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Labrique global health v4

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Labrique global health v4

  1. 1. Alain B. Labrique, PhD, MHS, MS Director JHU Global mHealth Initiative (JHU-GmI) Associate Professor Program in Global Disease Epidemiology and Control Dept. of International Health & Dept. of Epidemiology (jt) Johns Hopkins Bloomberg School of Public Health JHU School of Nursing JHU School of Medicine (Health Informatics)
  2. 2. Maternal Mortality 2010, Worldmapper.org
  3. 3. Euclidean map of 10 million of the 850 million Facebook users friend networks © Paul Butler, FB Mobile – Social Networks : New Frontiers for Global Health
  4. 4. 6.8 BILLION MOBILE-CELLULAR SUBSCRIPTIONS
  5. 5. Untethered, yet connected: Diverse applications of ubiquitous wireless and mobile technologies designed to improve and enhance health research, health services delivery and health outcomes mHealth
  6. 6. mHealth:The Four C’s Harnessing ubiquitous information and communication technology to collect data, connect individuals to each other and to information, compress time and create opportunities to intervene.
  7. 7. Global “mHealth” is a complex, diverse development space, and is not homogenous.
  8. 8. jhumhealth.org 133 mHealth Projects at JHU, as of September 2014
  9. 9. “JiVitA” Maternal and Child Health Research Project (WWW.JIVITA.ORG) Public Health, Maternal and Child Health and Nutrition Efficacy Research to Improve Health and Save Lives in Bangladesh, South Asia and Globally.
  10. 10. RANGPUR
  11. 11. Rural families use mobile phones during severe pregnancy crises N=11,451 (2007-2010) Source: Labrique, mHealth Summit, Washington DC, 2011
  12. 12. 168,231 Woman Survey – Gaibandha, Bangladesh (January-March 2012) • 71% Households own phones • 20% Used a phone in past 30 days for emergency health purpose • Phone owners 2.8 times more likely to use phone for health call • ONLY 23% Electricity in home! Labrique et al., Unpublished data, mHealth Summit 2012
  13. 13. 0 .2.4.6.8 1 2008 2009 2010 2011 2012 Year Lowest Quartile WI (n=17,176) Low Quartile WI (n=19,789) High Quartile WI (n=6,472) Highest Quartile WI (n=1,032) Mobile Phone Ownership by WI over Time Household Mobile Phone Ownership over time in rural Bangladesh, by “Wealth Index” (n=44,469) Labrique, Tran et al, 2013 (in press) ProportionofHHreporting“MobilePhoneOwnership”
  14. 14. Challenges in averting neonatal mortality – being at the right place, at the right time… •1st Day – 50% of deaths •1st Week – 75% of deaths Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths) “Hot Zone”
  15. 15. m-Labor Notification System Pilot Study Source: Gernand, JiVitA Data 2011 (Unpublished) 306 (88.9%) Births Attended
  16. 16. Tremendous time and effort is invested in manual data collection, aggregation and reporting. Example: Bangladesh CHW’s 19 ledgers contain 473 unique data fields. Only 60 fields are unique, required for a digital system to process the same information.
  17. 17. Census Enumeration
  18. 18. Smart Scheduling of Daily Activities, by Priority
  19. 19. Assessing pregnancy status
  20. 20. 2.5 minutes saved for a SINGLE task resulted in ~13 FTEs over a district. X X /60=
  21. 21. mCARE: Integrated Community-Health Worker System to Improve Antenatal & Postnatal Care and Increase Client Demand
  22. 22. Allow clients to report data to the system Try it: Text / SMS “birth” to 1(443) 393-2228
  23. 23. 25.2 65.8 74.8 34.2 Non-intervention group (n=135) Intervention group (n=193) June 2014 - Preliminary Results: Antenatal Care Utilization Received Not-received
