Djordje %A Redfern,Julie %A Xu,Dong Roman %A Patel,Anushka %+ The George Institute for Global Health at Peking University Health Science Center, Suite 1801, Tower B, Horizon Tower, 6 Zhichun Road, Beijing, 100088, China, 86 1082800577 ext 303, mtian@georgeinstitute.org.cn %K mHealth %K China %K health care systems %D 2017 %7 16.03.2017 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: With rapidly expanding infrastructure in China, mobile technology has been deemed to have the potential to revolutionize health care delivery. There is particular promise for mobile health (mHealth) to positively influence health system reform and confront the new challenges of chronic diseases. Objective: The aim of this study was to systematically review existing mHealth initiatives in China, characterize them, and examine the extent to which mHealth contributes toward the health system strengthening in China. Furthermore, we also aimed to identify gaps in mHealth development and evaluation. Methods: We systematically reviewed the literature from English and Chinese electronic database and trial registries, including PubMed, EMBASE, Cochrane, China National Knowledge of Infrastructure (CNKI), and World Health Organization (WHO) International Clinical Trials Registry Platform. We used the English keywords of mHealth, eHealth, telemedicine, telehealth, mobile phone, cell phone, text messaging, and China, as well as their corresponding Chinese keywords. All articles using mobile technology for health care management were included in the study. Results: A total of 1704 articles were found using the search terms, and eventually 72 were included. Overall, few high quality interventions were identified. Most interventions were found to be insufficient in scope, and their evaluation was of inadequate rigor to generate scalable solutions and provide reliable evidence of effectiveness. Most interventions focused on text messaging for consumer education and behavior change. There were a limited number of interventions that addressed health information management, health workforce issues, use of medicines and technologies, or leadership and governance from a health system perspective. Conclusions: We provide four recommendations for future mHealth interventions in China that include the need for the development, evaluation and trials examining integrated mHealth interventions to guide the development of future mHealth interventions, target disadvantaged populations with mHealth interventions, and generate appropriate evidence for scalable and sustainable models of care. %M 28302597 %R 10.2196/mhealth.6889 %U http://mhealth.jmir.org/2017/3/e32/ %U https://doi.org/10.2196/mhealth.6889 %U http://www.ncbi.nlm.nih.gov/pubmed/28302597 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 2 %P e23 %T For You and Your Baby (4YYB): Adapting the Centers for Disease Control and Prevention’s Text4Baby Program for Saudi Arabia %A Bahanshal,Soha %A Coughlin,Steven %A Liu,Benyuan %+ Department of Computer Science, University of Massachusetts Lowell, 1 University Ave, Lowell, MA,, United States, 1 781 654 7200, bahasoha@gmail.com %K Saudi Arabia %K telemedicine %K text messaging %K health knowledge, attitudes, practice %K pregnant women %D 2017 %7 28.02.2017 %9 Viewpoint %J JMIR Res Protoc %G English %X Background: Poor birth outcomes in the Kingdom of Saudi Arabia (KSA) have been found to be partially due to missed prenatal appointments as well as lack of knowledge of healthy pregnancy behaviors. Objective: The objectives are to summarize birth outcomes and the antenatal care system in KSA, summarize research related to the US Text4Baby mobile health program, and outline the development of an Arabic version of the Text4baby app, For You and Your Baby (4YYB). Methods: First, birth outcomes, health care access, and smartphone usage among Saudi Arabian women are reviewed. Next, the current evidence behind Text4Baby is described. Finally, a plan to develop and test 4YYB is proposed. In the plan, studies will need to be conducted to determine the effectiveness of 4YYB in educating pregnant Saudi women on healthy knowledge and behaviors. This will create an evidence base behind 4YYB before it is launched as a full-scale public health effort in KSA. Results: The KSA offers public medical services but remaining challenges include poor birth outcomes and health care access barriers. An estimated 73% to 84% of Saudi women of child-bearing age use smartphone social media apps. A total of 13 published articles on Text4Baby were identified and reviewed. Due to design limitations, the studies provide only limited evidence about the effectiveness of the program in increasing healthy pregnancy knowledge and behaviors. To be useful for Saudi women, the educational messages in 4YYB will need to be translated from English to Arabic and tailored for cultural norms. Conclusions: Developing the 4YYB Arabic-language app for use by pregnant Saudi Arabian women based on Text4Baby is a viable approach, but a rigorous study design is needed to determine its effectiveness in improving healthy pregnancy knowledge and behaviors. %M 28246065 %R 10.2196/resprot.5818 %U http://www.researchprotocols.org/2017/2/e23/ %U https://doi.org/10.2196/resprot.5818 %U http://www.ncbi.nlm.nih.gov/pubmed/28246065 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 3 %N 1 %P e5 %T Assessing Mobile Phone Access and Perceptions for Texting-Based mHealth Interventions Among Expectant Mothers and Child Caregivers in Remote Regions of Northern Kenya: A Survey-Based Descriptive Study %A Kazi,Abdul Momin %A Carmichael,Jason-Louis %A Hapanna,Galgallo Waqo %A Wangoo,Patrick Gikaria %A Karanja,Sarah %A Wanyama,Denis %A Muhula,Samuel Opondo %A Kyomuhangi,Lennie Bazira %A Loolpapit,Mores %A Wangalwa,Gilbert Bwire %A Kinagwi,Koki %A Lester,Richard Todd %+ Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver General Hospital site, Department of Medicine, 10th Floor, Gordon and Leslie Diamond Health Care Centre, room #10127 – 2775, Laurel Street, Vancouver, BC, V5Z 1M9, Canada, 1 604 875 4111 ext 63140, mominkazi@gmail.com %K mobile health %K text messaging %K prenatal care %K immunization %K Kenya %D 2017 %7 30.01.2017 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: With a dramatic increase in mobile phone use in low- and middle-income countries, mobile health (mHealth) has great potential to connect health care services directly to participants enrolled and improve engagement of care. Rural and remote global settings may pose both significant challenges and opportunities. Objective: The objective of our study was to understand the demographics, phone usage and ownership characteristics, and feasibility among patients in rural and remote areas of Kenya of having text messaging (short messaging service, SMS)-based mHealth intervention for improvements in antenatal care attendance and routine immunization among children in Northern Kenya. Methods: A survey-based descriptive study was conducted between October 2014 and February 2015 at 8 health facilities in Northern Kenya as part of a program to scale up an mHealth service in rural and remote regions. The study was conducted at 6 government health facilities in Isiolo, Marsabit, and Samburu counties in remote and northern arid lands (NAL). Two less remote health facilities in Laikipia and Meru counties in more populated central highlands were included as comparison sites. Results: A total of 284 participants were surveyed; 63.4% (180/284) were from NAL clinics, whereas 36.6% (104/284) were from adjacent central highland clinics. In the NAL, almost half (48.8%, 88/180) reported no formal education and 24.4% (44/180) self-identified as nomads. The majority of participants from both regions had access to mobile phone: 99.0% (103/104) of participants from central highlands and 82.1% (147/180) of participants from NAL. Among those who had access to a phone, there were significant differences in network challenges and technology literacy between the 2 regions. However, there was no significant difference in the proportion of participants from NAL and central highlands who indicated that they would like to receive a weekly SMS text message from their health care provider (90.0% vs 95.0%; P=.52). Overall, 92.0% (230/250) of participants who had access to a telephone said that they would like to receive a weekly SMS text message from their health care provider. Most phone users already spent the equivalent of 626 SMS text messages on mobile credit for personal use. Conclusions: Despite the remoteness of northern Kenya’s NAL, the results indicate that the majority of pregnant women or care givers attending the maternal, newborn, and child health clinics have access to mobile phone and would like to receive text messages from their health care provider. mHealth programs, if designed appropriately for these settings, may be an innovative way for engaging women in care for improved maternal and newborn child health outcomes in order to achieve sustainable development goals. %M 28137702 %R 10.2196/publichealth.5386 %U http://publichealth.jmir.org/2017/1/e5/ %U https://doi.org/10.2196/publichealth.5386 %U http://www.ncbi.nlm.nih.gov/pubmed/28137702 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 2 %N 2 %P e169 %T Effect of Performance Feedback on Community Health Workers’ Motivation and Performance in Madhya Pradesh, India: A Randomized Controlled Trial %A Kaphle,Sangya %A Matheke-Fischer,Michael %A Lesh,Neal %+ Dimagi Software Innovations, 585 Massachusetts Ave #3, Cambridge, MA, 02139, United States, 1 617 649 2214, sangyakaphle@gmail.com %K community health workers %K performance feedback %K motivation %K supportive supervision %K mHealth apps %D 2016 %7 07.12.2016 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Small-scale community health worker (CHW) programs provide basic health services and strengthen health systems in resource-poor settings. This paper focuses on improving CHW performance by providing individual feedback to CHWs working with an mHealth program to address malnutrition in children younger than 5 years. Objective: The paper aims to evaluate the immediate and retention effects of providing performance feedback and supportive supervision on CHW motivation and performance for CHWs working with an mHealth platform to reduce malnutrition in five districts of Madhya Pradesh, India. We expected a positive impact on CHW performance for the indicator they received feedback on. Performance on indicators the CHW did not receive feedback on was not expected to change. Methods: In a randomized controlled trial, 60 CHWs were randomized into three treatment groups based on overall baseline performance ranks to achieve balanced treatment groups. Data for each treatment indicator were analyzed with the other two treatments acting as the control. In total, 10 CHWs were lost to follow-up. There were three performance indicators: case activity, form submissions, and duration of counseling. Each group received weekly calls to provide performance targets and discuss their performance on the specific indicator they were allocated to as well as any challenges or technical issues faced during the week for a 6-week period. Data were collected for a further 4 weeks to assess intertemporal sustained effects of the intervention. Results: We found positive and significant impacts on duration of counseling, whereas case activity and number of form submissions did not show significant improvements as a result of the intervention. We found a moderate to large effect (Glass’s delta=0.97, P=.004) of providing performance feedback on counseling times in the initial 6 weeks. These effects were sustained in the postintervention period (Glass’s delta=1.69, P<.001). The counseling times decreased slightly from the intervention to postintervention period by 2.14 minutes (P=.01). Case activity improved for all CHWs after the intervention. We also performed the analysis by replacing the CHWs lost to follow-up with those in their treatment groups with the closest ranks in baseline performance and found similar results. Conclusions: Calls providing performance feedback are effective in improving CHW motivation and performance. Providing feedback had a positive effect on performance in the case of duration of counseling. The results suggest that difficulty in achieving the performance target can affect results of performance feedback. Regardless of the performance information disclosed, calls can improve performance due to elements of supportive supervision included in the calls encouraging CHW motivation. %M 27927607 %R 10.2196/publichealth.3381 %U http://publichealth.jmir.org/2016/2/e169/ %U https://doi.org/10.2196/publichealth.3381 %U http://www.ncbi.nlm.nih.gov/pubmed/27927607 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 4 %P e224 %T Efficacy of Mobile Serious Games in Increasing HIV Risk Perception in Swaziland: A Randomized Control Trial (SGprev Trial) Research Protocol %A Lukhele,Bhekumusa Wellington %A Musumari,Patou %A El-Saaidi,Christina %A Techasrivichien,Teeranee %A Suguimoto,S. Pilar %A Ono Kihara,Masako %A Kihara,Masahiro %+ Department of Global Health and Socio Epidemiology, Frontier Laboratory Bldg, 2nd Fl., Kyoto University School of Public Health Yoshida Konoe-cho, Sakyo-ku, Kyoto, 6068501, Japan, 81 757534350 ext 4350, bhekumusa.lukhele.36x@st.kyoto-u.ac.jp %K eHealth %K mHealth %K gamification %K Internet %K HIV prevention %K innovation %D 2016 %7 22.11.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: The human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) continue to be a major public health problem in Sub-Saharan Africa (SSA), particularly in Swaziland, which has the highest HIV prevalence in this region. A wide range of strategies and interventions have been used to promote behavior change, though almost all such interventions have involved mass media. Therefore, innovative behavior change strategies beyond mass media communication are urgently needed. Serious games have demonstrated effectiveness in advancing health in the developed world; however, no rigorous serious games interventions have been implemented in HIV prevention in SSA. Objective: We plan to test whether a serious game intervention delivered on mobile phones to increase HIV risk perception, increase intention to reduce sexual partnerships, and increase intention to know own and partners HIV status will be more effective compared with current prevention efforts. Methods: This is a two-arm randomized intervention trial. We will recruit 380 participants who meet the following eligibility criteria: 18-29 years of age, own a smartphone running an Android-based operating system, have the WhatsApp messaging app, live in Swaziland, and can adequately grant informed consent. Participants will be allocated into a smartphone interactive, educational story game, and a wait-list control group in a 1:1 allocation ratio. Subsequently, a self-administered Web-based questionnaire will be issued at baseline and after 4 weeks of exposure to the game. We hypothesize that the change in HIV risk perception between pre- and post-intervention assessment is greater in the intervention group compared with the change in the control group. Our primary hypothesis is based on the assumption that increased perceived risk of HIV provides cues to engage in protective behavior. Our primary outcome measure is HIV risk perceived mean change between pre- and post-intervention compared with the mean change in the wait-list control group at 4-weeks post-intervention. We will use standardized regression coefficients to calculate the effect of the intervention on our primary outcome with P values. We will conduct both intention to treat and as treated analysis. Results: This study is funded by Hayao Nakayama Foundation for Science & Technology and Culture; Grant number H26-A2-41. The research and development approval has been obtained from Kyoto University Graduate School and Faculty of Medicine Ethics Committee, Japan, and Swaziland’s Ministry of Health Ethics and Scientific committee. Results are expected in February 2017. Conclusions: This study will provide evidence on the efficiency of a mobile phone interactive game in increasing HIV risk perception in Swaziland. Our findings may also be generalizable to similar settings in SSA. Trial Registration: University Hospital Medical Information Network Clinical Trial Registry ID number (UMIN-CTR):UMIN000021781; URL:https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000025103 (Archived by WebCite at http://www.webcitation.org/6hOphB11a). %M 27876685 %R 10.2196/resprot.6543 %U http://www.researchprotocols.org/2016/4/e224/ %U https://doi.org/10.2196/resprot.6543 %U http://www.ncbi.nlm.nih.gov/pubmed/27876685 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 2 %N 2 %P e159 %T High Burden of Unrecognized Atrial Fibrillation in Rural India: An Innovative Community-Based Cross-Sectional Screening Program %A Soni,Apurv %A Earon,Allison %A Handorf,Anna %A Fahey,Nisha %A Talati,Kandarp %A Bostrom,John %A Chon,Ki %A Napolitano,Craig %A Chin,Michael %A Sullivan,John %A Raithatha,Shyamsundar %A Goldberg,Robert %A Nimbalkar,Somashekhar %A Allison,Jeroan %A Thanvi,Sunil %A McManus,David %+ University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA,, United States, 1 508 856 4265, apurv.soni@umassmed.edu %K atrial fibrillation %K India %K screening %K mobile technology %K community health workers %D 2016 %7 13.10.2016 %9 Short Paper %J JMIR Public Health Surveill %G English %X Background: Atrial fibrillation, the world’s most common arrhythmia, is a leading risk factor for stroke, a disease striking nearly 1.6 million Indians annually. Early detection and management of atrial fibrillation is a promising opportunity to prevent stroke but widespread screening programs in limited resource settings using conventional methods is difficult and costly. Objective: The objective of this study is to screen people for atrial fibrillation in rural western India using a US Food and Drug Administration-approved single-lead electrocardiography device, Alivecor. Methods: Residents from 6 villages in Anand District, Gujarat, India, comprised the base population. After obtaining informed consent, a team of trained research coordinators and community health workers enrolled a total of 354 participants aged 50 years and older and screened them at their residences using Alivecor for 2 minutes on 5 consecutive days over a period of 6 weeks beginning June, 2015. Results: Almost two-thirds of study participants were 55 years or older, nearly half were female, one-third did not receive any formal education, and more than one-half were from households earning less than US $2 per day. Twelve participants screened positive for atrial fibrillation yielding a sample prevalence of 5.1% (95% CI 2.7-8.7). Only one participant had persistent atrial fibrillation throughout all of the screenings, and 9 screened positive only once. Conclusions: Our study suggests a prevalence of atrial fibrillation in this Indian region (5.1%) that is markedly higher than has been previously reported in India and similar to the prevalence estimates reported in studies of persons from North America and Europe. Historically low reported burden of atrial fibrillation among individuals from low and middle-income countries may be due to a lack of routine screening. Mobile technologies may help overcome resource limitations for atrial fibrillation screening in underserved and low-resource settings. %M 27737818 %R 10.2196/publichealth.6517 %U http://publichealth.jmir.org/2016/2/e159/ %U https://doi.org/10.2196/publichealth.6517 %U http://www.ncbi.nlm.nih.gov/pubmed/27737818 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 8 %P e226 %T Effectiveness of mHealth Interventions Targeting Health Care Workers to Improve Pregnancy Outcomes in Low- and Middle-Income Countries: A Systematic Review %A Amoakoh-Coleman,Mary %A Borgstein,Alexander Berend-Jan %A Sondaal,Stephanie FV %A Grobbee,Diederick E %A Miltenburg,Andrea Solnes %A Verwijs,Mirjam %A Ansah,Evelyn K %A Browne,Joyce L %A Klipstein-Grobusch,Kerstin %+ Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands, P.O. Box 85500, Utrecht, 3508 GA, Netherlands, 31 244 623553, menba19@yahoo.com %K maternal %K mHealth %K neonatal %K providers of care %K low- and middle-income countries %D 2016 %7 19.08.