Sean Broomhead

Chief Technology Officer

  • WHO digital health guideline: 6. targeted client communication for behaviour change

    The sixth part of the WHO Guideline on Digital Interventions for Health Systems Strengthening deals with targeted communication.

    WHO recommends targeted client communication via mobile devices for behaviour change regarding sexual, reproductive, maternal, newborn and child health, under the condition that concerns about sensitive content and data privacy are adequately addressed.

    The idea of sending health messages to help people find care, or to retain them in care, has been around for some time. Digital channels allow progressively more precise targeting of those messages, based on a person’s health status or demographic profile. Channels include text messaging, voice, interactive voice response, multimedia and gamified apps on mobile devices, social media.

    Targeted communication appeared in two previous communicable disease guidelines. The 2016 guidelines on the use of antiretroviral drugs
    include a recommendation on the use of text messaging to support adherence to antiretroviral therapy; and the 2017 guidelines for treatment of drug-susceptible tuberculosis and patient care recommend the use of text messages and voice calls to support health education and treatment adherence.

    Effectiveness evidence evaluated for the Digital Interventions Guideline revealed the following.

    1. There may be positive impacts on some behaviours and health outcomes for:

    • Oral contraception use by adolescents
    • Modern contraception use by adults
    • Adherence to antiretroviral medications
    • Attendance of antenatal care appointments
    • Taking iron and folate tablets during pregnancy
    • Skilled birth attendance
    • Receipt of childhood vaccinations
    • Attendance of HIV appointments among exposed children.

    2. There may be little or no difference to:

    • Health status as assessed by CD4 count
    • Adherence to prenatal antiretroviral medication.

    3. Very low certainty of evidence for:

    • Adherence to antiretroviral medication
    • Attendance for STI/HIV testing among adolescents
    • Breast and cervical cancer screening
    • Women’s attendance for neonatal appointments.

    4. There may be some unintended negative consequences, such as women experiencing physical violence in the context of receiving targeted communications for sexual and reproductive health services.

    Evidence suggests that targeted communication is generally acceptable to individuals, creating feelings of support and connectedness. Nevertheless, some have concerns about the confidentiality of health information, particularly those with HIV infection and other aspects of sexual reproductive health, and may be difficult for people with low literacy, or limited or controlled access to mobile devices.

    There is extensive additional discussion in the Guideline. Pertinent comments include that measures should be taken to address issues such as mobile device access inequities and concerns about sensitive content and data privacy. Attention is also needed to implement adequate consenting procedures, ensuring that clients are aware of how to opt out of receiving the communication. Issues around policy, infrastructure and sociocultural considerations are discussed too.

    My next piece in this eHNA series will summarise recommendations on health worker decision support.

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    The WHO Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    Topics are:

    Evidence is presented under headings of:

    • Effectiveness
    • Acceptability
    • Feasibility
    • Resource use
    • Gender, equity and human rights.

    Implementation considerations address key topics from the WHO/ITU National eHealth strategy toolkit, such as:

    • Legislation, policy and compliance
    • Interoperability and standards
    • Workforce.

    Explore more eHNA coverage of WHO initiatives here.


  • WHO digital health guideline: 5. provider-to-provider telemedicine

    Countries need more than warm bodies to staff their health systems, they need those health workers to have appropriate competencies, skills and behaviours. Distance can be a serious barrier to health workers’ interactions. The role of telemedicine in overcoming this is the subject of the fifth recommendation of the WHO guideline on Digital Interventions for Health Systems Strengthening.

    WHO’s review of evidence suggests that provider-to-provider telemedicine “may improve health worker performance, reduce the time for clients to receive appropriate care or follow-up, and decrease length of stay among individuals visiting the emergency department”. It also notes that the opportunity to communicate with one other can help to reduce professional isolation, in particular helping lower-level health workers to access advice to enable better quality of care.

    Nevertheless, evidence also suggests that this form of telemedicine may have little or no effect on health outcomes and some health workers worry about liability and loss of control of their clients’ care.

    WHO recommends provider-to-provider telemedicine in settings where patient safety, privacy, traceability, accountability and security can be monitored.

    Additional comments include a recognition that telemedicine methods are changing with technological advances and that standard operating procedures may help address liability concerns. Implementation considerations include exploring integration with clinical record systems to support provider consultations, reviewing distribution of roles and responsibilities, and considering policy updates to clarify liability issues.

    My next piece in this eHNA series will summarise recommendations on targeted client communication for behavioural change.

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    The WHO Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.


    Topics are:

    Evidence is presented under headings of:

    • Effectiveness
    • Acceptability
    • Feasibility
    • Resource use
    • Gender, equity and human rights.

