1. USING MOBILE APPLICATIONS TO SUPPORT THE IMPLEMENTATION OF GUIDELINES Lawrence MBUAGBAW, MD, MPH, PhD Assistant Professor Department of Clinical Epidemiology and Biostatistics, McMaster University Plenary 4: Leveraging Technology to Promote Guideline Implementation

2. Disclosure of Interests (last 3 years) Lawrence Mbuagbaw I certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting.

3. Outline 1.Scope of work 2.Context 3.Why should we use mobile technology for guideline implementation? 4.How can we use it? 5.What do users think about it? 6.What are the outcomes? 7.So what next?

4. SCOPE M-health Health workers Doctors, nurses, community health workers etc Guidelines National International

5. CONTEXT WHO estimates: shortage of about 7.2 million health care workers [1] 57 countries facing a shortage of health care workers [1] 36 of them in sub-Saharan Africa [1] Suboptimal adherence to guidelines [2] Within a context of self-report bias[3] More tasks shifted to less qualified staff Guidelines are even more important to ensure: Quality of care Consistency of care

6. CONTEXT: new guidelines New guidelines published Training for central and provincial teams Provincial teams train district teams District teams train health area teams (nurses and community health workers) Health area teams implement new guidelines Central level (MOH) Regional level (Regional Delegation) District level (District Health Team)

7. CONTEXT: mhealth [5] Already used to improve health outcomes in patients HIV adherence to medication, viral load “There is high-quality evidence from the two RCTs that mobile phone text- messaging at weekly intervals is efficacious in enhancing adherence to ART, compared to standard care.”

8. Why should we use mobile technology to leverage guideline implementation? It’s ubiquitous It’s cheap It’s portable It’s user friendly It can be used in real time

9. Why should we [NOT] use mobile technology to leverage guideline implementation? Requires ownership of a device Requires a subscription (SIM card or airtime) Data is handled by a third party Requires a network Requires power

10. How can we use mobile technology to assist guideline implementation? Electronic version of guidelines on device Messages with reminders or prompts

11. How can we use mobile technology to assist guideline implementation?[1]

12. Example 1: QUALMAT Clinical Decision Support System[5] An electronic decision support system (Burkina Faso, Ghana, Tanzania) Based on WHO guideline: "Pregnancy, Childbirth, Postpartum and Newborn Care; A Guide for Essential Practice" Key features: (1)Guidance through routine actions in maternal and perinatal care (2) Integration of clinical data to detect situations of concern by algorithms (3)Electronic tracking of peri- and postnatal activities (4)Facilitates patient management and is a source of training material

13. Example 1: QUALMAT CDSS

15. Example 2: simple mobile phone text messaging [6] Kenya One-way communication of text messages about pediatric malaria case- management Based on recommendations from National guidelines Set of ten messages Sent Monday to Friday One at 9.am the other at 2pm For 6 months

16. Example 2: simple mobile phone text messaging Verbatim content and schedule of text-messages (three examples) Message one (Monday morning): Check ALL sick children <5yrs for any severe signs! Also check for fever, cough, diarrhea, pallor & any other problem. Quote: “Persistent work triumphs” Message two (Monday afternoon): Child has FEVER when complained by mother or child is hot or Temp is >=37·5 - Pls ask mother, touch child & take Temp! Quote: “Actions speak louder than words” Message three (Tuesday morning): TREAT with AL all children under 5yrs weighing >=5kg coming with FEVER for first visit & without severe signs. Quote: “Opportunity seldom knocks twice”

17. Example 3:eIMCI [7] Tanzania IMCI: Integrated Management of Childhood Illnesses A WHO-developed strategy to prevent death and disease in children under five Essentially a checklist of things to do: Paper-based Electronic

18. What do users think? eIMCI: PDA preferred to paper based Easier to use Inspired confidence from clients and caregivers

19. What are the outcomes? eIMCI: Care provided was more in agreement with expert assessment Care was more consistent TEXT MESSAGING: Improvement in correct management of malaria by 23.7 percentage points QUALMAT: Improvements in workflow

20. Key issues with using mHealth Strictly as an add-on Type of device Type of message Timing and tailoring Complexity of guidelines Acceptability

21. What‘s the way forward? Many options More research Further research on strategies to improve adherence to guidelines among health workers using mobile technology

22. References 1.Agarwal S, Perry HB, Long L-A, Labrique AB. Evidence on feasibility and effective use of mHealth strategies by frontline health workers in developing countries: systematic review. Tropical Medicine & International Health 2015; 20(8): 1003-14. 2.Gathara D, English M, van Hensbroek MB, Todd J, Allen E. Exploring sources of variability in adherence to guidelines across hospitals in low-income settings: a multi-level analysis of a cross-sectional survey of 22 hospitals. Implementation Science 2015; 10(1): 1-8. 3.Adams AS, Soumerai SB, Lomas J, Ross-Degnan D. Evidence of self-report bias in assessing adherence to guidelines. Int J Qual Health Care 1999; 11(3): 187-92. 4.Horvath T, Azman H, Kennedy GE, Rutherford GW. Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection. Cochrane Database Syst Rev 2012; 3: CD009756. 5.Blank A, Prytherch H, Kaltschmidt J, et al. "Quality of prenatal and maternal care: bridging the know-do gap" (QUALMAT study): an electronic clinical decision support system for rural Sub-Saharan Africa. BMC Med Inform Decis Mak 2013; 13: 44. 6.Zurovac D, Sudoi RK, Akhwale WS, et al. The effect of mobile phone text-message reminders on Kenyan health workers' adherence to malaria treatment guidelines: a cluster randomised trial. Lancet 2011; 378(9793): 795-803. 7.Mitchell M, Hedt-Gauthier BL, Msellemu D, Nkaka M, Lesh N. Using electronic technology to improve clinical care - results from a before-after cluster trial to evaluate assessment and classification of sick children according to Integrated Management of Childhood Illness (IMCI) protocol in Tanzania. BMC Med Inform Decis Mak. 2013;13:95.

23. Thanks for listening!