  24. 24. mTikka: Virtual Vaccine Registry and Immunization Improvement System Partners: ! " # $ %&' ( )$ * %+$ , $ - $ . , $ . - $ / , $ / - $ 0, $ 0- $ 1, $ 1- $ A B C D E F G Pregnancy Surveillance Pregnancy registration & survey of vaccination beliefs Birth notification Reminder for upcoming vaccination EPI camp open notification Up-to-date vaccination record Timely availability of performance indicators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• A 0,1+732%6/ 7 #. D%. * )/ >#6*)%*#1. 6Q6*/ ! +6#. >*1 )/ %05 %)/ %6 / (#7/ . 0/ 6+>>/ 6*6 *5%* 01! 4,/ */ #! ! +. #: %*#1. )%*/ 6 %)/ 6#>. #D#0%. *,Q,1J/ ) %. 7 )%. >/ D)1! UUZ *1 YNZ @ *+7#/ 6 651J *5%*01(/ )%>/ )%*/ 6 D+)*5/ ) 7/ 0,#. / D1) D1,,1J3+4 716/ 6@] %H1) 126*%0,/ 6 *1 %05#/ (#. > 5#>5 #! ! +. #: %*#1. 01(/ )%>/ #. =%. >,%7/ 65 #. 0,+7/ F #))/ >+,%) ^E9 605/ 7+,/ 6- D/ J 6*)%*/ >#/ 6 *1 %00/ 66 411) )/ 61+)0/ 6/ **#. >6- %. 7 ,#! #*/ 7 01! ! +. #*Q/ . >%>/ ! / . *J#*5 *5/ ^E9@ • A 0,1+732%6/ 7 #. D%. * )/ >#6*)%*#1. 6Q6*/ ! +6#. > %. 7)1#7 451. / 6D1) 7%*%/ . *)Q@ • " #! / ,Q(%00#. %*#1. 1D#. D%. *6 *5)1+>5 ] 32%6/ 7 )/ ! #. 7/ )6*1 4%)/ . *6%. 7 (%00#. / J1)$/ )6@ • ^! 41J/ )#. > 4%)/ . *6 *1 %00/ 66 *5/ #) 05#,7T6 (%00#. %*#1. )/ 01)76@ • 97/ . *#D#0%*#1. 1D2%))#/ )6- %. 7 #! 4,/ ! / . *%*#1. 1D *%)>/ */ 7- 01! ! +. #*Q32%6/ 7 #. */ )(/ . *#1. 6 *1 G+. 7#. >F_)%. 7 V5%,,/ . >/ 6 ^W4,1)%*#1. _)%. * - =#,, %. 7 ] / ,#. 7%_%*/ 6G1+. 7%*#1. #. 0)/ %6/ (%00#. / 01(/ )%>/ @ GoB National Health Information System
  25. 25. Emerging “Lessons” • User-centered / User-engaged design • Extensive formative research & workflow mapping • Iterative technical deployment and stabilization • Early government and community engagement • Mixed-methods evaluation • Plan for technical failures / build-in system redundancy • “Control” systems to prevent & monitor misuse
  26. 26. mHealth doesn’t work in a Vacuum
  27. 27. PROVIDER HEALTH SYSTEM PATIENT Access to information Behavior change Activity Monitoring Self-reported Data Workflow management Decision Support Surveillance and Tracking Remuneration / Incentives Workforce monitoring Real-time Data Streams Supply-chain management
  28. 28. Providing families access to timely information “If you have any bleeding during this month, seek medical attention right away” Expectant women/ new mothers sign up for service Users receive health-related messages weekly “Freemium” model to drive coverage “Your baby needs an immunization this week to stay healthy: Available free at all EPI clinics”
  29. 29. Photo: Text to Change
  30. 30. Healthcare Worker Communication and Training • Data collection and communication tools • Multimedia courses and lectures • mLearning on Demand • Interactive Quizzes www.emocha.org
  31. 31. Project Mwana: SMS to reduce Infant HIV PCR Turnaround Time (46%)
  32. 32. Amader Gram (Our Village) Breast Care • Educate • Identify • Refer • Track
  33. 33. SmartRegister.org
  34. 34. Emphasis on user-focused design to facilitate FHW utilization and feedback.
  35. 35. Nutrition (6) > Integrate workforce and client training as part of the exposures
  36. 36. New frontiers! • US FDA Approved • 2-lead ECG
  37. 37. New frontiers! Remote, Point-of-care Diagnostic tools Breslauer D., et al. 2009 Mobile Phone Based Clinical Microscopy for Global Health Applications. PLoS ONE 4(7): e6320
  38. 38. Mobile-based Flow Cytometry Ozcan Research Group (Nano-Bio Photonics / UCLA): Optical imaging techniques for point-of-care diagnostics Hongying Zhu , Serhan O. Isikman , Onur Mudanyali , Alon Greenbaum and Aydogan Ozcan Lab Chip, 2012, Advance Article
  39. 39. 62
  40. 40. Agriculture Health Money Research m Information Social Networks Entertainment
  41. 41. New paradigms for health data collection Blood chemistry Urinalysis + Medication adherence Vital signs Movement, activity ECG Body weight, mass
  42. 42. The Gartner “Hype” Cycle Fenn J, Maskino M: When to Leap on the Hype Cycle. Gartner Group 2008.