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Low- and middle-income countries (LMICs) face the highest burden of maternal and neonatal deaths. Concurrently, they have the lowest number of physicians. Innovative methods such as the exchange of health-related information using mobile devices (mHealth) may support health care workers in the provision of antenatal, delivery, and postnatal care to improve maternal and neonatal outcomes in LMICs. Objective: We conducted a systematic review evaluating the effectiveness of mHealth interventions targeting health care workers to improve maternal and neonatal outcomes in LMIC. Methods: The Cochrane Library, PubMed, EMBASE, Global Health Library, and Popline were searched using predetermined search and indexing terms. Quality assessment was performed using an adapted Cochrane Risk of Bias Tool. A strength, weakness, opportunity, and threat analysis was performed for each included paper. Results: A total of 19 studies were included for this systematic review, 10 intervention and 9 descriptive studies. mHealth interventions were used as communication, data collection, or educational tool by health care providers primarily at the community level in the provision of antenatal, delivery, and postnatal care. Interventions were used to track pregnant women to improve antenatal and delivery care, as well as facilitate referrals. None of the studies directly assessed the effect of mHealth on maternal and neonatal mortality. Challenges of mHealth interventions to assist health care workers consisted mainly of technical problems, such as mobile network coverage, internet access, electricity access, and maintenance of mobile phones. Conclusions: mHealth interventions targeting health care workers have the potential to improve maternal and neonatal health services in LMICs. However, there is a gap in the knowledge whether mHealth interventions directly affect maternal and neonatal outcomes and future research should employ experimental designs with relevant outcome measures to address this gap. %M 27543152 %R 10.2196/jmir.5533 %U http://www.jmir.org/2016/8/e226/ %U https://doi.org/10.2196/jmir.5533 %U http://www.ncbi.nlm.nih.gov/pubmed/27543152 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 8 %P e207 %T mHealth Intervention to Improve Diabetes Risk Behaviors in India: A Prospective, Parallel Group Cohort Study %A Pfammatter,Angela %A Spring,Bonnie %A Saligram,Nalini %A Davé,Raj %A Gowda,Arun %A Blais,Linelle %A Arora,Monika %A Ranjani,Harish %A Ganda,Om %A Hedeker,Donald %A Reddy,Sethu %A Ramalingam,Sandhya %+ Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Suite 1400, Chicago, IL, 60611, United States, 1 312 503 1574, angela.pfammatter@northwestern.edu %K mHealth %K diabetes %K health promotion %D 2016 %7 05.08.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: In low/middle income countries like India, diabetes is prevalent and health care access limited. Most adults have a mobile phone, creating potential for mHealth interventions to improve public health. To examine the feasibility and initial evidence of effectiveness of mDiabetes, a text messaging program to improve diabetes risk behaviors, a global nonprofit organization (Arogya World) implemented mDiabetes among one million Indian adults. Objective: A prospective, parallel cohort design was applied to examine whether mDiabetes improved fruit, vegetable, and fat intakes and exercise. Methods: Intervention participants were randomly selected from the one million Nokia subscribers who elected to opt in to mDiabetes. Control group participants were randomly selected from non-Nokia mobile phone subscribers. mDiabetes participants received 56 text messages in their choice of 12 languages over 6 months; control participants received no contact. Messages were designed to motivate improvement in diabetes risk behaviors and increase awareness about the causes and complications of diabetes. Participant health behaviors (exercise and fruit, vegetable, and fat intake) were assessed between 2012 and 2013 via telephone surveys by blinded assessors at baseline and 6 months later. Data were cleaned and analyzed in 2014 and 2015. Results: 982 participants in the intervention group and 943 in the control group consented to take the phone survey at baselne. At the end of the 6-month period, 611 (62.22%) in the intervention and 632 (67.02%) in the control group completed the follow-up telephone survey. Participants receiving texts demonstrated greater improvement in a health behavior composite score over 6 months, compared with those who received no messages F(1, 1238) = 30.181, P<.001, 95% CI, 0.251-0.531. Fewer intervention participants demonstrated health behavior decline compared with controls. Improved fruit, vegetable, and fat consumption (P<.01) but not exercise were observed in those receiving messages, as compared with controls. Conclusions: A text messaging intervention was feasible and showed initial evidence of effectiveness in improving diabetes-related health behaviors, demonstrating the potential to facilitate population-level behavior change in a low/middle income country. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN): 12615000423516; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367946&isReview=true (Archived by WebCite at http://www.webcitation.org/6j5ptaJgF) %M 27496271 %R 10.2196/jmir.5712 %U http://www.jmir.org/2016/8/e207/ %U https://doi.org/10.2196/jmir.5712 %U http://www.ncbi.nlm.nih.gov/pubmed/27496271 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 3 %P e158 %T MHealth to Improve Measles Immunization in Guinea-Bissau: Study Protocol for a Randomized Controlled Trial %A Rossing,Emil %A Ravn,Henrik %A Batista,Celso Soares Pereira %A Rodrigues,Amabelia %+ OPEN, Odense Patient data Explorative Network, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 9 a, 3. floor, Odense C, DK-5000, Denmark, 45 61779344, emro@ssi.dk %K mHealth %K eHealth %K SMS reminders %K voice reminders %K Guinea-Bissau, ODK %K Africa %K RapidSMS %K health systems strengthening %K randomized controlled trial %K measles %K immunization %D 2016 %7 27.07.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Recent studies have revealed a low measles vaccination (MV) rate in the Republic of Guinea-Bissau (West Africa) that has not increased in accordance with the increasing coverage of other vaccinations. Measles is the deadliest of all childhood rash/fever illnesses and spreads easily, implying that if the vaccination coverage is declining there is a significant risk of new measles outbreaks [27]. Meanwhile, mobile health (mHealth; the use of mobile phones for health interventions) has generated much enthusiasm, and shown potential in improving health service delivery in other contexts. Objective: The aim of this study is to evaluate the efficiency of mHealth as a tool for improving MV coverage while contributing to the mHealth evidence base. Methods: This study will take place at three health centers in different regions of Guinea-Bissau. Participants, defined as mothers of the children receiving the MV, will be enrolled when they arrive with their children at the health center to receive the Bacillus Calmette-Guérin vaccination, usually within one month of the child’s birth. Enrolment will continue until a study population of 990 children has been reached. The participants will be randomly assigned to a control arm or one of two intervention arms. Each of the three groups will have 330 participants, distributed equally between health centers. Participants in the first intervention arm will receive a scheduled short message service (SMS) text message reminding them of the MV. Participants in the second intervention arm will receive a voice call in addition to the SMS message, while the control arm will receive no interventions. The MV is scheduled to be administered at 9 months of age. Although the vaccine would still be effective after 12 months, local policy in Guinea-Bissau prevents children aged >12 months from receiving the vaccination, and thus the study will follow-up with participants after the children reach 12 months of age. Children who have not yet received the MV will be offered vaccination by the project group. Results: The study will analyze the efficiency of the intervention by determining its overall effect on MV coverage and timeliness when children reach 12 months of age. The main analysis will be stratified by intervention group, health center, level of education, ethnic group, and role of the person receiving the text messages (eg, mother, father, other family member). Secondary outcomes include the average number of health center visits (with intention to obtain the MV) required before successful administration. Conclusions: Despite the rapid proliferation of mHealth projects, only a small number have been evaluated in terms of direct links to health outcomes. This gap in knowledge requires solid evidence on which policy-makers can base decisions. This study aims to produce significant knowledge about mHealth implementation within a Sub-Saharan context while creating data-supported evidence. Trial Registration: Clinicaltrials.gov: NCT02662595; https://clinicaltrials.gov/ct2/show/NCT02662595 (Archived by WebCite at http://www.webcitation.org/6jH8YiSjY) %M 27466046 %R 10.2196/resprot.5968 %U http://www.researchprotocols.org/2016/3/e158/ %U https://doi.org/10.2196/resprot.5968 %U http://www.ncbi.nlm.nih.gov/pubmed/27466046 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 3 %P e155 %T Voice-Message–Based mHealth Intervention to Reduce Postoperative Penetrative Sex in Recipients of Voluntary Medical Male Circumcision in the Western Cape, South Africa: Protocol of a Randomized Controlled Trial %A Thomsen,Sarah C %A Skinner,Donald %A Toefy,Yoesrie %A Esterhuizen,Tonya %A McCaul,Michael %A Petzold,Max %A Diwan,Vinod %+ Global Health, Department of Public Health Sciences, Karolinska Institutet, Jarvstigen 4, Solna,, Sweden, 46 7 0280 6979, sarah.thomsen@ki.se %K protocol %K RCT %K male circumcision %K HIV %K mHealth %K VMMC %D 2016 %7 26.07.2016 %9 Original Paper %J JMIR Res Protoc %G English %X Background: There is an increased risk of transmission of sexually transmitted infections (STIs), including HIV, in the postoperative period after receiving voluntary medical male circumcision (VMMC). In South Africa, over 4 million men are being targeted with VMMC services but the health system is not able to offer quality counseling. More innovative strategies for communicating with and altering behavior in men and their partners in the postoperative period after VMMC are needed. Objective: This paper presents a study protocol to test the effectiveness of an mHealth intervention designed to task-shift behavior change communication from health care personnel to an automated phone message system, encouraging self-care. Methods: A single-blind, randomized controlled trial will be used. A total of 1188 participants will be recruited by nurses or clinicians at clinics in the study districts that have a high turnover of VMMC clients. The population will consist of men aged 18 years and older who indicate at the precounseling session that they possess a mobile phone and consent to participating in the study. Consenting participants will be randomized into either the control or intervention arm before undergoing VMMC. The control arm will receive the standard of care (pre- and postcounseling). The intervention arm will received standard of care and will be sent 38 messages over the 6-week recovery period. Patients will be followed up after 42 days. The primary outcome is self-reported sexual intercourse during the recovery period. Secondary outcomes include nonpenetrative sexual activity, STI symptoms, and perceived risk of acquiring HIV. Analysis will be by intention-to-treat. Results: Enrollment is completed. Follow-up is ongoing. Loss to follow-up is under 10%. No interim analyses have been conducted. Conclusions: The intervention has the potential of reducing risky sexual behavior after VMMC. The platform itself can be used for many other areas of health that require task shifting to patients for better efficiency and access. Trial Registration: Pan-African Clinical Trial Registry: PACTR201506001182385 %M 27460771 %R 10.2196/resprot.5958 %U http://www.researchprotocols.org/2016/3/e155/ %U https://doi.org/10.2196/resprot.5958 %U http://www.ncbi.nlm.nih.gov/pubmed/27460771 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 7 %P e149 %T A Social Media mHealth Solution to Address the Needs of Dengue Prevention and Management in Sri Lanka %A Lwin,May O %A Vijaykumar,Santosh %A Rathnayake,Vajira Sampath %A Lim,Gentatsu %A Panchapakesan,Chitra %A Foo,Schubert %A Wijayamuni,Ruwan %A Wimalaratne,Prasad %A Fernando,Owen Noel Newton %+ Nanyang Technological University, School of Computer Science and Engineering, 50 Nanyang Avenue, North Spine, N4-02c-75, Singapore, 639798, Singapore, 65 67905783, santoshv@ntu.edu.sg %K dengue %K public health inspector %K mhealth %K social media %K surveillance %K needs assessment %K prevention and management %D 2016 %7 01.07.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Sri Lanka has witnessed a series of dengue epidemics over the past five years, with the western province, home to the political capital of Colombo, bearing more than half of the dengue burden. Existing dengue monitoring prevention programs are exhausted as public health inspectors (PHIs) cope with increasing workloads and paper-based modes of surveillance and education, characterizing a reactive system unable to cope with the enormity of the problem. On the other hand, the unprecedented proliferation and affordability of mobile phones since 2009 and a supportive political climate have thus far remained unexploited for the use of mobile-based interventions for dengue management. Objective: To conduct a needs assessment of PHIs in Colombo with respect to their dengue-related tasks and develop a new mobile-based system to address these needs while strengthening existing systems. Methods: One-on-one in-depth interviews were conducted with 29 PHIs to a) gain a nuanced, in-depth understanding of the current state of surveillance practices, b) understand the logistical, technological and social challenges they confront, and c) identify opportunities for mobile-based interventions. Quantitative analysis included simple descriptive statistics while qualitative analysis comprised textual analysis of 209 pages of transcripts (or nearly 600 minutes of conversations) using grounded theory approaches. Results: Current paper-based data collection practices for dengue surveillance involved a circuitous, time consuming process that could take between 7-10 days to officially report and record a single case. PHIs confronted challenges in terms of unreliable, standalone GIS devices, delays in registering mosquito breeding sites and lack of engagement from communities while delivering dengue education. These findings, in concert with a high motivation to use mobile-based systems, informed the development of Mo-Buzz, a mobile-based system that integrates three components – digitized surveillance, dynamic disease mapping and digitized dengue education – on a common platform. The system was developed through an iterative, evolutionary, collaborative process, consistent with the Spiral model of software development and is currently being used by all 55 PHIs in the CMC system. Conclusions: Given the entrenched nature of existing paper-based systems in PHIs’ work habits, we expect a gradual adoption curve for Mo-Buzz in the future. Equally, we expect variable adoption of the system with respect to its specific components, and specific PHI sub-groups (younger versus older). The Mo-Buzz intervention is a response to multiple calls by the global mHealth community for collaborations in the area of mobile interventions for global health. Our experience revealed that the benefits of this paradigm lies in alleviating country-specific public health challenges through a commonly shared understanding of cultural mores, and sharing of knowledge and technologies. We call upon future researchers to further dissect the applicability of the Spiral Model of software development to mHealth interventions and contribute to the mHealth evidence debate from theoretical and applied perspectives. %M 27369296 %R 10.2196/jmir.4657 %U http://www.jmir.org/2016/7/e149/ %U https://doi.org/10.2196/jmir.4657 %U http://www.ncbi.nlm.nih.gov/pubmed/27369296 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 2 %N 1 %P e28 %T Development and Implementation of Culturally Tailored Offline Mobile Health Surveys %A McIntosh,Scott %A Pérez-Ramos,José %A Demment,Margaret M %A Vélez Vega,Carmen %A Avendaño,Esteban %A Ossip,Deborah J %A Dye,Timothy D %+ School of Medicine & Dentistry, Department of Public Health Sciences, University of Rochester, CU420644, 265 Crittenden Blvd, Rochester, NY, 14642, United States, 1 585 802 9944, scott_mcintosh@urmc.rochester.edu %K mobile health %K survey research %K ethical review %D 2016 %7 02.06.2016 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: In low and middle income countries (LMICs), and other areas with low resources and unreliable access to the Internet, understanding the emerging best practices for the implementation of new mobile health (mHealth) technologies is needed for efficient and secure data management and for informing public health researchers. Innovations in mHealth technology can improve on previous methods, and dissemination of project development details and lessons learned during implementation are needed to provide lessons learned to stakeholders in both the United States and LMIC settings. Objective: The aims of this paper are to share implementation strategies and lessons learned from the development and implementation stages of two survey research projects using offline mobile technology, and to inform and prepare public health researchers and practitioners to implement new mobile technologies in survey research projects in LMICs. Methods: In 2015, two survey research projects were developed and piloted in Puerto Rico and pre-tested in Costa Rica to collect face-to-face data, get formative evaluation feedback, and to test the feasibility of an offline mobile data collection process. Fieldwork in each setting involved survey development, back translation with cultural tailoring, ethical review and approvals, data collector training, and piloting survey implementation on mobile tablets. Results: Critical processes and workflows for survey research projects in low resource settings were identified and implemented. This included developing a secure mobile data platform tailored to each survey, establishing user accessibility, and training and eliciting feedback from data collectors and on-site LMIC project partners. Conclusions: Formative and process evaluation strategies are necessary and useful for the development and implementation of survey research projects using emerging mHealth technologies in LMICs and other low resource settings. Lessons learned include: (1) plan institutional review board (IRB) approvals in multiple countries carefully to allow for development, implementation, and feedback, (2) in addition to testing the content of survey instruments, allow time and consideration for testing the use of novel mHealth technology (hardware and software), (3) incorporate training for and feedback from project staff, LMIC partner staff, and research participants, and (4) change methods accordingly, including content, as mHealth technology usage influences and is influenced by the content and structure of the survey instrument. Lessons learned from early phases of LMIC research projects using emerging mHealth technologies are critical for informing subsequent research methods and study designs. %M 27256208 %R 10.2196/publichealth.5408 %U http://publichealth.jmir.org/2016/1/e28/ %U https://doi.org/10.2196/publichealth.5408 %U http://www.ncbi.nlm.nih.gov/pubmed/27256208 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 2 %N 1 %P e7 %T Enabling Access to Medical and Health Education in Rwanda Using Mobile Technology: Needs Assessment for the Development of Mobile