    Implementation considerations address key topics from the WHO/ITU National eHealth strategy toolkit, such as:

    • Legislation, policy and compliance
    • Interoperability and standards
    • Workforce.

    Explore more eHNA coverage of WHO initiatives here.

  • WHO digital health guideline: 4. client-to-provider telemedicine

    Human resource shortages are a significant obstacle to Universal Health Coverage (UHC) in many countries. Telemedicine, by definition, supports “the provision of health care services at a distance”. The WHO 2010 report Telemedicine Opportunities and Developments in Member States provides a recent update on the factors affecting telemedicine and the WHO guideline builds on this.

    WHO recommends client-to-provider telemedicine:

    • Under the condition that it complements, rather than replaces, face-to-face delivery of health services
    • In settings where patient safety, privacy, traceability, accountability and security can be monitored.

    Effectiveness evidence suggests that telemedicine may improve some outcomes, such as reducing mortality for some conditions, though little or no difference on other outcomes, such as hospital admissions. Qualitative evidence suggests that health workers appreciate being able to offer prompt advice and care, even if physical contact with the patient is not possible, though have concerns about telemedicine reducing client-health worker relationships, leading to poorer care, making health workers work beyond their capabilities, and leading to clinical liability.

    Despite the mix of available evidence, the guideline development group felt that telemedicine has the potential to expand access to health services, though should not detract for health workforce strengthening and needs standard operating procedures to be established. In African countries, where large distances compound health access barriers, telemedicine may be an important part of a national digital health strengthening plan.  

    This is the fourth piece in an eHNA series on the WHO guideline Recommendations on Digital Interventions for Health Systems Strengthening. The previous chapter was about using mobile devices for birth and death notification. The next one deals with provider-to-provider telemedicine.

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    The Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    You can find more eHNA coverage of WHO initiatives here.

  • WHO digital health guideline: 3. stock notification and commodity management via mobile devices

    The availability of health supplies at the point of care is critical to providing effective health services. This guideline explores the opportunity that increasing mobile phone penetration may provide to improve availability and reduce stock-outs.

    Evidence on effectiveness is limited and while qualitative evidence supports the principle of making stock availability data available digitally, it highlights feasibility challenges such as a mismatch of national and local order routines and obstacles of connectivity, electricity and application usability. WHO therefor recommends the use of stock notification and commodity management via mobile devices in settings where supply chain management systems have the capacity to respond in a timely and appropriate manner to the notifications.

    Additional comments include that stock notification via mobile devices is:

    • Likely to provide a more expedient means of effecting stock notifications and ensuring the subsequent availability of commodities at the point of services, despite feasibility barriers
    • A relatively low-risk intervention with potentially high impact.

    A policy issue includes that implementers should ensure there is no harm or reprisal to health workers for reporting stock-outs or wastage. Other considerations address workforce and interoperability.

    This is the third piece in an eHNA series on the WHO guideline Recommendations on Digital Interventions for Health Systems Strengthening. The previous chapter was about using mobile devices for birth and death notification. The next one will summarise the fourth guideline chapter on client-to-provider telemedicine.

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    The Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    You can find more eHNA coverage of WHO initiatives here.


  • HELINA 2019 will be in Botswana – submit your paper by 10 July

    The Health Informatics Africa (HELINA) conference is a highlight on the African digital health calendar. The 2019 event will take place in Gaborone, Botswana, 20 to 22 November. eHNA will be there and we hope to see you too.

    The conference theme is “From Evidence to Practice: The implementation of digital health interventions in Africa for achievement of Universal Health Coverage (UHC)”. Its UHC focus provides a timely opportunity for countries to learn from one another’s experiences. Topics include:

    • The maturity model approach to implementation of digital health solutions
    • Digital health learning systems
    • Quality and use of health data and systems
    • Big Data Analytics in health care
    • Health Information Systems Interoperability
    • Continuous quality Improvement of health data and systems
    • Development of competent human capacity for digital health
    • Sustainable ICT-solutions for health service delivery
    • Artificial Intelligence and frontier technologies in digital health.

    Original presentations are invited in English or French. They should follow HELINA rules and be uploaded by 10 July 2019. Accepted papers will be published in electronic conference proceedings and some will be included in a special edition of the Journal of Health Informatics in Africa.

    Hosts include the Botswana Ministry of Health and Wellness, University of Botswana e-Health Research Unit, Botswana Institute for Technology Research and Innovation, Botswana Health Information Management Association. The event is supported by the US Centers for Disease Control and Prevention and Health First.

    For more information, read the online announcement, email the conference chair Dr. Tom Oluoch or local organizing committee chair Kagiso Ndlovu, or email the scientific committee chair Prof. Nicky Mostert.