  43. 43. “Pilotitis”
  44. 44. Healthy mSkepticism
  45. 45. The Bellagio eHealth Evaluation Declaration 2011 “Rigorous evaluation of e- & m-Health is necessary to generate useful evidence and promote the appropriate integration of technologies to improve health and reduce inequalities.”
  46. 46. Bellagio Call to Action 2011 If used improperly, eHealth may divert valuable resources and even cause harm… implementation must be guided by evidence…
  47. 47. “mHealth tools and interventions must be backed up by rigorous scientific development, evaluation, and evidence generation to enhance meaningful innovation and best practices, and to validate tools and methods for health professionals, consumers, payers, governments, and industry.”
  48. 48. Why “Evidence” ? 1. Health investments in global health are driven by more than market forces 2. Limited resources = Need for stringent, cost- effectiveness based planning 3. Two decades of Emphasis on EBD ! 4. Donors: Increased transparency / scrutiny 5. Population-side demand for improved quality 6. e-Health / ICT induced political fatigue
  49. 49. Evidence for whom ?
  50. 50. Is there evidence ? Who is asking the question ? Improving the Evidence for Mobile Health, 2011
  51. 51. Evidence of what ?
  52. 52. “Maturity” of the mHealth Project AmountofInformation(RED) Threshold of “Information” Stability Functionality Useability Efficacy Effectiveness Methodology Systems Engineering Qualitative Quantitative Mixed Q/Q / M&E “Evidence” Across The mHealth Maturity Lifecycle OF WHAT ? MEASURED HOW ?
  53. 53. mHealth Technical Evidence Review Group for RMNCH “m-TERG” “Providing governments and implementing agencies objective, evidence-based guidance for the selection and scale of mHealth strategies across the reproductive, maternal, newborn and child health continuum”
  54. 54. INTERVENTION OF KNOWN EFFICACY EFFECTIVE COVERAGE mHEALTH: A Health Systems Catalyst Jo Y, Labrique AB et al. PLOS One 2014 Shift focus from “Does mHealth work?” to “Does mHealth optimize what we know works ?”
  55. 55. Need for Structure
  56. 56. Step 1: Develop a common vocabulary Help us as innovators, researchers, funders talk about mHealth…
  57. 57. A Taxonomy for mHealth
  58. 58. What is the problem we’re trying to solve ? AVAILABILITY 4.2.1 Supplyof commodities 4.2.2 Supplyof services 4.2.3 Supplyof equipment 4.2.4 Diversityof treatment options INFORMATION 4.1.1 Lack of population enumeration 4.1.2 Delayed reportingof events 4.1.3 Quality/ unreliabilityof data 4.1.4 Communication roadblocks 4.1.5 Accessto informationor data COST 4.7.1 Expenses relatedto commodity production 4.7.2 Expenses relatedto commodity supply 4.7.3 Expenses relatedto commodity disbursement 4.7.4 Expenses relatedtoservice delivery 4.7.5 Client-side expenses UTILIZATION 4.5.4 Lossto follow up 4.5.1 Demandfor services 4.5.2 Geographic inaccessibility 4.5.3 Low adherenceto treatments ACCEPTABILITY 4.4.3 Stigma 4.4.1Alignment withlocal norms 4.4.2Addressing individual beliefs andpractices EFFICIENCY 4.6.1 Workflow management 4.6.2 Effective resource allocation 4.6.5 Timeliness of care 4.6.3 Unnecessary referrals/ transportation 4.6.4 Planning andcoordination QUALITY 4.3.1 Qualityof care 4.3.3 Qualityof Commodity 4.3.4 Health worker motivation 4.3.2 Health worker competence 4.3.6 Supportive supervision 4.3.5 Continuity of care
  59. 59. mHealth Strategy Intermediate Outcome Outcome / Impact Provider Competence, Accountability, Effectiveness. Client Knowledge and Self-Efficacy Improved Health Outcomes Improved Quality of Care Improved Health Behaviors Disease Surveillance Electronic Medical Records Remote Monitoring Logistics monitoring and tracking Decision Support Systems Point-of-care Diagnostics Appointment Scheduling Client reporting of quality / performance On-Demand Training / Assessment Client Education On-demand Information / Helplines Supply Chain Integrity Accuracy of Information Continuity of Care Affordability of Care Financing (Banking, Insurance) Enhanced Counseling Improved Efficiency / Coverage Vital Statistics Reporting Improved Population Health Real-time Data Access / PHRCLIENTPROVIDERHEALTHSYSTEM Remote Consultation Improved Dem. / Hlth. Data Appropriate Resource Alloc. Policy Adjustments Workflow Management Systems Responsive Health System
  60. 60. Is your “mHealth” the same as my “mHealth” ?