Medical Educator Apps %A Rusatira,Jean Christophe %A Tomaszewski,Brian %A Dusabejambo,Vincent %A Ndayiragije,Vincent %A Gonsalves,Snedden %A Sawant,Aishwarya %A Mumararungu,Angeline %A Gasana,George %A Amendezo,Etienne %A Haake,Anne %A Mutesa,Leon %+ College of Medicine and Health Sciences, University of Rwanda, KN 73 ST, Kigali, 3286, Rwanda, 250 788665979, rusatirac2001@gmail.com %K mobile medical education %K technology %K user-centered design %D 2016 %7 01.06.2016 %9 Original Paper %J JMIR Med Educ %G English %X Background: Lack of access to health and medical education resources for doctors in the developing world is a serious global health problem. In Rwanda, with a population of 11 million, there is only one medical school, hence a shortage in well-trained medical staff. The growth of interactive health technologies has played a role in the improvement of health care in developed countries and has offered alternative ways to offer continuous medical education while improving patient's care. However, low and middle-income countries (LMIC) like Rwanda have struggled to implement medical education technologies adapted to local settings in medical practice and continuing education. Developing a user-centered mobile computing approach for medical and health education programs has potential to bring continuous medical education to doctors in rural and urban areas of Rwanda and influence patient care outcomes. Objective: The aim of this study is to determine user requirements, currently available resources, and perspectives for potential medical education technologies in Rwanda. Methods: Information baseline and needs assessments data collection were conducted in all 44 district hospitals (DHs) throughout Rwanda. The research team collected qualitative data through interviews with 16 general practitioners working across Rwanda and 97 self-administered online questionnaires for rural areas. Data were collected and analyzed to address two key questions: (1) what are the currently available tools for the use of mobile-based technology for medical education in Rwanda, and (2) what are user's requirements for the creation of a mobile medical education technology in Rwanda? Results: General practitioners from different hospitals highlighted that none of the available technologies avail local resources such as the Ministry of Health (MOH) clinical treatment guidelines. Considering the number of patients that doctors see in Rwanda, an average of 32 patients per day, there is need for a locally adapted mobile education app that utilizes specific Rwandan medical education resources. Based on our results, we propose a mobile medical education app that could provide many benefits such as rapid decision making with lower error rates, increasing the quality of data management and accessibility, and improving practice efficiency and knowledge. In areas where Internet access is limited, the proposed mobile medical education app would need to run on a mobile device without Internet access. Conclusions: A user-centered design approach was adopted, starting with a needs assessment with representative end users, which provided recommendations for the development of a mobile medical education app specific to Rwanda. Specific app features were identified through the needs assessment and it was evident that there will be future benefits to ongoing incorporation of user-centered design methods to better inform the software development and improve its usability. Results of the user-centered design reported here can inform other medical education technology developments in LMIC to ensure that technologies developed are usable by all stakeholders. %M 27731861 %R 10.2196/mededu.5336 %U http://mededu.jmir.org/2016/1/e7/ %U https://doi.org/10.2196/mededu.5336 %U http://www.ncbi.nlm.nih.gov/pubmed/27731861 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 2 %P e65 %T Perceptions of the Feasibility and Practicalities of Text Messaging-Based Infectious Disease Surveillance: A Questionnaire Survey %A Dang,Linh Thuy %A Vu,Nguyen Cong %A Vu,Thiem Dinh %A James,Spencer L %A Katona,Peter %A Katona,Lindsay %A Rosen,Joseph M %A Nguyen,Cuong Kieu %+ Institute of Population, Health and Development, 18 Lane 132, Hoa Bang Street, Hanoi, 122667, Vietnam, 84 437822388 ext 822, cuong.kieu.nguyen@phad.org %K SMS %K SMS-based %K infectious diseases %K text messaging %K surveillance %K Vietnam %D 2016 %7 25.05.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: In Vietnam, infectious disease surveillance data are collected via a paper-based system through four government tiers leading to a large delay. Meanwhile, mobile phones are abundant and very popular in the country, and known to be a useful tool in health care worldwide. Therefore, there is a great potential for the development of a timely disease surveillance system through the use of mobile phone short message service (SMS) text messages. Objective: This study aims to explore insights about the feasibility and practicalities of the utilization of SMS text messaging-based interventions in disease-reporting systems by identifying potential challenges and barriers in the text messaging process and looking at lessons learned. Methods: An SMS text messaging-based disease tracking system was set up in Vietnam with patient reports texted by clinic staff. Two 6-month trials utilizing this disease tracking system were designed and implemented in two northern provinces of Vietnam to report two infectious diseases: diarrhea and influenza-like illness. A structured self-reported questionnaire was developed to measure the feasibility and practicalities of the system from the participants. On the completion of the second trial in 2013, participating health staff from 40 commune health centers in the two pilot provinces were asked to complete the survey (N=80). Results: Most participants were female (61%, 49/80) and nearly half (44%, 35/80) were heads of a commune health center. Approximately two-thirds (63%, 50/80) of participants retained the basic structure of the SMS text message report and there was a strong influence (OR 28.2, 95% CI 5.3-151.2) of those people on the time they spent texting the information. The majority (88%, 70/80) felt the information conveyed in the SMS text message report was not difficult to understand. Most (86%, 69/80) believed that they could report all 28 infectious diseases asked for by the Ministry of Health by using SMS text messaging. Conclusions: From a health center staff perspective, a disease-reporting system utilizing text messaging technology is easy to use and has great potential to be implemented and expanded nationwide. The survey showed positive perceptions and feedback from the participants and contributed to a promising practical solution to improve the surveillance system of infectious disease in Vietnam. %M 27226418 %R 10.2196/mhealth.4509 %U http://mhealth.jmir.org/2016/2/e65/ %U https://doi.org/10.2196/mhealth.4509 %U http://www.ncbi.nlm.nih.gov/pubmed/27226418 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 2 %P e64 %T The Use of Mobile Phone and Medical Apps among General Practitioners in Hangzhou City, Eastern China %A Liu,Ying %A Ren,Wen %A Qiu,Yan %A Liu,Juanjuan %A Yin,Pei %A Ren,Jingjing %+ General Practice Department, The First Affiliated Hospital, College of Medicine, Zhejiang University, #79 Qingchun Road, Hangzhou, 310003, China, 86 138 1948 5898, lisarjj@126.com %K mobile phone %K app use %K general practitioner %K mobile technology %D 2016 %7 24.05.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Mobile phones and mobile phone apps have expanded new forms of health professionals’ work. There are many studies on the use of mobile phone apps for different specialists. However, there are no studies on the current use of mobile phone apps among general practitioners (GPs). Objective: The objective of the study was to investigate the extent to which GPs own smartphones with apps and use them to aid their clinical activities. Methods: A questionnaire survey of GPs was undertaken in Hangzhou, Eastern China. Data probing GPs’ current use of medical apps in their clinical activities and factors influencing app use were collected and analyzed Results: 125 GPs participated in the survey. 90.4% of GPs owned a mobile phone, with 48.7% owning an iPhone and 47.8% owning an Android phone. Most mobile phone owners had 1-3 medical-related apps, with very few owning more than 4. There was no difference in number of apps between iPhone and Android owners (χ2=1.388, P=0.846). 36% of GPs reported using medical-related apps on a daily basis. The majority of doctors reported using apps to aid clinical activities less than 30 minutes per day. Conclusions: A high level of mobile phone ownership and usage among GPs was found in this study, but few people chose medical-related apps to support their clinical practice. %M 27220417 %R 10.2196/mhealth.4508 %U http://mhealth.jmir.org/2016/2/e64/ %U https://doi.org/10.2196/mhealth.4508 %U http://www.ncbi.nlm.nih.gov/pubmed/27220417 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 5 %P e114 %T Potential Reach of mHealth Versus Traditional Mass Media for Prevention of Chronic Diseases: Evidence From a Nationally Representative Survey in a Middle-Income Country in Africa %A Yepes,Maryam %A Maurer,Jürgen %A Viswanathan,Barathi %A Gedeon,Jude %A Bovet,Pascal %+ University Institute of Social and Preventive Medicine (IUMSP), Route de la Corniche 10, 1010 Lausanne,, Switzerland, +41 21 314 7272, pascal.bovet@chuv.ch %K digital divide %K mHealth %K eHealth %K mass media %K mobile phone %K noncommunicable diseases %K short message service %K email %K internet access %K developing countries %K low- and middle-income countries %K Africa %D 2016 %7 20.05.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Public radio and television announcements have a long tradition in public health education. With the global rise of computer and mobile device ownership, short message service (SMS) and email-based health services (mHealth) are promising new tools for health promotion. Objective: Our objectives were to examine 1) self-reported exposure to programs related to noncommunicable diseases (NCDs) on national public television and radio during the 12 months preceding the survey (2013–2014), 2) current ownership of a mobile phone, smartphone, computer, or tablet, and use of the Internet, and 3) willingness of individuals to receive SMS or emails with information on health, with a focus on distribution of these variables across different demographic, socioeconomic status (SES), and NCD risk groups. Methods: We obtained data in a population survey of 1240 participants aged 25–64 years conducted in 2013–2014 in the Seychelles, a rapidly developing small island state in the African region. We administered a structured questionnaire and measured NCD risk factors. Univariate and multivariate analyses explored the relationships between outcomes and sociodemographic variables. Results: Of 1240 participants, 1037 (83.62%) reported exposure to NCD-related programs on public television, while a lower proportion of 740 adults (59.67%), reported exposure via public radio (P <.001). Exposure to NCD-related programs on public television was associated with older age (P <.001) and female sex (P <.001), but not with SES, while exposure to NCD-related programs on public radio was associated with older age (P <.001) and lower SES (P <.001). A total of 1156 (93.22%) owned a mobile phone and ownership was positively associated with female sex (P <.001), younger age (P <.001), and higher SES (P <.001). Only 396 adults (31.93%) owned a smartphone and 244 adults (19.67%) used their smartphone to access the Internet. A total of 1048 adults (84.51%) reported willingness to receive health-related SMS, which was positively associated with female sex (P <.001), younger age (P <.001), and higher SES (P <.001). Controlling for SES, exposure to NCD-related programs on public television or radio and willingness to receive health-related SMS were not independently associated with a person’s NCD risk. Conclusions: Broadcasting health programs through traditional mass media (national public radio and television) reached the majority of the population under study, including older adults and those in lower socioeconomic groups. With a high penetration of mobile phones and willingness to receive health-related SMS, mHealth presents an opportunity for health programs, especially when targeted SMS messages are intended for younger adults and those in higher socioeconomic groups. By contrast, due to reduced Internet access, email-based programs had a more limited reach for health promotion programs. These findings emphasize the different reach of interventions using SMS or email versus traditional mass media, according to demographic and socioeconomic categories, for health education programs in a developing country. %M 27207074 %R 10.2196/jmir.5592 %U http://www.jmir.org/2016/5/e114/ %U https://doi.org/10.2196/jmir.5592 %U http://www.ncbi.nlm.nih.gov/pubmed/27207074 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 2 %P e52 %T Are Text Messages a Feasible and Acceptable Way to Reach Female Entertainment Workers in Cambodia with Health Messages? A Cross-Sectional Phone Survey %A Brody,Carinne %A Dhaliwal,Sukhmani %A Tuot,Sovannary %A Johnson,Michael %A Pal,Khuondyla %A Yi,Siyan %+ Touro University California, Public Health Program, Center for Global Health Research, 1310 Club Drive, Vallejo, CA, 94592, United States, 1 7076388533, carinne.brody@gmail.com %K mHealth %K short message service %K Cambodia %K female sex workers %K HIV %D 2016 %7 20.05.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Despite great achievements in reducing the prevalence of HIV, eliminating new HIV infections remains a challenge in Cambodia. Entertainment venues such as restaurants, karaoke bars, beer gardens, cafes, pubs, and massage parlors are now considered important venues for HIV prevention efforts and other health outreach interventions. Objective: The purpose of this study was to explore phone use and texting practices of female entertainment workers (FEWs) in order to determine if text messaging is a feasible and acceptable way to link FEWs to health services. Methods: This cross-sectional phone survey was conducted in May 2015 with 97 FEWs aged 18–35 years and currently working at an entertainment venue in Phnom Penh. Results: Of the 96 respondents, 51% reported sending text messages daily; of them, 47% used Khmer script and 45% used Romanized Khmer. Younger FEWs were more likely to report daily texting (P<.001). Most FEWs (98%) in this study reported feeling comfortable receiving private health messages despite the fact that 39% were sharing their phone with others. Younger FEWs were less likely to share their phone with others (P=.02). Of all of the FEWs, 47% reported owning a smartphone, and younger women were more likely to own a smartphone than were older women (P=.08). Conclusions: The findings from this study support the development of mHealth interventions targeting high-risk groups in urban areas of Cambodia. Our data suggest that mHealth interventions using texting may be a feasible way of reaching FEWs in Phnom Penh. %M 27207374 %R 10.2196/mhealth.5297 %U http://mhealth.jmir.org/2016/2/e52/ %U https://doi.org/10.2196/mhealth.5297 %U http://www.ncbi.nlm.nih.gov/pubmed/27207374 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 2 %P e61 %T Mobile Phone Use Among Medical Residents: A Cross-Sectional Multicenter Survey in Saudi Arabia %A Jamal,Amr %A Temsah,Mohamad-Hani %A Khan,Samina A %A Al-Eyadhy,Ayman %A Koppel,Cristina %A Chiang,Michael F %+ College of Medicine, Department of Family and Community Medicine, King Saud University, PO Box 90714, Riyadh, 11623, Saudi Arabia, 966 114690822, amrjamal@ksu.edu.sa %K cell phones %K mobile phone %K telemedicine %K medical education %K medical residencies %K educational techniques %K patient care %K communication methods %K WhatsApp %K Saudi Arabia %K point of care technology %D 2016 %7 19.05.2016 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile phones have great potential for medical education, as they allow health care providers and students to access resources efficiently at the precise time at the point-of-care to help in informed decision making. Objective: The objective of the study was to evaluate the prevalence of mobile phone usage among medical residents and to explore their attitudes, perceptions, and the challenges they experience when using mobile phones in academic and clinical practice. Methods: A cross-sectional survey was conducted on all 133 residents in 17 different specialties across two large academic hospitals in Riyadh, Saudi Arabia. The Web-based validated questionnaire measured mobile phone platform preferences, and their uses in general and medical practice. The perception of confidentiality and safety impact of using mobile phones for communication and accessing patient’s data was also explored, alongside challenges of use and how residents learn to use their mobile phone. Results: With a response rate of 101/133 (75.9%) and mean age of 27.8 (SD 3.0) years, we found that 100/101 (99.0%) of participants were mobile phone users with mean duration of use of 5.12 (SD 2.4) years, and a range from 1 to 12 years. There was no significant difference in use between male and female respondents. A negative linear correlation was found between age and use duration (P=.004). The most common operating system used by participants was the iOS platform (55/101, 54.5%), with English the most commonly used language to operate residents’ mobile phones (96/100, 96.0%) despite their native language being Arabic. For communication outside medical practice, chatting applications such as WhatsApp matched phone calls as most commonly used tools (each 88/101, 87.1%). These were also the primary tools for medical communication, but used at a lower rate (each 65/101, 64.4%). In medical practice, drug (83/101, 82.2%) and medical (80/101, 79.2%) references and medical calculation applications (61/101, 60.4%) were the most commonly used. Short battery life (48/92, 52%) was the most common technical difficulty, and distraction at least on a weekly basis (54/92, 58%) was the most likely side effect of using a mobile phone in medical practice. Practically, all participants agreed with the idea of integrating medical staff mobile phones with the hospital information system. Most residents described themselves as self-learners, while half learned from peers, and a quarter learned from the Internet. Only 7/101 (6.9%) had received formal training on the medical use of mobile phones. Over half of residents thought it was safe to discuss patients over their personal, nonencrypted email. Conclusions: Mobile phone use among medical residents has become almost universal in academic and clinical settings. Thus, academic and health care institutions should support proper utilization of these devices in medical training and point-of-care decision making, while continuing to protect patient confidentiality. %M 27197618 %R 10.2196/mhealth.4904 %U http://mhealth.jmir.org/2016/2/e61/ %U https://doi.org/10.2196/mhealth.4904 %U http://www.ncbi.nlm.nih.gov/pubmed/27197618 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 2 %P e37 %T Mobile Health Insurance System and Associated Costs: A Cross-Sectional Survey of Primary Health Centers in Abuja, Nigeria %A Chukwu,Emeka %A Garg,Lalit %A Eze,Godson %+ University of Liverpool, Faculty of Computer Science and Engineering, Liverpool, Mercy side, Liverpool, L69 3BX, United Kingdom, 44 8037760629, emeka.chukwu@online.liverpool.ac.uk %K mobile health %K mHealth %K eHealth %K health financing %K health insurance %K public health informatics %D 2016 %7 17.05.