    Digital health continues to expand in Africa. We look forward to the Gaborone update on countries’ health strengthening successes.

  • WHO digital health guideline: 2. birth and death notification with mobile devices

    A global effort is underway to strengthen Civil Registration and Vital Statistics (CRVS). Its ambitious goal is to achieve “universal civil registration of births, deaths and other vital events, including cause of death, and access to legal proof of registration for all individuals by 2030”. It’s led by World Bank and WHO.

    The guideline confirms that there is limited evidence on the effectiveness of using mobile devices for birth notification and no evidence of its effectiveness for death notification. It summarises qualitative data that suggest some acceptability, feasibility and equity issues that arise when using mobile phones for CRVS.

    The specific recommendations provided in the guide include an advisory that they only be applied after rigorous assessment of specific contexts and conditions. A number of other legal, workforce, infrastructure and ethical considerations are also discussed.

    WHO recommends the use of birth notification via mobile devices under these conditions:

    • In settings where the notifications provide individual-level data to the health system and/or a civil registration and vital statistics (CRVS) system
    • The health system and/or CRVS system has the capacity to respond to the notifications.

    WHO recommends the use of death notification via mobile devices under these conditions:

    • In the context of rigorous research
    • In settings where the notifications provide individual-level data to the health system and/or a CRVS system
    • The health system and/or CRVS system has the capacity to respond to the notifications.

    The guideline development group (GDG) acknowledged that despite evidence limitations, the following potential advantages justify consideration of mobile notifications, after careful due diligence. The GDG notes that:

    • Birth notification represents a vital first step in a care cascade that can ultimately lead to increased and timely access to health services and other social services, though birth notification should not be viewed as a substitute for legal birth registration
    • Death notification Is recommended via mobile devices in the context of rigorous research and where notifications can be linked to health and/or CRVS systems, to address the lack of information on deaths, especially deaths outside of facilities.

    These CRVS recommendations and cautionary notes emphasise the complexities of digital health and the critical importance of understanding human contexts before promoting the use of mobile devices. African countries, which have numerous mobile health initiatives already underway, will find the discussion of this guidelines chapter useful to carefully consider mobile approaches to CRVS.

    This is the second piece in an eHNA series on the WHO guideline Recommendations on Digital Interventions for Health Systems Strengthening. The previous one was about acceptability and feasibility. The next one will unpack the third guideline chapter on stock notification and commodity management via mobiles.

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    The Guideline provides evidence-based recommendations for ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    You can find more eHNA coverage of WHO initiatives here.


  • WHO digital health guideline: 1. acceptability and feasibility

    This is the first piece in an eHNA series to unpack the WHO Guideline Recommendations on Digital Interventions for Health Systems Strengthening. The perspectives are relevant to digital health in African countries, where digital health is becoming a key driver of our health systems transformation.

    The chapter on acceptability and feasibility begins by describing factors that increase digital health acceptability for health workers, such as to:

    • Help health workers to be more efficient
    • Save travelling time, allowing health workers to spend more time with their clients or to provide more services, remotely to clients in rural areas
    • Allow health workers to expand their range of tasks and take on tasks previously assigned to higher-level workers.

    It suggests that some health workers appreciate how digital technologies:

    • Improve flexibility to work when convenient
    • Reduce the need to be office-bound to access information
    • Improve coordination by connecting people, including clients and communities
    • Raise health workers’ social status and increase the trust and respect they receive in communities.

    The guideline also recognises that digital health can be a double-edged sword, and some factors may decrease acceptability. It points out that some health workers may:

    • Experience workload increases due by technological interventions
    • Face data costs that are not covered by the employer
    • Be anxious about carrying multiple devices and fear loss, damage or theft of the devices
    • Fear job security risks if they have poor digital literacy.

    The authors list factors that affected the feasibility for health workers to take up digital health opportunities, such as:

    • Network connectivity and access to electricity to charge their mobile phones
    • Usability of digital devices and integration with other digital systems
    • User interface issues, particularly around language and utility of the interface for capturing and retrieving data
    • The extent to which confidentiality of medical information and data security issues are addressed
    • Change management issues such as training and familiarity with digital technologies to help support users
    • Supportive supervision to build confidence in new approaches
    • Health workers’ perception about whether tracking and monitoring, which makes their work more visible, is positive or negative
    • The extent to which health workers’ efforts are limited by broader health systems challenges, such as underlying medical supplies shortages that reduce health system effectiveness regardless of digital health interventions.