  61. 61. Why a mHealth and ICT Framework for RMNCH? •Allows focus on health systems strategy of the mHealth innovation, not just the technology. •Provides projects with a communication tool when talking with different stakeholders, including governments about what mHealth offers. •Allows identification of uniqueness, commonalities and gaps across multiple mHealth projects through the use of a consistent and health systems-focused vocabulary.
  62. 62. 12 Common mHealth Applications
  63. 63. RMNCH Continuum: Known Interventions mHealth Strategy: …overcoming these constraints: Touching these “actors” in the system: Labrique, Mehl, Vasudevan et al. 2013 (MS in Review)
  64. 64. Labrique, Mehl, Vasudevan et al. 2013 (MS in Review)
  65. 65. Step 2: Develop repositories of m-evidence and m-activities Help to identify, collate and grade the quality of information on mHealth strategies
  66. 66. What do we know ? What has been tried ? mHealthEvidence.org / mHealthKnowledge.org
  67. 67. Helping to Consolidate efforts Globally And other partners… MREGISTRY.ORG A Global mHealth Project Registry
  68. 68. Step 3: Facilitate the review and synthesis of evidence Help to understand when sufficient information exists to recommend mHealth as part of the standard of care
  69. 69. What kind of evidence ?
  70. 70. mTERG Criteria for Grading mHealth Information Quality
  71. 71. Step 4: Create tools to help with structured evaluation, common indicators moving forward
  72. 72. Develop Common Indicators and Measurement Standards for mHealth Projects Agarwal et al. mHS 2013
  73. 73. Evidence Prioritization Summary mHealth strategies likely to demonstrate: • improved client access to information • enhanced traditional methods of counseling and BCC • bolstered client adherence to medication, and attendance to scheduled appointments • shortened turnaround time for performance data submission • improved workforce scheduling, monitoring and accountability • improved workforce training and continued education • supported caregivers through decision support tools • strengthened commodities supply chains and reduce risk of stockouts • created shorter feedback loops for systemic response “mHealth Extends REACH, Creates CONVENIENCE, Shortens INFORMATION lag, and Facilitates TARGETTED CARE when and where its needed.” mTERG
  74. 74. Where can we have the most impact ? Mehl G, Labrique AB. Science Sept. 2014.
  75. 75. An Ecosystem of mTools for Cross-Sectoral Development exists! “m” – spans Health, Agriculture, Education, Politics, Finance, Data Collection
  76. 76. Eras of mHealth I Innovation and Experimentation II Discordant Proliferation III Scrutiny and Consolidation IV Integration and Scale
  77. 77. Degree to which the mHealth strategy changes the status quo INCREMENTAL CHANGE DISRUPTIVE INNOVATION DIFFICULTYOFSCALING COMPLEXITYOFENGAGEDECOSYSTEM INSTITUTIONAL/HEALTHSYSTEMINERTIA
  78. 78. Challenges - Tentative funding for pilots and demonstrations, limited investment in scale - Rapidly growing, complex ecosystem with new non-health actors - Duplicative efforts, lack of interoperability - Siloes of innovation, without clear pathways to integration - Economic evaluations of mHealth interventions are lacking
  79. 79. • For scale-up / Mainstreaming of mHealth, we need to: • …Reach BEYOND the “converted” Speak the language of HEALTH decision-makers • …STOP taking shortcuts – measuring attributable impact or cost is not an afterthought, an inexpensive or easy task. • …SUPPORT a high threshold of information quality, establishing new methods where appropriate, but aligning claims with data.
  80. 80. Two last thoughts
  81. 81. A phone… as a phone !
  82. 82. From this…
  83. 83. To this ? More data is not better information.
  84. 84. Draw inspiration from Botswana and Bangladesh to Brussels and Baltimore to understand what is m…… POSSIBLE Thank you. http://tinyurl.com/mpossible-video
  85. 85. Mobiles ? alabriqu@jhsph.edu / @gmail.com alabriqu jhumhealth www.jhumhealth.org
  86. 86. Follow a robust process USERS •Identify Users •Define Target Population ROLES •Define Roles •Map Workflow / Scheduling rules DATA •Map Data “Universe” •Deconstruct data elements OPTIMIZE •Assess Data Efficiency •Identify opportunities for Optimization DESIGN •End User Engagement •User-Acceptability / Functionality BUILD •Program, Deploy, Test •Evaluate
  87. 87. UN IWG mHealth Catalytic Grantee Projects mehlg@who.int
  88. 88. Other Tools: Balsamiq.com
  89. 89. Other Tools: Captricity

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