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Nigeria contributes only 2% to the world’s population, accounts for 10% of the global maternal death burden. Health care at primary health centers, the lowest level of public health care, is far below optimal in quality and grossly inadequate in coverage. Private primary health facilities attempt to fill this gap but at additional costs to the client. More than 65% Nigerians still pay out of pocket for health services. Meanwhile, the use of mobile phones and related services has risen geometrically in recent years in Nigeria, and their adoption into health care is an enterprise worth exploring. Objective: The purpose of this study was to document costs associated with a mobile technology–supported, community-based health insurance scheme. Methods: This analytic cross-sectional survey used a hybrid of mixed methods stakeholder interviews coupled with prototype throw-away software development to gather data from 50 public primary health facilities and 50 private primary care centers in Abuja, Nigeria. Data gathered documents costs relevant for a reliable and sustainable mobile-supported health insurance system. Clients and health workers were interviewed using structured questionnaires on services provided and cost of those services. Trained interviewers conducted the structured interviews, and 1 client and 1 health worker were interviewed per health facility. Clinic expenditure was analyzed to include personnel, fixed equipment, medical consumables, and operation costs. Key informant interviews included a midmanagement staff of a health-management organization, an officer-level staff member of a mobile network operator, and a mobile money agent. Results: All the 200 respondents indicated willingness to use the proposed system. Differences in the cost of services between public and private facilities were analyzed at 95% confidence level (P<.001). This indicates that average out-of-pocket cost of services at private health care facilities is significantly higher than at public primary health care facilities. Key informant interviews with a health management organizations and a telecom operator revealed high investment interests. Cost documentation analysis of income versus expenditure for the major maternal and child health service areas—antenatal care, routine immunization, and birth attendance for 1 year—showed that primary health facilities would still profit if technology-supported, health insurance schemes were adopted. Conclusions: This study demonstrates a case for the implementation of enrolment, encounter management, treatment verification, claims management and reimbursement using mobile technology for health insurance in Abuja, Nigeria. Available data show that the introduction of an electronic job aid improved efficiency. Although it is difficult to make a concrete statement on profitability of this venture but the interest of the health maintenance organizations and telecom experts in this endeavor provides a positive lead. %M 27189312 %R 10.2196/mhealth.4342 %U http://mhealth.jmir.org/2016/2/e37/ %U https://doi.org/10.2196/mhealth.4342 %U http://www.ncbi.nlm.nih.gov/pubmed/27189312 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 5 %N 2 %P e72 %T The Mobile Solutions for Immunization (M-SIMU) Trial: A Protocol for a Cluster Randomized Controlled Trial That Assesses the Impact of Mobile Phone Delivered Reminders and Travel Subsidies to Improve Childhood Immunization Coverage Rates and Timeliness in Western Kenya %A Gibson,Dustin G %A Kagucia,E. Wangeci %A Ochieng,Benard %A Hariharan,Nisha %A Obor,David %A Moulton,Lawrence H %A Winch,Peter J %A Levine,Orin S %A Odhiambo,Frank %A O'Brien,Katherine L %A Feikin,Daniel R %+ Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States, 1 443 287 8763, dgibso28@jhu.edu %K text message %K reminders %K SMS %K M-PESA %K Kenya %K mobile %K conditional cash transfer %K CCT %K incentive %K measles %K mHealth %K immunization %K pentavalent %D 2016 %7 17.05.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Text message (short message service, SMS) reminders and incentives are two demand-side interventions that have been shown to improve health care–seeking behaviors by targeting participant characteristics such as forgetfulness, lack of knowledge, and transport costs. Applying these interventions to routine pediatric immunizations may improve vaccination coverage and timeliness. Objective: The Mobile Solutions for Immunization (M-SIMU) trial aims to determine if text message reminders, either with or without mobile phone–based incentives, sent to infant’s parents can improve immunization coverage and timeliness of routine pediatric vaccines in rural western Kenya. Methods: This is a four-arm, cluster, randomized controlled trial. Villages are randomized to one of four study arms prior to enrollment of participants. The study arms are: (1) no intervention (a general health-related text message will be texted to this group at the time of enrollment), (2) text message reminders only, (3) text message reminders and a 75 Kenyan Shilling (KES) incentive, or (4) text message reminders and a KES200 incentive. Participants assigned to study arms 2-4 will receive two text message reminders; sent 3 days before and one day before the scheduled immunization visit at 6, 10, and 14 weeks for polio and pentavalent (containing diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenza type b antigens) type b antigens) vaccines, and at 9 months for measles vaccine. Participants in incentive arms will, in addition to text message reminders as above, receive mobile phone–based incentives after each timely vaccination, where timely is defined as vaccination within 2 weeks of the scheduled date for each of the four routine expanded program immunization (EPI) vaccination visits. Mother-infant pairs will be followed to 12 months of age where the primary outcome, a fully immunized child, will be ascertained. A fully immunized child is defined as a child receiving vaccines for bacille Calmette-Guerin, three doses of pentavalent and polio, and measles by 12 months of age. General estimating equation (GEE) models that account for clustering will be employed for primary outcome analyses. Results: Enrollment was completed in October 2014. Twelve month follow-up visits to ascertain immunization status from the maternal and child health booklet were completed in February 2016. Conclusions: This is one of the first studies to examine the effect of text message reminders on immunization coverage and timeliness in a lower income country and is the first study to assess the effect of mobile money-based incentives to improve immunization coverage. Trial Registration: Clinicaltrials.gov NCT01878435; https://clinicaltrials.gov/ct2/show/NCT01878435 (Archived by WebCite at http://www.webcitation.org/6hQlwGYJR) %M 27189422 %R 10.2196/resprot.5030 %U http://www.researchprotocols.org/2016/2/e72/ %U https://doi.org/10.2196/resprot.5030 %U http://www.ncbi.nlm.nih.gov/pubmed/27189422 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 2 %P e30 %T Acceptability, Usability, and Views on Deployment of Peek, a Mobile Phone mHealth Intervention for Eye Care in Kenya: Qualitative Study %A Lodhia,Vaishali %A Karanja,Sarah %A Lees,Shelley %A Bastawrous,Andrew %+ London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom, 44 7796277602, vaishali.lodhia@gmail.com %K mobile phone %K mHealth %K qualitative %K ophthalmic testing %K acceptability %K usability %K Kenya %D 2016 %7 09.05.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: The Portable Eye Examination Kit (Peek) is a mobile phone–based ophthalmic testing system that has been developed to perform comprehensive eye examinations. Shortages in ophthalmic personnel, the high cost, and the difficulty in transporting equipment have made it challenging to offer services, particularly in rural areas. Peek offers a solution for overcoming barriers of limited access to traditional ophthalmic testing methods and has been pilot tested on adults in Nakuru, Kenya, and compared with traditional eye examination tools. Objective: This qualitative study evaluated the acceptability and usability of Peek in addition to perceptions regarding its adoption and nationwide deployment. Methods: Semistructured interviews were conducted with patients and analyzed using a framework approach. This included analysis of interviews from 20 patients, 8 health care providers (HCPs), and 4 key decision makers in ophthalmic health care provision in Kenya. The participants were purposefully sampled. The coding structure involved predefined themes for assessing the following: (1) the context, that is, environment, user, task, and technology; (2) patient acceptability, that is, patients' perceived benefits, patient preference, and patient satisfaction; (3) usability, that is, efficiency, effectiveness, learnability, and flexibility and operability of Peek; and (4) the benefits of Peek in strengthening eye care provision, that is, capabilities enhancer, opportunity creator, social enabler, and knowledge generator. Emerging themes relating to the objectives were explored from the data using thematic analysis. Results: Patients found Peek to be acceptable because of its benefits in overcoming the barriers to accessing ophthalmic services. Most thought it to be fast, convenient, and able to reach a large population. All patients expressed being satisfied with Peek. The HCPs perceived it to satisfy the criteria for usability and found Peek to be acceptable based on the technology acceptance model. Peek was also found to have features required for strengthening ophthalmic delivery by aiding detection and diagnosis, provision of decision support, improving communication between provider and patient and among providers, linking patients to services, monitoring, and assisting in education and training. Some of the deployment-related issues included the need for government and community involvement, communication and awareness creation, data protection, infrastructure development including capacity creation, and training and maintenance support. Conclusions: According to all parties interviewed, Peek is an acceptable solution, as it provides a beneficial service, supports patients' needs, and fulfills HCPs' roles, overall contributing to strengthening eye health. %M 27160779 %R 10.2196/mhealth.4746 %U http://mhealth.jmir.org/2016/2/e30/ %U https://doi.org/10.2196/mhealth.4746 %U http://www.ncbi.nlm.nih.gov/pubmed/27160779 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 1 %P e22 %T Hypertension Health Promotion via Text Messaging at a Community Health Center in South Africa: A Mixed Methods Study %A Hacking,Damian %A Haricharan,Hanne J %A Brittain,Kirsty %A Lau,Yan Kwan %A Cassidy,Tali %A Heap,Marion %+ Health and Human Rights Programme, Department of Public Health and Family Medicine, University of Cape Town, Observatory, Cape Town, 7925, South Africa, 27 848238040, damianuct@gmail.com %K telemedicine %K health knowledge, attitudes, practice %K developing countries %K hypertension %D 2016 %7 10.03.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: The use of mobile phones to deliver health care (mHealth) is increasing in popularity due to the high prevalence of mobile phone penetration. This is seen in developing countries, where mHealth may be particularly useful in overcoming traditional access barriers. Non-communicable diseases may be particularly amenable to mHealth interventions, and hypertension is one with an escalating burden in the developing world. Objective: The objective of this study was to test whether the dissemination of health information via a short message service (SMS) led to improvements in health knowledge and self-reported health-related behaviors. Methods: A mixed methods study was carried out among a cohort of 223 hypertension clinic patients, in a resource-poor setting in Cape Town, South Africa, in 2012. Hypertensive outpatients were recruited at the clinic and administered a baseline questionnaire to establish existing knowledge of hypertension. Participants were then randomly assigned to intervention or control groups. The intervention group received 90 SMSes over a period of 17 weeks. Thereafter, the baseline questionnaire was readministered to both groups to gauge if any improvements in health knowledge had occurred. Those who received SMSes were asked additional questions about health-related behavior changes. A focus group was then conducted to obtain in-depth feedback about participants’ experience with, and response to, the SMS campaign. Results: No statistically significant changes in overall health knowledge were observed between the control and intervention groups. The intervention group had positive increases in self-reported behavior changes. These were reaffirmed by the focus groups, which also revealed a strong preference for the SMS campaign and the belief that the SMSes acted as a reminder to change, as opposed to providing new information. Conclusions: Although the content of the SMSes was not new, and did not improve health knowledge, SMSes were effective in motivating positive self-reported behavior change among hypertensive patients. Trial Registration: Pan African Clinical Trials Registry Number: PACTR201412000968462. Registered 18 December 2014 (Archived by WebCite at http://www.webcitation.org/6fhtyLRcO). %M 26964505 %R 10.2196/mhealth.4569 %U http://mhealth.jmir.org/2016/1/e22/ %U https://doi.org/10.2196/mhealth.4569 %U http://www.ncbi.nlm.nih.gov/pubmed/26964505 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 1 %P e16 %T The PAediatric Risk Assessment (PARA) Mobile App to Reduce Postdischarge Child Mortality: Design, Usability, and Feasibility for Health Care Workers in Uganda %A English,Lauren Lacey %A Dunsmuir,Dustin %A Kumbakumba,Elias %A Ansermino,John Mark %A Larson,Charles P %A Lester,Richard %A Barigye,Celestine %A Ndamira,Andrew %A Kabakyenga,Jerome %A Wiens,Matthew O %+ Division of Infectious Diseases, Department of Medicine, University of British Columbia, 2733 Heather Street, Vancouver, BC, , Canada, 1 604 997 7753, mowiens@outlook.com %K infectious disease %K postdischarge mortality %K mHealth %K prediction model %K risk assessment %K usability %K Africa %K resource-limited settings %D 2016 %7 15.02.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Postdischarge death in children is increasingly being recognized as a major contributor to overall child mortality. The PAediatric Risk Assessment (PARA) app is an mHealth tool developed to aid health care workers in resource-limited settings such as Sub-Saharan Africa to identify pediatric patients at high risk of both in-hospital and postdischarge mortality. The intended users of the PARA app are health care workers (ie, nurses, doctors, and clinical officers) with varying levels of education and technological exposure, making testing of this clinical tool critical to successful implementation. Objective: Our aim was to summarize the usability evaluation of the PARA app among target users, which consists of assessing the ease of use, functionality, and navigation of the interfaces and then iteratively improving the design of this clinical tool. Methods: Health care workers (N=30) were recruited to participate at Mbarara Regional Referral Hospital and Holy Innocents Children’s Hospital in Mbarara, Southwestern Uganda. This usability study was conducted in two phases to allow for iterative improvement and testing of the interfaces. The PARA app was evaluated using quantitative and qualitative measures, which were compared between Phases 1 and 2 of the study. Participants were given two patient scenarios that listed hypothetical information (ie, demographic, social, and clinical data) to be entered into the app and to determine the patient’s risk of in-hospital and postdischarge mortality. Time-to-completion and user errors were recorded for each participant while using the app. A modified computer system usability questionnaire was utilized at the end of each session to elicit user satisfaction with the PARA app and obtain suggestions for future improvements. Results: The average time to complete the PARA app decreased by 30% from Phase 1 to Phase 2, following user feedback and modifications. Participants spent the longest amount of time on the oxygen saturation interface, but modifications following Phase 1 cut this time by half. The average time-to-completion (during Phase 2) for doctors/medical students was 3 minutes 56 seconds. All participants agreed they would use the PARA app if available at their health facility. Given a high PARA risk score, participants suggested several interventions that would be appropriate for the sociocultural context in southwestern Uganda, which involved strengthening discharge and referral procedures within the current health care system. Conclusions: Through feedback and modifications made during this usability study, the PARA app was developed into a user-friendly app, encompassing user expectations and culturally intuitive interfaces for users with a range of technological exposure. Doctors and medical students had shorter task completion times, though all participants reported the usefulness of this tool to improve postdischarge outcomes. %M 26879041 %R 10.2196/mhealth.5167 %U http://mhealth.jmir.org/2016/1/e16/ %U https://doi.org/10.2196/mhealth.5167 %U http://www.ncbi.nlm.nih.gov/pubmed/26879041 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 1 %P e10 %T Unpacking the Black Box: A Formative Research Approach to the Development of Theory-Driven, Evidence-Based, and Culturally Safe Text Messages in Mobile Health Interventions %A Maar,Marion A %A Yeates,Karen %A Toth,Zsolt %A Barron,Marcia %A Boesch,Lisa %A Hua-Stewart,Diane %A Liu,Peter %A Perkins,Nancy %A Sleeth,Jessica %A Wabano,Mary Jo %A Williamson,Pamela %A Tobe,Sheldon W %+ Faculty of Medicine, Northern Ontario School of Medicine, Laurentian University, 935 Ramsey Lake Road, Sudbury, ON, , Canada, 1 705 662 7233, mmaar@nosm.ca %K Aboriginal people %K behavioral change wheel %K cultural safety %K grounded theory %K mobile phone %K semiotics %K SMS %K Tanzania %K text messages %D 2016 %7 22.01.