    Since clients are often active participants in digital interventions, the guideline describes factors that may influence their acceptance of digital health. This includes that:

    • Some clients appreciate the fact that someone is taking the time to send them messages, appreciating the support, guidance and information, reassurance and motivation.
    • Individuals who are dealing with health conditions that are personal or stigmatized, such as HIV or family planning services, may worry that their confidential health information might be disclosed if they participate in digital health
    • Some clients prefer face-to-face contact to telemedicine services, yet these services can also help to give individuals who speak minority languages access to health workers who speak this language
    • Telemedicine may help clients save money and reduce the burden of travel for specialist opinions
    • Out of pocket expenses may be an issue where clients are charged to participate in digital health
    • Barriers such as poor access to network services, electricity or mobile devices, low literacy or digital literacy skills need to be addressed.

    My next eHNA piece will unpack the next chapter in the guideline, birth and death notification via mobile devices.

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    The Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    You can find more eHNA coverage of WHO initiatives here.


  • Have your say on WHO’s draft Global Strategy on Digital Health

    April 2019 has been a busy month for global digital health, with two key announcements by the World Health Organization (WHO). One is the call for comments on the draft Global Strategy on Digital Health. It is the first strategy of its kind for digital health and an opportunity not to be missed.

    WHO invites consultation from all stakeholders in the digital health arena on a strategy aiming to help focus our efforts on digital health that achieves maximum impact. It identifies four strategic objectives:

    • Work together
    • Help to accelerate the digital health agenda in countries
    • Address global issues
    • Set the future direction for innovation and research.

    The period for commenting closes 30 April 2019, 00:00 CESTInputs can be provided via a web-based accessible here or you can email WHO for more information.


    A second pivotal event was last week’s publication of the WHO Guideline: Recommendations on Digital Interventions for Health Systems Strengthening, a much anticipated and important milestone in digital health’s journey to maturity and health systems impact. It has emerged out of a group that developed guidelines on digital health interventions for RMNCAH and health systems strengthening. 

    As we invest in our African National Digital Health Strategies and implementation plans, global publications like these are timely and helpful. eHNA will unpack the contents and their implications for our African digital health initiatives over the next few weeks.

  • WHO launches digital health guideline, Wednesday 17 April

    Figuring out how to use digital health for health systems strengthening is an important task. Now World Health Organization (WHO) has a guideline document to help, launching 14:00 CEST, Wednesday 17 April 2019. Join the live stream here to be part of the launch and gain access to the guideline.

    The title is WHO Guideline Recommendations on Digital Health Interventions for Health Systems Strengthening. This is the first WHO guideline on Digital Health Interventions. It provides evidence-based recommendations for ten ways that countries can use digital health to improve health services.

    eHNA will have more news on what the guideline contains and how we can use it productively for our African initiatives, after the launch.

  • IoT “in the wild” may help us manage stress better

    In his TEDx talk, Pablo Peredes makes a case for using the Internet of Things (IoT) to help humans manage stress. He points out that to be stress free, humans need more outdoor activity than our modern lives allow, and suggests that our “new” natural environment of homes, offices and cars can be more intuitive and responsive to support what we need. In his talk, he uses a book to explain our current stress-increasing predicament.

    Why Zebras don’t get ulcers is a book by biologist Robert M. Sapolsky. Sapolsky explains that for animals such as zebras, stress is typically episodic, such as when avoiding being eaten by a lion, and this stress is well managed by abundant opportunities for the free Zebra to engage in stress-relieving activities rambling around the savanna. In contrast, modern human stress is often chronic, such as worrying about losing a good job or how to survive a stressful one, and our natural environment is no longer the ubiquitous outdoors, but confined to homes, offices and cars, which offer too few opportunities for natural stress relief.

    Since we are unlikely to abandon our homes, offices and cars, Peredes suggests that IoT can help repurpose common household objects to make these devices able to help us manage our health better, transforming our homes, cars and workplaces into environments that identify and manage our stress. He suggests starting existing devices, avoiding the costs of adding new sensors. By collecting and analysing data from things we touch, such as a PC mouse, or a steering wheel in a car, Peredes says we can identify stress and do something about it.

    Peredes describes two reasons for people not managing stress: lack of willpower and lack of time. He suggests that we use the time available during our commute from home to office to diagnose stress levels and improve our stress management, such as making car seats talk us through breathing exercises, office chairs remind us to stand when we’ve been sitting too long, and adding imperceptible screen colour changes to adjust our breathing and heartrates.

    Peredes believes that the everyday devices around us should help us to manage stress. He calls it “stress management IOT in the wild” and invites us to share new design ideas via email.

    Many of our African homes are still connected to the natural environment, providing ample opportunities to blow off steam. Nevertheless, in Africa people are urbanising rapidly too, and it is reassuring to know that people like Peredes are thinking about how to make our modern environments more supportive. I look forward to writing more eHNA pieces about his IoT adventuring in the wild.