• WHO
  • 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 drugsinclude 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 adolescentsModern contraception use by adultsAdherence to antiretroviral medicationsAttendance of antenatal care appointmentsTaking iron and folate tablets during pregnancySkilled birth attendanceReceipt of childhood vaccinationsAttendance 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 medicationAttendance for STI/HIV testing among adolescentsBreast and cervical cancer screeningWomen’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:

    Acceptability and feasibility findings Birth and death notification via mobile devicesStock notification and commodity management with mobile devicesClient-to-provider telemedicineProvider-to-provider telemedicineTargeted client communication for behaviour change Health worker decision supportDigital tracking of clients’ health status and services Training and education via mobile devices

    Evidence is presented under headings of:

    EffectivenessAcceptabilityFeasibilityResource useGender, equity and human rights.

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

    Legislation, policy and complianceInteroperability and standardsWorkforce.

    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:

    Acceptability and feasibility findings Birth and death notification via mobile devicesStock notification and commodity management with mobile devicesClient-to-provider telemedicineProvider-to-providertelemedicineTargeted client communication for behaviour change Health worker decision supportDigital tracking of clients’ health status and services Training and education via mobile devices

    Evidence is presented under headings of:

    EffectivenessAcceptabilityFeasibilityResource useGender, equity and human rights.

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

    Legislation, policy and complianceInteroperability and standardsWorkforce.

    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 servicesIn 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 barriersA 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.

  • 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) systemThe 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 researchIn settings where the notifications provide individual-level data to the health system and/or a CRVS systemThe 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 registrationDeath 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 efficientSave travelling time, allowing health workers to spend more time with their clients or to provide more services, remotely to clients in rural areasAllow 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 informationImprove 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 interventionsFace data costs that are not covered by the employerBe anxious about carrying multiple devices and fear loss, damage or theft of the devicesFear 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 systemsUser interface issues, particularly around language and utility of the interface for capturing and retrieving dataThe extent to which confidentiality of medical information and data security issues are addressedChange management issues such as training and familiarity with digital technologies to help support users Supportive supervision to build confidence in new approachesHealth workers’ perception about whether tracking and monitoring, which makes their work more visible, is positive or negativeThe 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 healthSome 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 opinionsOut 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 togetherHelp to accelerate the digital health agenda in countriesAddress global issuesSet the future direction for innovation and research.

    The period for commenting closes 30 April 2019, 00:00 CEST. Inputs 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.

  • An ITU/WHO “how to” guide for building interoperable digital health infrastructure

    As we strengthen African national eHealth strategies, interoperability is gathering momentum too. It's a critical component of our national eHealth programmes. We are looking for a common, comprehensive framework, incorporating all data sources and information flows, both electronic and paper-based, providing a clear development and consolidation path for all components, along a digital development maturity model.

    Fortunately, there’s a handbook about how to do it: Digital Health Platform: Building a Digital Information Infrastructure (Infostructure) for Health, published by the International Telecommunications Union (ITU) in collaboration with the World Health Organization.

    The figure below provides a high level overview of the Digital Health Platform (DHP) concept, its components, and how users interact with it. 

    Figure: How a DHP interacts with external applications and users

    The handbook suggests that a well-designed DHP will help countries to achieve the following priorities:

    Overall quality and continuity of careAdherence to clinical guidelines and best practicesEfficiency and affordability of services and health commodities, by reducing duplication of effort and ensuring effective use of time and resources Health-financing models and processesRegulation, oversight, and patient safety resulting from increased availability of performance data and reductions in errorsHealth policy-making and resource allocation based on better quality data.

    The DHP Handbook illustrates how DHP components are derived from the National eHealth Strategy. It is a detailed guide including illustrative case studies from Liberia, Estonia, Canada, India and Norway. It’s essential reading for African countries’ as we invest in our national eHealth programmes.

  • WHO can help you keep up to date on global eHealth trends

    Awareness of eHealth achievements and dynamics from other users is crucial in framing eHealth strategies, investment decisions, benefits realisation and mitigating risk exposure. Finding the information’s often a challenge. A new publication from Johns Hopkins University Bloomberg School of Public Heath in collaboration with WHO can help.

    The first issue of Global Health: Science and Practice was supported by an Aetna Foundation grant. It deals with five themes:

    Establishing standards to evaluate eHealth’s impact on health systemsGovernanceFinancing UHC in low and middle income countriesWorkforceHealth service supply side and demand generation.

    These themes fit into WHO’s eHealth themes of information and research, governance, financing, workforce and health services. Africa’s health systems can use the findings to support the sustainability and direction of their eHealth trajectories.

    Within these, it’s important to avoid strategic mistakes identified by Rosabeth Kanter:

    Rejecting opportunities that initially seem too smallAssuming that new services and improved processes aren’t strategic goalsLaunching too many minor service changes the confuse stakeholders and increase internal complexity.

    These are some of her innovation traps. Africa’s health systems don’t need them.