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Mobile-cellular subscriptions have increased steadily over the past decade. The accessibility of SMS messages over existing mobile networks is high and has almost universal availability even on older and unsophisticated mobile phones and in geographic settings where wireless coverage is weak. There is intensive exploration of this inexpensive mobile telecommunication technology to improve health services and promote behavior change among vulnerable populations. However, a neglected area of research is the documentation and critical analysis of the formative research process required in the development and refinement of effective SMS messages. Objective: The objective of this qualitative research study was to identify major factors that may impact on the effectiveness of evidence-based SMS messages designed to reduce health inequities in hypertension management in low resource settings, including Aboriginal populations in high-income countries and rural populations in low-income countries. Specifically, we were interested in uncovering the range of mediators that impact on appropriate message content transmission and, ultimately, on health behavior improvements in a range of these sociocultural settings. Methods: Collaborative qualitative research with Canadian Aboriginal and Tanzanian participants was conducted to deconstruct the content and transmission of evidence-based health information contained in SMS messages in the context of an international research project designed to address health inequalities in hypertension, and to develop a grounded theory of the major factors that mediate the effectiveness of this communication. We also examined the interrelationship of these mediators with the three essential conditions of the behavior system of the Behavioral Change Wheel model (capability, opportunity, and motivation) and cultural safety. Results: Four focus groups with a total of 45 participants were conducted. Our grounded theory research revealed how discrepancies develop between the evidence-based text message created by researchers and the message received by the recipient in mobile health interventions. These discrepancies were primarily generated by six mediators of meaning in SMS messages: (1) negative or non-affirming framing of advocacies, (2) fear- or stress-inducing content, (3) oppressive or authoritarian content, (4) incongruity with cultural and traditional practices, (5) disconnect with the reality of the social determinants of health and the diversity of cultures within a population, and (6) lack of clarity and/or practicality of content. These 6 mediators of meaning provide the basis for sound strategies for message development because they impact directly on the target populations’ capability, opportunity, and motivation for behavior change. Conclusions: The quality of text messages impacts significantly on the effectiveness of a mobile health intervention. Our research underscores the urgent need for interventions to incorporate and evaluate the quality of SMS messages and to examine the mediators of meaning within each targeted cultural and demographic group. Reporting on this aspect of mobile health intervention research will allow researchers to move away from the current black box of SMS text message development, thus improving the transparency of the process as well as the quality of the outcomes. %M 26800712 %R 10.2196/mhealth.4994 %U http://mhealth.jmir.org/2016/1/e10/ %U https://doi.org/10.2196/mhealth.4994 %U http://www.ncbi.nlm.nih.gov/pubmed/26800712 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 4 %N 1 %P e9 %T Possibilities and Expectations for mHealth in the Pacific Islands: Insights From Key Informants %A Umali,Elaine %A McCool,Judith %A Whittaker,Robyn %+ Epidemiology and Biostatistics, School of Population Health, University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland, , New Zealand, 64 3737599 ext 82372, elaine.umali@gmail.com %K mHealth %K Pacific Islands %K prevention %K health systems %K health policy %D 2016 %7 20.01.2016 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: The increase in mobile phone use across the globe is creating mounting interest for its application in addressing health system constraints. Although still limited, there is growing evidence of success in using mobile phones for health (mHealth) in low- and middle- income countries. The promise of mHealth to address key health system issues presents a huge potential for the Pacific Island countries where mobile use has radically increased. Current projections indicate an improved information and communications technology (ICT) environment to support greater access to mobile and digital devices in the Pacific region. Objective: The objective of the study was to explore key stakeholder perspectives on the potential for mHealth in the Pacific region. Methods: A series of in-depth interviews were conducted either face-to-face, via Skype or by email, with a series of key informants from the Pacific Rim region. Interviews were audio-recorded and later transcribed for detailed thematic analysis. Results: We found widespread support for the potential to use mobile phones as a mechanism to facilitate improved health service delivery in the region. Essential elements for the successful development and implementation of mHealth were identified by these stakeholders. These included: developing an understanding of the local context and the problems that may be usefully addressed by the addition of mHealth to existing strategies and services; consideration of local infrastructure, capability, policy, mobile literacy and engagement; learning from others, particularly other low- and middle-income countries (LMICs); the importance of building supportive environments and of evaluation to provide evidence of impact and total cost. Conclusions: The rapid growth of mobile phone use in the region presents a unique juxtaposition of opportunity and promise. Though the region lags behind other LMICs in the adoption of mHealth technologies, this offers the convenience of learning from past mHealth interventions and applying these learnings to achieve scale, sustainability and success. This study deepens the understanding of the potential of mHealth for the region, and offers a baseline from which discussions can be made to examine the limitations, barriers and complexities inherent in mHealth applications. %M 26792386 %R 10.2196/mhealth.4626 %U http://mhealth.jmir.org/2016/1/e9/ %U https://doi.org/10.2196/mhealth.4626 %U http://www.ncbi.nlm.nih.gov/pubmed/26792386 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 3 %P e76 %T Potential Roles of Mhealth for Community Health Workers: Formative Research With End Users in Uganda and Mozambique %A Thondoo,Meelan %A Strachan,Daniel Ll %A Nakirunda,Maureen %A Ndima,Sozinho %A Muiambo,Abel %A Källander,Karin %A Hill,Zelee %A , %+ Institute for Global Health, University College London, 30 guilford street, London, , United Kingdom, 44 207 905 2603, zhill.ich@gmail.com %K mobile phones %K mHealth %K community health workers %K motivation %K performance %D 2015 %7 23.07.2015 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Community health workers are reemerging as an essential component of health systems in low-income countries. However, there are concerns that unless they are adequately supported, their motivation and performance will be suboptimal. mHealth presents an opportunity to improve support for community health workers; however, most interventions to date have been designed through a top-down approach, rarely involve the end user, and have not focused on motivation. Objective: To use formative research to explore the views of community health workers in Uganda and Mozambique on the potential role of mHealth in their work delivering integrated community case management of children. Methods: We conducted 24 in-depth interviews and 5 focus group discussions with community health workers in Uganda and Mozambique. Data were collected on: current phone use, preferred phone and charger characteristics, and perceptions of a range of potential mHealth interventions. Interviews were conducted in the local language, were audio recorded and converted into expanded notes. Interviews were coded for key thematic areas using both deductive and inductive codes. Deductive codes included mHealth’s potential impact on motivation and performance. Results: The most salient roles of mHealth in improving performance and motivation were reducing the need for travel, improving efficiency and planning, receiving feedback and information, and improving communication with supervisors and other community health workers. This was mostly through improved voice and short message service (SMS) text communication. Specific components of mHealth interventions that participants felt could improve motivation included increasing their visibility and credibility through branding of phones; providing an SMS response to data submission; and sending SMS messages about the importance of their work and achievements, rather than just reminders or technical messages. Participants identified feasibility issues related to the language of SMS messages, network coverage, and the need for a balance between phone function and battery life. Phones with a dual SIM cards would ameliorate network problems but would reduce battery life. The provision of a solar charger was viewed as beneficial. Conclusions: Conducting formative research with end users is likely to improve mHealth interventions by: (1) identifying interventions that are likely to have the greatest impact and be the most acceptable, (2) developing salient SMS messages, and (3) identifying feasibility issues. mHealth interventions also could have an important impact on health worker motivation, which should be considered by intervention developers and in evaluations, especially as small modifications could have a significant impact. Our study suggests that using phones to improve direct communication should be considered, even when planners aim to focus on the provision of a specific application. %M 26206419 %R 10.2196/mhealth.4208 %U http://mhealth.jmir.org/2015/3/e76/ %U https://doi.org/10.2196/mhealth.4208 %U http://www.ncbi.nlm.nih.gov/pubmed/26206419 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 3 %P e75 %T Effectiveness of Using Mobile Phone Image Capture for Collecting Secondary Data: A Case Study on Immunization History Data Among Children in Remote Areas of Thailand %A Jandee,Kasemsak %A Kaewkungwal,Jaranit %A Khamsiriwatchara,Amnat %A Lawpoolsri,Saranath %A Wongwit,Waranya %A Wansatid,Peerawat %+ Center of Excellence for Biomedical and Public Health Informatics (BIOPHICS), Faculty of Tropical Medicine, Mahidol University, The 60 Anniversary of His Majesty the King's Accession to the Throne Building, 420/6, Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand, 66 23549181, jaranitk@biophics.org %K health care information system %K DEPIC %K mobile technology %K maternal and child health %K mHealth %K vaccine record %K electronic data capture %D 2015 %7 20.07.2015 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Entering data onto paper-based forms, then digitizing them, is a traditional data-management method that might result in poor data quality, especially when the secondary data are incomplete, illegible, or missing. Transcription errors from source documents to case report forms (CRFs) are common, and subsequently the errors pass from the CRFs to the electronic database. Objective: This study aimed to demonstrate the usefulness and to evaluate the effectiveness of mobile phone camera applications in capturing health-related data, aiming for data quality and completeness as compared to current routine practices exercised by government officials. Methods: In this study, the concept of “data entry via phone image capture” (DEPIC) was introduced and developed to capture data directly from source documents. This case study was based on immunization history data recorded in a mother and child health (MCH) logbook. The MCH logbooks (kept by parents) were updated whenever parents brought their children to health care facilities for immunization. Traditionally, health providers are supposed to key in duplicate information of the immunization history of each child; both on the MCH logbook, which is returned to the parents, and on the individual immunization history card, which is kept at the health care unit to be subsequently entered into the electronic health care information system (HCIS). In this study, DEPIC utilized the photographic functionality of mobile phones to capture images of all immunization-history records on logbook pages and to transcribe these records directly into the database using a data-entry screen corresponding to logbook data records. DEPIC data were then compared with HCIS data-points for quality, completeness, and consistency. Results: As a proof-of-concept, DEPIC captured immunization history records of 363 ethnic children living in remote areas from their MCH logbooks. Comparison of the 2 databases, DEPIC versus HCIS, revealed differences in the percentage of completeness and consistency of immunization history records. Comparing the records of each logbook in the DEPIC and HCIS databases, 17.3% (63/363) of children had complete immunization history records in the DEPIC database, but no complete records were reported in the HCIS database. Regarding the individual’s actual vaccination dates, comparison of records taken from MCH logbook and those in the HCIS found that 24.2% (88/363) of the children’s records were absolutely inconsistent. In addition, statistics derived from the DEPIC records showed a higher immunization coverage and much more compliance to immunization schedule by age group when compared to records derived from the HCIS database. Conclusions: DEPIC, or the concept of collecting data via image capture directly from their primary sources, has proven to be a useful data collection method in terms of completeness and consistency. In this study, DEPIC was implemented in data collection of a single survey. The DEPIC concept, however, can be easily applied in other types of survey research, for example, collecting data on changes or trends based on image evidence over time. With its image evidence and audit trail features, DEPIC has the potential for being used even in clinical studies since it could generate improved data integrity and more reliable statistics for use in both health care and research settings. %M 26194880 %R 10.2196/mhealth.4183 %U http://mhealth.jmir.org/2015/3/e75/ %U https://doi.org/10.2196/mhealth.4183 %U http://www.ncbi.nlm.nih.gov/pubmed/26194880 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 2 %P e76 %T Using Ecological Momentary Assessment to Study Tobacco Behavior in Urban India: There’s an App for That %A Soong,Andrea %A Chen,Julia Cen %A Borzekowski,Dina LG %+ Institute for Global Tobacco Control, Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St, 4th Floor, Baltimore, MD, 21205, United States, 1 410 502 2482, asoong@jhu.edu %K ecological momentary assessment %K tobacco control %K cell phones %K mobile phones %K mHealth %K telemedicine %K smoking %D 2015 %7 24.06.2015 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Ecological momentary assessment (EMA) uses real-time data collection to assess participants’ behaviors and environments. This paper explores the strengths and limitations of using EMA to examine social and environmental exposure to tobacco in urban India among older adolescents and adults. Objective: Objectives of this study were (1) to describe the methods used in an EMA study of tobacco use in urban India using a mobile phone app for data collection, (2) to determine the feasibility of using EMA in the chosen setting by drawing on participant completion and compliance rates with the study protocol, and (3) to provide recommendations on implementing mobile phone EMA research in India and other low- and middle-income countries. Methods: Via mobile phones and the Internet, this study used two EMA surveys: (1) a momentary survey, sent multiple times per day at random to participants, which asked about their real-time tobacco use (smoked and smokeless) and exposure to pro- and antitobacco messaging in their location, and 2) an end-of-day survey sent at the end of each study day. Trained participants, from Hyderabad and Kolkata, India, reported on their social and environmental exposure to tobacco over 10 consecutive days. This feasibility study examined participant compliance, exploring factors related to the successful completion of surveys and the validity of EMA data. Results: The sample included 205 participants, the majority of whom were male (135/205, 65.9%). Almost half smoked less than daily (56/205, 27.3%) or daily (43/205, 21.0%), and 4.4% (9/205) used smokeless tobacco products. Participants completed and returned 46.87% and 73.02% of momentary and end-of-day surveys, respectively. Significant predictors of momentary survey completion included employment and completion of end-of-day surveys. End-of-day survey completion was only significantly predicted by momentary survey completion. Conclusions: This first study of EMA in India offers promising results, although more research is needed on how to increase compliance. End-of-day survey completion, which has a lower research burden, may be the more appropriate approach to understanding behaviors such as tobacco use within vulnerable populations in challenging locations. Compliance may also be improved by increasing the number of study visits, compliance checks, or opportunities for retraining participants before and during data collection. %M 26109369 %R 10.2196/resprot.4408 %U http://www.researchprotocols.org/2015/2/e76/ %U https://doi.org/10.2196/resprot.4408 %U http://www.ncbi.nlm.nih.gov/pubmed/26109369 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 2 %P e61 %T Adoption and Usage of mHealth Technology on Quality and Experience of Care Provided by Frontline Workers: Observations From Rural India %A Kaphle,Sangya %A Chaturvedi,Sharad %A Chaudhuri,Indrajit %A Krishnan,Ram %A Lesh,Neal %+ Dimagi Software Innovations, Taarifa Road, Parklands, Nairobi, , Kenya, 254 733962903, sangyakaphle@gmail.com %K mHealth %K technology adoption %K community health workers %K CommCare %D 2015 %7 28.05.2015 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: mHealth apps are deployed with the aim of improving access, quality, and experience of health care. It is possible that any mHealth intervention can yield differential impacts for different types of users. Mediating and determining factors, including personal and socioeconomic factors, affect technology adoption, the way health workers leverage and use the technology, and subsequently the quality and experience of care they provide. Objective: To develop a framework to assess whether mHealth platforms affect the quality and experience of care provided by frontline workers, and whether these effects on quality and experience are different depending on the level of technology adoption and individual characteristics of the health worker. Literacy, education, age, and previous mobile experience are identified as individual factors that affect technology adoption and use, as well as factors that affect the quality and experience of care directly and via the technology. Methods: Formative research was conducted with 15 community health workers (CHWs) using CommCare, an mHealth app for maternal and newborn care, in Bihar, India. CHWs were first classified on the level of CommCare adoption using data from CommCareHQ and were then shadowed on home visits to evaluate their levels of technology proficiency, and the quality and experience of care provided. Regression techniques were employed to test the relationships. Out of all the CHWs, 2 of them refused to participate in the home visits, however, we did have information on their levels of technology adoption and background characteristics, which were included in the analysis as relevant. Results: Level of technology adoption was important for both quality and experience of care. The quality score for high users of CommCare was higher by 33.4% (P=.04), on average, compared to low users of CommCare. Those who scored higher on CommCare proficiency also provided significantly higher quality and experience of care, where an additional point in CommCare proficiency score increased the quality score by around half a point (0.541, P=.07), and experience score by around a third of a point (0.308, P=.03). Age affected CommCare user type negatively, with an increase in age increasing the likelihood of belonging to a lower category of CommCare adoption (-0.105, P=.08). Other individual characteristics did not affect adoption or the predicted values estimating the relationship between adoption and quality and experience of care, although illiteracy was able to affect the relationship negatively. Conclusions: mHealth technology adoption by frontline workers can positively impact the quality and experience of care they provide. Individual characteristics, especially literacy and age, can be important elements affecting technology adoption and the way users leverage the technology for their work. Our formative study provides informed hypotheses and methods for further research. %M 26023001 %R 10.2196/mhealth.4047 %U http://mhealth.jmir.org/2015/2/e61/ %U https://doi.org/10.2196/mhealth.4047 %U http://www.ncbi.nlm.nih.gov/pubmed/26023001 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 2 %P e41 %T What Overweight Women Want From a Weight Loss App: A Qualitative Study on Arabic Women %A Alnasser,Aroub Abdulaziz %A Alkhalifa,Abdulrahman Saleh %A Sathiaseelan,Arjuna %A Marais,Debbi %+ King Saud University, Food Science and Nutrition, PO Box 86683, Riyadh, 11632, Saudi Arabia, 966 114556208, aroub@ksu.edu.sa %K weight loss %K focus groups %K smartphone %K mobile apps %K Arabic %K qualitative research %D 2015 %7 20.05.2015 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Overweight and obesity are international public health issues. With mobile and app use growing globally, the development of weight loss apps are increasing along with evidence that interventions using technology have been effective in the treatment of obesity. Although studies have been conducted regarding what content health professionals would recommend within weight loss apps, there are limited studies that explore users’ viewpoints. There is specifically a paucity of research that takes the cultural background of the user into consideration, especially in Middle Eastern countries where the lives and weight loss intervention needs of women not only vary vastly from the West, but the obesity rate is also increasing exponentially. Objective: The current study sought to explore the proposed features of an Arabic weight loss app by seeking the experiences and opinions of overweight and obese Saudi Arabian users in order to design a mobile phone app to fit their needs. Methods: Focus group discussions were conducted with a purposive sample of volunteer overweight and obese Saudi women (BMI ≥ 25) who were older than 18 years and who owned a mobile phone. The most common Arabic and English weight loss mobile apps were downloaded to initiate dialogue about app usage and to get their opinions on what an ideal weight loss app would look like and the features it would include. All transcribed, translated discussions were thematically analyzed, categorized for each of the main topics of the discussion, and specific quotations were identified. Results: Four focus groups were conducted with a total of 39 participants. Most participants owned an Android mobile phone and only a few participants were aware of the availability of health-related apps. Barriers to weight loss were identified including: motivation, support (social and professional), boring diets, customs, and lifestyle. Diverse themes emerged as suggestions for an ideal weight loss app including: Arabic language and culturally sensitive; motivational support and social networking; dietary and physical activity tools; and a tailorable, user-friendly interface. Conclusions: This study identifies weight loss app features from the users’ perspective, which should be considered in the development of a weight loss app for this population. %M 25993907 %R 10.2196/mhealth.4409 %U http://mhealth.jmir.org/2015/2/e41/ %U https://doi.org/10.2196/mhealth.4409 %U http://www.ncbi.nlm.nih.gov/pubmed/25993907 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 3 %P e78 %T Know Your Audience: Predictors of Success for a Patient-Centered Texting App to Augment Linkage to HIV Care in Rural Uganda %A Siedner,Mark J %A Santorino,Data %A Haberer,Jessica E %A Bangsberg,David R %+ Center for Global Health, Massachusetts Genneral Hospital, Harvard Medical School, 15th Floor, 100 Cambridge Street, Boston, MA, 02114, United States, 1 617 726 4686, msiedner@partners.org %K telemedicine %K text messaging %K randomized controlled trial %K Uganda %K HIV %D 2015 %7 24.03.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite investments in infrastructure and evidence for high acceptability, few mHealth interventions have been implemented in sub-Saharan Africa. Objective: We sought to (1) identify predictors of uptake of an mHealth application for a low-literacy population of people living with HIV (PLWH) in rural Uganda and (2) evaluate the efficacy of various short message service (SMS) text message formats to optimize the balance between confidentiality and accessibility. Methods: The trial evaluated the efficacy of a SMS text messaging app to notify PLWH of their laboratory results and request return to care for those with abnormal test results. Participants with a normal laboratory result received a single SMS text message indicating results were normal. Participants with an abnormal test result were randomized to 1 of 3 message formats designed to evaluate trade-offs between clarity and privacy: (1) an SMS text message that stated results were abnormal and requested return to clinic (“direct”), (2) the same message protected by a 4-digit PIN code (“PIN”), and (3) the message “ABCDEFG” explained at enrollment to indicate abnormal results (“coded”). Outcomes of interest were (1) self-reported receipt of the SMS text message, (2) accurate identification of the message, and (3) return to care within 7 days (for abnormal results) or on the date of the scheduled appointment (for normal results). We fit regression models for each outcome with the following explanatory variables: sociodemographic characteristics, CD4 count result, ability to read a complete sentence, ability to access a test message on enrollment, and format of SMS text message. Results: Seventy-two percent (234/385) of participants successfully receiving a message, 87.6% (219/250) correctly identified the message format, and 60.8% (234/385) returned to clinic at the requested time. Among participants with abnormal tests results (138/385, 35.8%), the strongest predictors of reported message receipt were the ability to read a complete sentence and a demonstrated ability to access a test message on enrollment. Participants with an abnormal result who could read a complete sentence were also more likely to accurately identify the message format (AOR 4.54, 95% CI 1.42-14.47, P=.01) and return to clinic appropriately (AOR 3.81, 95% CI 1.61-9.03, P=.002). Those who were sent a PIN-protected message were less likely to identify the message (AOR 0.11, 95% CI 0.03-0.44, P=.002) or return within 7 days (AOR 0.26, 95% CI 0.10-0.66, P=.005). Gender, age, and socioeconomic characteristics did not predict any outcomes and there were no differences in outcomes between those receiving direct or coded messages. Conclusions: Confirmed literacy at the time of enrollment was a robust predictor of SMS text message receipt, identification, and appropriate response for PLWH in rural Uganda. PIN-protected messages reduced odds of clinic return, but coded messages were as effective as direct messages and might augment privacy. Trial Registration: Clinicaltrials.gov NCT 01579214; https://clinicaltrials.gov/ct2/show/NCT01579214 (Archived by WebCite at http://www.webcitation.org/6Ww8R4sKq). %M 25831269 %R 10.2196/jmir.3859 %U http://www.jmir.org/2015/3/e78/ %U https://doi.org/10.2196/jmir.3859 %U http://www.ncbi.nlm.nih.gov/pubmed/25831269 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 1 %N 1 %P e1 %T Stories From the Field: The Use of Information and Communication Technologies to Address the Health Needs of Underserved Populations in Latin America and the Caribbean %A Farach,Nasim %A Faba,Gladys %A Julian,Soroya %A Mejía,Felipe %A Cabieses,Báltica %A D'Agostino,Marcelo %A Cortinois,Andrea A %+ Public eHealth, Innovation & Equity in Latin America & the Caribbean (eSAC) project, Altos de Miraflores Sur, S7, Tegucigalpa, , Honduras, 504 94573521, nfarach@gmail.com %K eHealth %K Latin America %K vulnerable populations %K qualitative research %D 2015 %7 17.03.2015 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: As their availability grew exponentially in the last 20 years, the use of information and communication technologies (ICT) in health has been widely espoused, with many emphasizing their potential to decrease health inequities. Nonetheless, there is scarce availability of information regarding ICT as tools to further equity in health, specifically in Latin American and Caribbean settings. Objective: Our aim was to identify initiatives that used ICT to address the health needs of underserved populations in Latin America and Caribbean. Among these projects, explore the rationale behind the selection of ICT as a key component, probe perceptions regarding contributions to health equity, and describe the challenges faced during implementation. Methods: We conducted an exploratory qualitative study. Interviews were completed via Skype or face-to-face meetings using a semistructured interview guide. Following participant consent, interviews were audio recorded and verbatim transcriptions were developed. All transcriptions were coded using ATLASti7 software. The text was analyzed for patterns, shared themes, and diverging opinions. Emerging findings were reviewed by all interviewers and shared with participants for feedback. Results: We interviewed representatives from eight organizations in six Latin American and Caribbean countries that prominently employed ICT in health communication, advocacy, or surveillance projects. ICT expanded project's geographic coverage, increased their reach into marginalized or hard-to-reach groups, and allowed real-time data collection. Perceptions of contributions to health equity resided mainly in the provision of health information and linkage to health services to members of groups experiencing greater morbidity because of poverty, remote place of residence, lack of relevant public programs, and/or stigma and discrimination, and in more timely responses by authorities to the health needs of these groups as a result of the increased availability of strategic information on morbidity and its social determinants. Most projects faced initial resistance to implementation because of lack of precedents. Their financial and technical sustainability was threatened by reliance on external funding and weak transitional structures amidst key staff changes. Projects often experienced challenges in establishing meaningful communication with target audience members, mainly because of divergent motivations behind ICT use between projects and its target audience and the lack of access or familiarity with ICT among the most underserved members of such audiences. Conclusions: ICT can benefit projects focusing on the health needs of underserved populations by expanding the breadth and depth of target audience coverage and improving data management. Most projects tended to be small, short-term pilot interventions with limited engagement with the formal health sector and did not include health equity as an explicit component. Collaborative projects with government institutions, particularly those with health surveillance objectives, seemed to be the most optimistic about long-term sustainability. %M 27227124 %R 10.2196/publichealth.4108 %U http://publichealth.jmir.org/2015/1/e1/ %U https://doi.org/10.2196/publichealth.4108 %U http://www.ncbi.nlm.nih.gov/pubmed/27227124 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 1 %P e26 %T SMSaúde: Design, Development, and Implementation of a Remote/Mobile Patient Management System to Improve Retention in Care for HIV/AIDS and Tuberculosis Patients %A Nhavoto,José António %A Grönlund,Åke %A Chaquilla,Walter Ponce %+ Informatics, School of Business, Örebro University, Fakultetsgatan 1, Örebro, 70182, Sweden, 46 760833032, janhavoto@gmail.com %K mobile health %K text messaging %K SMS system %K patient management %K design science research %K Mozambique %D 2015 %7 09.03.2015 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: The widespread and low cost of mobile phones and the convenience of short message service (SMS) text messaging suggest potential suitability for use with alternative strategies for supporting retention in care and adherence to the treatment of various chronic diseases, such as HIV and tuberculosis (TB). Despite the growing body of literature reporting positive outcomes of SMS text message-based communication with patients, there is yet very little research about the integration of communication technologies and electronic medical records or electronic patient tracking systems. Objective: To design, develop, and implement an integrated mobile phone text messaging system used to follow up with patients with HIV and TB in treatment in Mozambique. Methods: Following the design science research methodology, we developed a Web-based system that provides support to patients. A case study involving three health care sites in Mozambique was a basis for discussing design issues for this kind of system. We used brainstorming techniques to solicit usability requirements, focus group meetings to discuss and define system architecture, and prototyping to test in real environments and to improve the system. Results: We found six sets of system requirements that need to be addressed for success: data collection, telecommunication costs, privacy and data security, text message content, connectivity, and system scalability. A text messaging system was designed and implemented in three health facilities. These sites feed data into a central data repository, which can be used for analysis of operations and decision support. Based on the treatment schedule, the system automatically sent SMS text message appointment reminders, medication reminders, as well as motivational and educational messages to patients enrolled in antiretroviral therapy and TB treatment programs. Conclusions: We successfully defined the requirements for, designed, and implemented a mobile phone text messaging system to support HIV and TB treatments. Implementation of this system could improve patients’ self-management skills and strengthen communication between patients and health care providers. %M 25757551 %R 10.2196/mhealth.3854 %U http://mhealth.jmir.org/2015/1/e26/ %U https://doi.org/10.2196/mhealth.3854 %U http://www.ncbi.nlm.nih.gov/pubmed/25757551 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 1 %P e21 %T Qualitative Evaluation of a Text Messaging Intervention to Support Patients With Active Tuberculosis: Implementation Considerations %A Iribarren,Sarah J %A Sward,Katherine A %A Beck,Susan L %A Pearce,Patricia F %A Thurston,Diana %A Chirico,Cristina %+ School of Nursing, Columbia University, 617 West 168th Street, New York, NY, 10032, United States, 1 212 342 0689, si2277@cumc.columbia.edu %K mHealth %K tuberculosis %K sociotechnical evaluation %K text messaging %D 2015 %7 27.02.2015 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Tuberculosis (TB) remains a major global public health problem and mobile health (mHealth) interventions have been identified as a modality to improve TB outcomes. TextTB, an interactive text-based intervention to promote adherence with TB medication, was pilot-tested in Argentina with results supporting the implementation of trials at a larger scale. Objective: The objective of this research was to understand issues encountered during pilot-testing in order to inform future implementation in a larger-scale trial. Methods: A descriptive, observational qualitative design guided by a sociotechnical framework was used. The setting was a clinic within a public pulmonary-specialized hospital in Argentina. Data were collected through workflow observation over 115 days, text messages (n=2286), review of the study log, and stakeholder input. Emerging issues were categorized as organizational, human, technical, or sociotechnical considerations. Results: Issues related to the intervention included workflow issues (eg, human, training, security), technical challenges (eg, data errors, platform shortcomings), and message delivery issues (eg, unintentional sending of multiple messages, auto-confirmation problems). System/contextual issues included variable mobile network coverage, electrical and Internet outages, and medication shortages. Conclusions: Intervention challenges were largely manageable during pilot-testing, but need to be addressed systematically before proceeding with a larger-scale trial. Potential solutions are outlined. Findings may help others considering implementing an mHealth intervention to anticipate and mitigate certain challenges. Although some of the issues may be context dependent, other issues such as electrical/Internet outages and limited resources are not unique issues to our setting. Release of new software versions did not result in solutions for certain issues, as specific features used were removed. Therefore, other software options will need to be considered before expanding into a larger-scale endeavor. Improved automation of some features will be necessary, however, a goal will be to retain the intervention capability to be interactive, user friendly, and patient focused. Continued collaboration with stakeholders will be required to conduct further research and to understand how such an mHealth intervention can be effectively integrated into larger health systems. %M 25802968 %R 10.2196/mhealth.3971 %U http://mhealth.jmir.org/2015/1/e21/ %U https://doi.org/10.2196/mhealth.3971 %U http://www.ncbi.nlm.nih.gov/pubmed/25802968 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 1 %P e24 %T Analyzing the Mobile “Digital Divide”: Changing Determinants of Household Phone Ownership Over Time in Rural Bangladesh %A Tran,Michael Clifton %A Labrique,Alain Bernard %A Mehra,Sucheta %A Ali,Hasmot %A Shaikh,Saijuddin %A Mitra,Maithilee %A Christian,Parul %A West Jr,Keith %+ Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, United States, 1 443 287 4744, alabriqu@gmail.com %K digital %K mobile Health (mHealth) %K finances %K mobile %K phones %K Bangladesh %K family characteristics %K Demography, ownership %K socioeconomic factors %D 2015 %7 25.02.2015 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: We had a unique opportunity to examine demographic determinants of household mobile phone ownership in rural Bangladesh using socioeconomic data collected as part of a multiyear longitudinal cohort study of married women of reproductive age. Objectives: This paper explores how the demographics of household mobile phone owners have changed over time in a representative population of rural Bangladesh. Methods: We present data collected between 2008 and 2011 on household mobile phone ownership and related characteristics including age, literacy, education, employment, electricity access, and household wealth among 35,306 individuals. Respondents were enrolled when found to be newly pregnant and contributed socioeconomic information once over the course of the time period serving as a “sample” of families within the population at that time. Univariate and multiple logistic regressions analyses were performed to identify the socioeconomic determinants of household phone ownership. Results: Across 3 fiscal years, we found that reported household ownership of at least 1 working mobile phone grew from 29.85% in the first fiscal year to 56.07% in the third fiscal year. Illiteracy, unavailability of electricity, and low quartiles of wealth were identified as overall demographic constraints to mobile phone ownership. However, over time, these barriers became less evident and equity gaps among demographic status began to dissipate as access to mobile technology became more democratized. We saw a high growth rate in ownership among households in lower economic standing (illiterate, without electricity, low and lowest wealth index), likely a result of competitive pricing and innovative service packages that improve access to mobile phones as the mobile phone market matures. In contrast, as market saturation is rapidly attained in the most privileged demographics (literate, secondary schooling, electricity, high wealth index), members of the lower wealth quartiles seem to be following suit, with more of an exponential growth. Conclusions: Upward trends in household mobile phone ownership in vulnerable populations over time underline the potential to leverage this increasingly ubiquitous infrastructure to extend health and finance services across social and economic strata. %M 25720457 %R 10.2196/mhealth.3663 %U http://mhealth.jmir.org/2015/1/e24/ %U https://doi.org/10.2196/mhealth.3663 %U http://www.ncbi.nlm.nih.gov/pubmed/25720457 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 1 %P e19 %T Design and Multi-Country Validation of Text Messages for an mHealth Intervention for Primary Prevention of Progression to Hypertension in Latin America %A Diez-Canseco,Francisco %A Zavala-Loayza,J Alfredo %A Beratarrechea,Andrea %A Kanter,Rebecca %A Ramirez-Zea,Manuel %A Rubinstein,Adolfo %A Martinez,Homero %A Miranda,J Jaime %+ CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Miraflores, Lima, Lima 18, Peru, 51 12416978, Jaime.Miranda@upch.pe %K cross-cultural comparison %K developing countries %K health literacy %K hypertension %K Latin America %K mHealth %K preventive medicine %K prehypertension %K text messages %K validation studies %D 2015 %7 18.02.2015 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Mobile health (mHealth) has been posited to contribute to the reduction in health gaps and has shown fast and widespread growth in developing countries. This growth demands understanding of, and preparedness for, local cultural contexts. Objective: To describe the design and validation of text messages (short message service, SMS) that will be used for an mHealth behavioral change intervention to prevent hypertension in three Latin American countries: Argentina, Guatemala, and Peru. Methods: An initial set of 64 SMS text messages were designed to promote healthy lifestyles among individuals in different stages of behavior change, addressing four key domains: salt and sodium intake, fruit and vegetable intake, consumption of high fat and sugar foods, and physical activity. The 64 SMS text messages were organized into nine subsets for field validation. In each country 36 people were recruited, half of them being male. Of the participants, 4 per country evaluated each subset of SMS text messages, which contained between 6 and 8 SMS text messages regarding different key domains and stages of change. The understanding and appeal of each SMS text message was assessed using a 7-item questionnaire. The understanding and appeal ratings were used to reach a final set of 56 SMS text messages. Results: Overall, each of the 64 SMS text messages received a total of 12 evaluations (4 per country). The majority of evaluations—742 out of a total of 767 (96.7%) valid responses—revealed an adequate understanding of the key idea contained in the SMS text message. On a scale from 1 to 10, the average appeal score was 8.7 points, with a range of 4 to 10 points. Based on their low scores, 8 SMS text messages per country were discarded. Once the final set of 56 SMS text messages was established, and based on feedback obtained in the field, wording and content of some SMS text messages were improved. Of the final set, 9, 8, and 16 of the SMS text messages were improved based on participant evaluations from Argentina, Guatemala, and Peru, respectively. Most SMS text messages selected for the final set (49/56, 88%) were the same in all countries, except for small wording differences. Conclusions: The final set of SMS text messages produced had very high rates of understanding and appeal in three different Latin American countries. This study highlights the importance of developing and validating a package of simple, preventative SMS text messages, grounded in evidence and theory, across three different Latin American countries with active engagement of end users. %M 25693595 %R 10.2196/mhealth.3874 %U http://mhealth.jmir.org/2015/1/e19/ %U https://doi.org/10.2196/mhealth.3874 %U http://www.ncbi.nlm.nih.gov/pubmed/25693595 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 1 %P e17 %T Implementation of a Confidential Helpline for Men Having Sex With Men in India %A Agarwal,Ashok %A Hamdallah,Myriam %A Swain,Suvakanta N %A Mukherjee,Sonali %A Singh,Neetu %A Mahapatra,Sudip %A King,Elizabeth J %A Pulerwitz,Julie %A Thior,Ibou %+ FHI 360, H-5 Green Park Extension, New Delhi, 110016, India, 91 9873001090, aashok365@gmail.com %K mobile phone %K helpline %K MSM %K HIV prevention %K India %D 2015 %7 11.02.2015 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: In India, men who have sex with men (MSM) often face physical violence and harassment from police and the general society. Many MSM may not openly disclose their sexual identity, especially if they are married to women and have families. Due to pervasive stigma and discrimination, human immunodeficiency virus (HIV) prevention programs are unable to reach many MSM effectively. Objective: The objective of this paper was to describe the design, operations, and monitoring of the Sahaay helpline, a mHealth intervention for the MSM population of India. Methods: We established the “Sahaay” mHealth intervention in 2013; a MSM-dedicated helpline whose main goal was to increase access to comprehensive, community-based HIV prevention services and improve knowledge, attitudes, and behaviors of MSM towards HIV and sexually transmitted infections (STI) in three states of India (Chhattisgarh, Delhi, and Maharashtra). The helpline provided a 24x7 confidential and easy to use interactive voice response system (IVRS) to callers. IVRS function was monitored through an online dashboard of indicators. The system also provided real-time reporting on callers and services provided. Results: The helpline received more than 100,000 calls from 39,800 callers during the first nine months of operation. The helpline maintained an operational uptime of 99.81% (6450/6462 hours); and answered more than 81.33% (83,050/102,115) of all calls. More than three-fourths of the calls came between 9:00 am-12:00 pm. The most successful promotional activity was “interpersonal communication” (reported by 70.05%, 27,880/39,800, of the callers). Nearly three-fourths of the callers self-identified as MSM, including 17.05% (6786/39,800) as rural MSM and 5.03% (2001/39,800) as a married MSM. Most callers (93.10%, 37,055/39,800) requested information, while some (27.01%, 10,750/39,800) requested counseling on HIV/acquired immune deficiency syndrome (AIDS), STIs, and other health and nonhealth issues. There were 38.97% (15,509/39,800) of the callers that were provided contacts of different HIV/AIDS referral services. Many MSM clients reported increased self-esteem in dealing with their sexual identity and disclosing the same with their family and spouse; and an increase in HIV/AIDS risk-reduction behaviors like consistent condom use and HIV testing. Conclusions: National HIV/AIDS prevention interventions for MSM in India should consider scaling-up this helpline service across the country. The helpline may serve as an important mechanism for accessing hard-to-reach MSM, and thus improving HIV prevention programing. %M 25673240 %R 10.2196/mhealth.3978 %U http://mhealth.jmir.org/2015/1/e17/ %U https://doi.org/10.2196/mhealth.3978 %U http://www.ncbi.nlm.nih.gov/pubmed/25673240 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 1 %P e2 %T Health Checkup and Telemedical Intervention Program for Preventive Medicine in Developing Countries: Verification Study %A Nohara,Yasunobu %A Kai,Eiko %A Ghosh,Partha Pratim %A Islam,Rafiqul %A Ahmed,Ashir %A Kuroda,Masahiro %A Inoue,Sozo %A Hiramatsu,Tatsuo %A Kimura,Michio %A Shimizu,Shuji %A Kobayashi,Kunihisa %A Baba,Yukino %A Kashima,Hisashi %A Tsuda,Koji %A Sugiyama,Masashi %A Blondel,Mathieu %A Ueda,Naonori %A Kitsuregawa,Masaru %A Nakashima,Naoki %+ Medical Information Center, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 8128582, Japan, 81 92 642 5881, y-nohara@info.med.kyushu-u.ac.jp %K public health informatics %K preventive medicine %K teleconsultation %K body area network %K sensor %K developing countries %D 2015 %7 28.01.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: The prevalence of non-communicable diseases is increasing throughout the world, including developing countries. Objective: The intent was to conduct a study of a preventive medical service in a developing country, combining eHealth checkups and teleconsultation as well as assess stratification rules and the short-term effects of intervention. Methods: We developed an eHealth system that comprises a set of sensor devices in an attaché case, a data transmission system linked to a mobile network, and a data management application. We provided eHealth checkups for the populations of five villages and the employees of five factories/offices in Bangladesh. Individual health condition was automatically categorized into four grades based on international diagnostic standards: green (healthy), yellow (caution), orange (affected), and red (emergent). We provided teleconsultation for orange- and red-grade subjects and we provided teleprescription for these subjects as required. Results: The first checkup was provided to 16,741 subjects. After one year, 2361 subjects participated in the second checkup and the systolic blood pressure of these subjects was significantly decreased from an average of 121 mmHg to an average of 116 mmHg (P<.001). Based on these results, we propose a cost-effective method using a machine learning technique (random forest method) using the medical interview, subject profiles, and checkup results as predictor to avoid costly measurements of blood sugar, to ensure sustainability of the program in developing countries. Conclusions: The results of this study demonstrate the benefits of an eHealth checkup and teleconsultation program as an effective health care system in developing countries. %M 25630348 %R 10.2196/jmir.3705 %U http://www.jmir.org/2015/1/e2/ %U https://doi.org/10.2196/jmir.3705 %U http://www.ncbi.nlm.nih.gov/pubmed/25630348 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 3 %N 1 %P e4 %T Application of Mobile Technology for Improving Expanded Program on Immunization Among Highland Minority and Stateless Populations in Northern Thailand Border %A Kaewkungwal,Jaranit %A Apidechkul,Tawatchai %A Jandee,Kasemsak %A Khamsiriwatchara,Amnat %A Lawpoolsri,Saranath %A Sawang,Surasak %A Sangvichean,Aumnuyphan %A Wansatid,Peerawat %A Krongrungroj,Sarinya %+ Center of Excellence for Biomedical and Public Health Informatics (BIOPHICS), Faculty of Tropical Medicine, Mahidol University, The 60 Anniversary of His Majesty the King's Accession to the Throne Building, 3rd - 4th floor,, 420/6, Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand, 66 23549181, jaranitk@biophics.org %K expanded program on immunization %K EPI %K hill tribes %K stateless %K behavioral change communication %K mobile technology %D 2015 %7 14.01.2015 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Studies of undervaccinated children of minority/stateless populations have highlighted significant barriers at individual, community, and state levels. These include geography-related difficulties, poverty, and social norms/beliefs. Objective: The objective of this study was to assess project outcomes regarding immunization coverage, as well as maternal attitudes and practices toward immunization. Methods: The “StatelessVac” project was conducted in Thailand-Myanmar-Laos border areas using cell phone-based mechanisms to increase immunization coverage by incorporating phone-to-phone information sharing for both identification and prevention. With limitation of the study among vulnerable populations in low-resource settings, the pre/post assessments without comparison group were conducted. Immunization coverage was collected from routine monthly reports while behavior-change outcomes were from repeat surveys. Results: This study revealed potential benefits of the initiative for case identification; immunization coverage showed an improved trend. Prevention strategies were successfully integrated into the routine health care workflows of immunization activities at point-of-care. A behavior-change-communication package contributes significantly in raising both concern and awareness in relation to child care. Conclusions: The mobile technology has proven to be an effective mechanism in improving a children’s immunization program among these hard-to-reach populations. Part of the intervention has now been revised for use at health centers across the country. %M 25589367 %R 10.2196/mhealth.3704 %U http://mhealth.jmir.org/2015/1/e4/ %U https://doi.org/10.2196/mhealth.3704 %U http://www.ncbi.nlm.nih.gov/pubmed/25589367 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 4 %P e49 %T Consumers' Perspectives on National Health Insurance in South Africa: Using a Mobile Health Approach %A Weimann,Edda %A Stuttaford,Maria C %+ School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, PBag, Anzio Road, Observatory, Cape Town, 7925, South Africa, 27 794981377, prof.dr.weimann@gmail.com %K health systems reform %K public consultation %K South Africa %K National Health Insurance (NHI) %K health systems strengthening (HSS) %K WHO building blocks %K social media, GINI Index %D 2014 %7 28.10.2014 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Building an equitable health system is a cornerstone of the World Health Organization (WHO) health system building block framework. Public participation in any such reform process facilitates successful implementation. South Africa has embarked on a major reform in health policy that aims at redressing inequity and enabling all citizens to have equal access to efficient and quality health services. Objective: This research is based on a survey using Mxit as a mobile phone–based social media network. It was intended to encourage comments on the proposed National Health Insurance (NHI) and to raise awareness among South Africans about their rights to free and quality health care. Methods: Data were gathered by means of a public e-consultation, and following a qualitative approach, were then examined and grouped in a theme analysis. The WHO building blocks were used as the conceptual framework in analysis and discussion of the identified themes. Results: Major themes are the improvement of service delivery and patient-centered health care, enhanced accessibility of health care providers, and better health service surveillance. Furthermore, health care users demand stronger outcome-based rather than rule-based indicators of the health system’s governance. Intersectoral solidarity and collaboration between private and public health care providers are suggested. Respondents also propose a code of ethical values for health care professionals to address corruption in the health care system. It is noteworthy that measures for dealing with corruption or implementing ethical values are neither described in the WHO building blocks nor in the NHI. Conclusions: The policy makers of the new health system for South Africa should address the lack of trust in the health care system that this study has exposed. Furthermore, the study reveals discrepancies between the everyday lived reality of public health care consumers and the intended health policy reform. %M 25351980 %R 10.2196/mhealth.3533 %U http://mhealth.jmir.org/2014/4/e49/ %U https://doi.org/10.2196/mhealth.3533 %U http://www.ncbi.nlm.nih.gov/pubmed/25351980 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 3 %P e38 %T Sexual and Reproductive Health for Young Adults in Colombia: Teleconsultation Using Mobile Devices %A Lopez,Catalina %A Ramirez,Daniel Camilo %A Valenzuela,Jose Ignacio %A Arguello,Arturo %A Saenz,Juan Pablo %A Trujillo,Stephanie %A Correal,Dario Ernesto %A Fajardo,Roosevelt %A Dominguez,Cristina %+ Center for Innovation and Health Education, Fundacion Santa Fe de Bogota, Cra 7B No 123 - 90, Bogota, , Colombia, 57 16030303 ext 5721, catalina.lopez@fsfb.edu.co %K mobile health %K youth and adolescents %K telemedicine %K remote consultation %K Colombia %K Latin America. %D 2014 %7 25.09.2014 %9 Original Paper %J JMIR mHealth uHealth %G English %X Background: Sexual risk behaviors associated with poor information on sexuality have contributed to major public health problems in the area of sexual and reproductive health in teenagers and young adults in Colombia. Objective: To report our experience with the use of DoctorChat Mobile to provide sexual education and information among university students in Bogota, Colombia, and knowledge about the sexual risk factors detected among them. Methods: A mobile app that allows patients to ask about sexual and reproductive health issues was developed. Sexual and reproductive risk behaviors in a sample of young adults were measured before and after the use of the app through the validated survey Family Health International (FHI) Behavioral Surveillance Survey (BSS) for Use With Adults Between 15 and 49 Years. A nonprobabilistic convenience recruitment was undertaken through the study´s webpage. After completing the first survey, participants were allowed to download and use the app for a 6-month period (intervention), followed by completion of the same survey once again. For the inferential analysis, data was divided into 3 groups (dichotomous data, discrete quantitative data, and ordinal data) to compare the results of the questions between the first and the second survey. The study was carried out with a sample of university students between 18 and 29 years with access to mobile phones. Participation in the study was voluntary and anonymous. Results: A total of 257 subjects met the selection criteria. The preintervention survey was answered by 232 subjects, and 127 of them fully answered the postintervention survey. In total, 54.3% (69/127) of the subjects completed the survey but did not use the app, leaving an effective population of 58 subjects for analysis. Of these subjects, 53% (31/58) were women and 47% (27/58) were men. The mean age was 21 years, ranging between 18 and 29 years. The differences between the answers from both surveys were not statistically significant. The main sexual risk behaviors identified in the population were homosexual intercourse, nonuse of condoms, sexual intercourse with nonregular and commercial partners, the use of psychoactive substances, and lack of knowledge on symptoms of sexually transmitted diseases and HIV transmission. Conclusions: Although there were no differences between the pre- and postintervention results, the study revealed different risk behaviors among the participating subjects. These findings highlight the importance of promoting high-impact educational strategies on this matter and the importance of providing teenagers and young adults with easily accessible tools with reliable health information, regardless of their socioeconomic status. %M 25263432 %R 10.2196/mhealth.2904 %U http://mhealth.jmir.org/2014/3/e38/ %U https://doi.org/10.2196/mhealth.2904 %U http://www.ncbi.nlm.nih.gov/pubmed/25263432 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 2 %P e21 %T Mobile Technologies and Geographic Information Systems to Improve Health Care Systems: A Literature Review %A Nhavoto,José António %A Grönlund,Åke %+ Informatics, Örebro University School of Business, Örebro University, Fakultetsgatan 1, Örebro, 70182, Sweden, 46 760833032, janhavoto@gmail.com %K health care %K eHealth %K mobile technology %K mobile phone %K SMS %K text messaging %K geographic information system %K GIS %D 2014 %7 08.05.2014 %9 Review %J JMIR mHealth uHealth %G English %X Background: A growing body of research has employed mobile technologies and geographic information systems (GIS) for enhancing health care and health information systems, but there is yet a lack of studies of how these two types of systems are integrated together into the information infrastructure of an organization so as to provide a basis for data analysis and decision support. Integration of data and technical systems across the organization is necessary for efficient large-scale implementation. Objective: The aim of this paper is to identify how mobile technologies and GIS applications have been used, independently as well as in combination, for improving health care. Methods: The electronic databases PubMed, BioMed Central, Wiley Online Library, Scopus, Science Direct, and Web of Science were searched to retrieve English language articles published in international academic journals after 2005. Only articles addressing the use of mobile or GIS technologies and that met a prespecified keyword strategy were selected for review. Results: A total of 271 articles were selected, among which 220 concerned mobile technologies and 51 GIS. Most articles concern developed countries (198/271, 73.1%), and in particular the United States (81/271, 29.9%), United Kingdom (31/271, 11.4%), and Canada (14/271, 5.2%). Applications of mobile technologies can be categorized by six themes: treatment and disease management, data collection and disease surveillance, health support systems, health promotion and disease prevention, communication between patients and health care providers or among providers, and medical education. GIS applications can be categorized by four themes: disease surveillance, health support systems, health promotion and disease prevention, and communication to or between health care providers. Mobile applications typically focus on using text messaging (short message service, SMS) for communication between patients and health care providers, most prominently reminders and advice to patients. These applications generally have modest benefits and may be appropriate for implementation. Integration of health data using GIS technology also exhibit modest benefits such as improved understanding of the interplay of psychological, social, environmental, area-level, and sociodemographic influences on physical activity. The studies evaluated showed promising results in helping patients treating different illnesses and managing their condition effectively. However, most studies use small sample sizes and short intervention periods, which means limited clinical or statistical significance. Conclusions: A vast majority of the papers report positive results, including retention rate, benefits for patients, and economic gains for the health care provider. However, implementation issues are little discussed, which means the reasons for the scarcity of large-scale implementations, which might be expected given the overwhelmingly positive results, are yet unclear. There is also little combination between GIS and mobile technologies. In order for health care processes to be effective they must integrate different kinds of existing technologies and data. Further research and development is necessary to provide integration and better understand implementation issues. %M 25099368 %R 10.2196/mhealth.3216 %U http://mhealth.jmir.org/2014/2/e21/ %U https://doi.org/10.2196/mhealth.3216 %U http://www.ncbi.nlm.nih.gov/pubmed/25099368 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 1 %P e15 %T Mobile Phone Intervention Reduces Perinatal Mortality in Zanzibar: Secondary Outcomes of a Cluster Randomized Controlled Trial %A Lund,Stine %A Rasch,Vibeke %A Hemed,Maryam %A Boas,Ida Marie %A Said,Azzah %A Said,Khadija %A Makundu,Mkoko Hassan %A Nielsen,Birgitte Bruun %+ Department of International Health, Immunology and Microbiology, University of Copenhagen, Blegdamsvej 9, Copenhagen N, 2200, Denmark, 45 22440789, stine_lund@dadlnet.dk %K perinatal mortality %K text messaging (SMS) %K mobile phones %K developing countries %D 2014 %7 26.03.2014 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile phones are increasingly used in health systems in developing countries and innovative technical solutions have great potential to overcome barriers of access to reproductive and child health care. However, despite widespread support for the use of mobile health technologies, evidence for its role in health care is sparse. Objective: We aimed to evaluate the association between a mobile phone intervention and perinatal mortality in a resource-limited setting. Methods: This study was a pragmatic, cluster-randomized, controlled trial with primary health care facilities in Zanzibar as the unit of randomization. At their first antenatal care visit, 2550 pregnant women (1311 interventions and 1239 controls) who attended antenatal care at selected primary health care facilities were included in this study and followed until 42 days after delivery. Twenty-four primary health care facilities in six districts were randomized to either mobile phone intervention or standard care. The intervention consisted of a mobile phone text message and voucher component. Secondary outcome measures included stillbirth, perinatal mortality, and death of a child within 42 days after birth as a proxy of neonatal mortality. Results: Within the first 42 days of life, 2482 children were born alive, 54 were stillborn, and 36 died. The overall perinatal mortality rate in the study was 27 per 1000 total births. The rate was lower in the intervention clusters, 19 per 1000 births, than in the control clusters, 36 per 1000 births. The intervention was associated with a significant reduction in perinatal mortality with an odds ratio (OR) of 0.50 (95% CI 0.27-0.93). Other secondary outcomes showed an insignificant reduction in stillbirth (OR 0.65, 95% CI 0.34-1.24) and an insignificant reduction in death within the first 42 days of life (OR 0.79, 95% CI 0.36-1.74). Conclusions: Mobile phone applications may contribute to improved health of the newborn and should be considered by policy makers in resource-limited settings. Trial Registration: ClinicalTrials.gov NCT01821222; http://www.clinicaltrials.gov/ct2/show/NCT01821222 (Archived by WebCite at http://www.webcitation.org/6NqxnxYn0). %M 25098184 %R 10.2196/mhealth.2941 %U http://mhealth.jmir.org/2014/1/e15/ %U https://doi.org/10.2196/mhealth.2941 %U http://www.ncbi.nlm.nih.gov/pubmed/25098184 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 1 %P e10 %T The Schisto Track: A System for Gathering and Monitoring Epidemiological Surveys by Connecting Geographical Information Systems in Real Time %A Leal Neto,Onicio B %A Albuquerque,Cesar M %A Albuquerque,Jones O %A Barbosa,Constança S %+ Aggeu Magalhaes Research Center, Schistosomiasis Reference Service, Oswaldo Cruz Foundation, Professor Moraes Rego Avenue, Cidade Universitaria., Recife, 50670420, Brazil, 55 21012572, onicio@gmail.com %K epidemiological survey %K schistosomiasis %K public health %D 2014 %7 10.03.2014 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Using the Android platform as a notification instrument for diseases and disorders forms a new alternative for computerization of epidemiological studies. Objective: The objective of our study was to construct a tool for gathering epidemiological data on schistosomiasis using the Android platform. Methods: The developed application (app), named the Schisto Track, is a tool for data capture and analysis that was designed to meet the needs of a traditional epidemiological survey. An initial version of the app was finished and tested in both real situations and simulations for epidemiological surveys. Results: The app proved to be a tool capable of automation of activities, with data organization and standardization, easy data recovery (to enable interfacing with other systems), and totally modular architecture. Conclusions: The proposed Schisto Track is in line with worldwide trends toward use of smartphones with the Android platform for modeling epidemiological scenarios. %M 25099881 %R 10.2196/mhealth.2859 %U http://mhealth.jmir.org/2014/1/e10/ %U https://doi.org/10.2196/mhealth.2859 %U http://www.ncbi.nlm.nih.gov/pubmed/25099881 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 1 %P e7 %T Customized-Language Voice Survey on Mobile Devices for Text and Image Data Collection Among Ethnic Groups in Thailand: A Proof-of-Concept Study %A Jandee,Kasemsak %A Lawpoolsri,Saranath %A Taechaboonsermsak,Pimsurang %A Khamsiriwatchara,Amnat %A Wansatid,Peerawat %A Kaewkungwal,Jaranit %+ Center of Excellence for Biomedical and Public Health Informatics (BIOPHICS), Mahidol University, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand, 66 23549181 ext 412, jaranit.kae@mahidol.ac.th %K expanded program on immunization %K EPI %K ethnicity %K mobile technology %K smartphone questionnaire survey %K voiced question %D 2014 %7 06.03.2014 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Public health surveys are often conducted using paper-based questionnaires. However, many problems are associated with this method, especially when collecting data among ethnic groups who speak a different language from the survey interviewer. The process can be time-consuming and there is the risk of missing important data due to incomplete surveys. Objective: This study was conducted as a proof-of-concept to develop a new electronic tool for data collection, and compare it with standard paper-based questionnaire surveys using the research setting of assessing Knowledge Attitude and Practice (KAP) toward the Expanded Program on Immunization (EPI) among 6 ethnic groups in Chiang Rai Province, Thailand. The two data collection methods were compared on data quality in terms of data completeness and time consumed in collecting the information. In addition, the initiative assessed the participants’ satisfaction toward the use of a smartphone customized-language voice-based questionnaire in terms of perceived ease of use and perceived usefulness. Methods: Following a cross-over design, all study participants were interviewed using two data collection methods after a one-week washout period. Questions in the paper-based questionnaires in Thai language were translated to each ethnic language by the interviewer/translator when interviewing the study participant. The customized-language voice-based questionnaires were programmed to a smartphone tablet in six, selectable dialect languages and used by the trained interviewer when approaching participants. Results: The study revealed positive data quality outcomes when using the smartphone, voice-based questionnaire survey compared with the paper-based questionnaire survey, both in terms of data completeness and time consumed in data collection process. Since the smartphone questionnaire survey was programmed to ask questions in sequence, no data was missing and there were no entry errors. Participants had positive attitudes toward answering the smartphone questionnaire; 69% (48/70) reported they understood the questions easily, 71% (50/70) found it convenient, and 66% (46/70) reported a reduced time in data collection. The smartphone data collection method was acceptable by both the interviewers and by the study participants of different ethnicities. Conclusions: To our knowledge, this is the first study showing that the application of specific features of mobile devices like smartphone tablets (including dropdown choices, capturing pictures, and voiced questions) can be successfully used for data collection. The mobile device can be effectively used for capturing photos of secondary data and collecting primary data with customized-language and voiced questionnaire survey. Using smartphone questionnaires can minimize or eliminate missing data and reduce the time consumed during the data collection process. Smartphone customized-language, voice-based questionnaires for data collection can be an alternative and better approach than standard translated paper-based questionnaires for public health surveys, especially when collecting data among ethnic and hard-to-reach groups residing in multilanguage-speaking settings. %M 25098776 %R 10.2196/mhealth.3058 %U http://mhealth.jmir.org/2014/1/e7/ %U https://doi.org/10.2196/mhealth.3058 %U http://www.ncbi.nlm.nih.gov/pubmed/25098776 %0 Journal Article %@ 2291-5222 %I JMIR Publications Inc. %V 2 %N 1 %P e5 %T Integrating Mobile Phones into Medical Abortion Provision: Intervention Development, Use, and Lessons Learned From a Randomized Controlled Trial %A de Tolly,Katherine Marianne %A Constant,Deborah %+ Cell-Life, Avalon 4 Building, 123 Hope Street, Gardens, Cape Town, 8001, South Africa, 27 21 462 6481, kmdetolly@gmail.com %K mHealth %K telemedicine %K SMS %K medical abortion %K USSD %K mobisite %D 2014 %7 14.02.2014 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Medical abortion is legal in South Africa but access and acceptability are hampered by the current protocol requiring a follow-up visit to assess abortion completion. Objective: To assess the feasibility and efficacy of information and follow-up provided via mobile phone after medical abortion in a randomized controlled trial (RCT). Methods: Mobile phones were used in three ways in the study: (1) coaching women through medical abortion using short message service (SMS; text messages); (2) a questionnaire to assess abortion completion via unstructured supplementary service data (USSD, a protocol used by GSM mobile telephones that allows the user to interact with a server via text-based menus) and the South African mobile instant message and social networking application Mxit; and (3) family planning information via SMS, mobisite and Mxit. A needs and context assessment was done to learn about women’s experiences undergoing medical abortion and their use of mobile phones. After development, the mobile interventions were piloted. Recruitment was done by field workers at the clinics. In the RCT, women were interviewed at baseline and exit. Computer logs were also analyzed. All study participants received standard of care at the clinics. Results: In the RCT, 234 women were randomized to the intervention group. Eight did not receive the intervention due to invalid numbers, mis-registration, system failure, or opt-out, leaving 226 participants receiving the full intervention. Of the 226, 190 returned and were interviewed at their clinic follow-up visit. The SMSs were highly acceptable, with 97.9% (186/190) saying that the SMSs helped them through the medical abortion. In terms of mobile phone privacy, 86.3% (202/234) said that it was not likely or possible that someone would see SMSs on their phone, although at exit, 20% (38/190) indicated that they had worried about phone privacy. Having been given training at baseline and subsequently asked via SMS to complete the self-assessment questionnaire, 90.3% (204/226) attempted it, and of those, 86.3% (176/204) reached an endpoint of the questionnaire. For the family planning information, a preference for SMS was indicated by study clients, although the publicly available Mxit/mobisite was heavily used (813,375 pages were viewed) over the study duration. Conclusions: SMS provided a good medium for timed, "push" information that guided and supported women through medical abortion. Women were able to perform a self-assessment questionnaire via mobile phones if provided training and prompted by SMS. Phone privacy needs to be protected in similar settings. This study may contribute to the successful expansion of medical abortion provision aided by mobile phones. Trial Registration: Pan African Clinical Trials Registry (PACTR): PACTR201302000427144; http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?dar=true&tNo=PACTR201302000427144 (Archived by WebCite at http://www.webcitation.org/6N0fnZfzm). %M 25098569 %R 10.2196/mhealth.3165 %U http://mhealth.jmir.org/2014/1/e5/ %U https://doi.org/10.2196/mhealth.3165 %U http://www.ncbi.nlm.nih.gov/pubmed/25098569 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 12 %P e269 %T Text Messaging Data Collection for Monitoring an Infant Feeding Intervention Program in Rural China: Feasibility Study %A Li,Ye %A Wang,Wei %A van Velthoven,Michelle Helena %A Chen,Li %A Car,Josip %A Rudan,Igor %A Zhang,Yanfeng %A Wu,Qiong %A Du,Xiaozhen %A Scherpbier,Robert W %+ Department of Integrated Early Childhood Development, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, China, 86 1085695554, summyzh@126.com %K text messaging %K data collection %K program evaluation %K child nutrition sciences %D 2013 %7 04.12.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: An effective data collection method is crucial for high quality monitoring of health interventions. The traditional face-to-face data collection method is labor intensive, expensive, and time consuming. With the rapid increase of mobile phone subscribers, text messaging has the potential to be used for evaluation of population health interventions in rural China. Objective: The objective of this study was to explore the feasibility of using text messaging as a data collection tool to monitor an infant feeding intervention program. Methods: Participants were caregivers of children aged 0 to 23 months in rural China who participated in an infant feeding health education program. We used the test-retest method. First, we collected data with a text messaging survey and then with a face-to-face survey for 2 periods of 3 days. We compared the response rate, data agreement, costs, and participants’ acceptability of the two methods. Also, we interviewed participants to explore their reasons for not responding to the text messages and the reasons for disagreement in the two methods. In addition, we evaluated the most appropriate time during the day for sending text messages. Results: We included 258 participants; 99 (38.4%) participated in the text messaging survey and 177 (68.6%) in the face-to-face survey. Compared with the face-to-face survey, the text messaging survey had much lower response rates to at least one question (38.4% vs 68.6%) and to all 7 questions (27.9% vs 67.4%) with moderate data agreement (most kappa values between .5 and .75, the intraclass correlation coefficients between .53 to .72). Participants who took part in both surveys gave the same acceptability rating for both methods (median 4.0 for both on a 5-point scale, 1=disliked very much and 5=liked very much). The costs per questionnaire for the text messaging method were much lower than the costs for the face-to-face method: ¥19.7 (US $3.13) versus ¥33.9 (US $5.39) for all questionnaires, and ¥27.1 (US $4.31) versus ¥34.4 (US $5.47) for completed questionnaires. The main reasons for not replying were that participants did not receive text messages, they were too busy to reply, or they did not see text messages in time. The main reasons for disagreement in responses were that participants forgot their answers in the text messaging survey and that they changed their minds. We found that participants were more likely to reply to text messages immediately during 2 time periods: 8 AM to 3 PM and 8 PM to 9 PM. Conclusions: The text messaging method had reasonable data agreement and low cost, but a low response rate. Further research is needed to evaluate effectiveness of measures that can increase the response rate, especially in collecting longitudinal data by text messaging. %M 24305514 %R 10.2196/jmir.2906 %U http://www.jmir.org/2013/12/e269/ %U https://doi.org/10.2196/jmir.2906 %U http://www.ncbi.nlm.nih.gov/pubmed/24305514 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 6 %P e116 %T Collecting Maternal Health Information From HIV-Positive Pregnant Women Using Mobile Phone-Assisted Face-to-Face Interviews in Southern Africa %A van Heerden,Alastair %A Norris,Shane %A Tollman,Stephen %A Richter,Linda %A Rotheram-Borus,Mary Jane %+ Human Sciences Research Council, PO Box 90, Msunduzi, Pietermaritzburg, 3201, South Africa, 27 333245015, avanheerden@hsrc.ac.za %K mobile phones %K human immunodeficiency virus %K mobile health %D 2013 %7 10.06.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Most of the world’s women living with human immunodeficiency virus (HIV) reside in sub-Saharan Africa. Although efforts to reduce mother-to-child transmission are underway, obtaining complete and accurate data from rural clinical sites to track progress presents a major challenge. Objective: To describe the acceptability and feasibility of mobile phones as a tool for clinic-based face-to-face data collection with pregnant women living with HIV in South Africa. Methods: As part of a larger clinic-based trial, 16 interviewers were trained to conduct mobile phone–assisted personal interviews (MPAPI). These interviewers (participant group 1) completed the same short questionnaire based on items from the Technology Acceptance Model at 3 different time points. Questions were asked before training, after training, and 3 months after deployment to clinic facilities. In addition, before the start of the primary intervention trial in which this substudy was undertaken, 12 mothers living with HIV (MLH) took part in a focus group discussion exploring the acceptability of MPAPI (participant group 2). Finally, a sample of MLH (n=512) enrolled in the primary trial were asked to assess their experience of being interviewed by MPAPI (participant group 3). Results: Acceptability of the method was found to be high among the 16 interviewers in group 1. Perceived usefulness was reported to be slightly higher than perceived ease of use across the 3 time points. After 3 months of field use, interviewer perceptions of both perceived ease of use and perceived usefulness were found to be higher than before training. The feasibility of conducting MPAPI interviews in this setting was found to be high. Network coverage was available in all clinics and hardware, software, cost, and secure transmission to the data center presented no significant challenges over the 21-month period. For the 12 MHL participants in group 2, anxiety about the multimedia capabilities of the phone was evident. Their concern centered on the possibility that their privacy may be invaded by interviewers using the mobile phone camera to photograph them. For participants in group 3, having the interviewer sit beside vs across from the interviewee during the MPAPI interview was received positively by 94.7% of MHL. Privacy (6.3%) and confidentiality (5.3%) concerns were low for group 3 MHL. Conclusions: Mobile phones were found both to be acceptable and feasible in the collection of maternal and child health data from women living with HIV in South Africa. Trial Registration: Clinicaltrials.gov NCT00972699; http://clinicaltrials.gov/ct2/show/NCT00972699 (Archived by WebCite at http://clinicaltrials.gov/ct2/show/NCT00972699) %M 23748182 %R 10.2196/jmir.2207 %U http://www.jmir.org/2013/6/e116/ %U https://doi.org/10.2196/jmir.2207 %U http://www.ncbi.nlm.nih.gov/pubmed/23748182