Strengths, Weaknesses, Opportunities, and Threats Analysis of the Use of Digital Health Technologies in Primary Health Care in the Sub-Saharan African Region: Qualitative Study.

BACKGROUND: Digital health technologies (DHTs) have become increasingly commonplace as a means of delivering primary care. While DHTs have been postulated to reduce inequalities, increase access, and strengthen health systems, how the implementation of DHTs has been realized in the sub-Saharan Africa (SSA) health care environment remains inadequately explored. OBJECTIVE: This study aims to capture the multidisciplinary experiences of primary care professionals using DHTs to explore the strengths and weaknesses, as well as opportunities and threats, regarding the implementation and use of DHTs in SSA primary care settings. METHODS: A combination of qualitative approaches was adopted (ie, focus groups and semistructured interviews). Participants were recruited through the African Forum for Primary Care and researchers' contact networks using convenience sampling and included if having experience with digital technologies in primary health care in SSA. Focus and interviews were conducted, respectively, in November 2021 and January-March 2022. Topic guides were used to cover relevant topics in the interviews, using the strengths, weaknesses, opportunities, and threats framework. Transcripts were compiled verbatim and systematically reviewed by 2 independent reviewers using framework analysis to identify emerging themes. The COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist was used to ensure the study met the recommended standards of qualitative data reporting. RESULTS: A total of 33 participants participated in the study (n=13 and n=23 in the interviews and in focus groups, respectively; n=3 participants participated in both). The strengths of using DHTs ranged from improving access to care, supporting the continuity of care, and increasing care satisfaction and trust to greater collaboration, enabling safer decision-making, and hastening progress toward universal health coverage. Weaknesses included poor digital literacy, health inequalities, lack of human resources, inadequate training, lack of basic infrastructure and equipment, and poor coordination when implementing DHTs. DHTs were perceived as an opportunity to improve patient digital literacy, increase equity, promote more patient-centric design in upcoming DHTs, streamline expenditure, and provide a means to learn international best practices. Threats identified include the lack of buy-in from both patients and providers, insufficient human resources and local capacity, inadequate governmental support, overly restrictive regulations, and a lack of focus on cybersecurity and data protection. CONCLUSIONS: The research highlights the complex challenges of implementing DHTs in the SSA context as a fast-moving health delivery modality, as well as the need for multistakeholder involvement. Future research should explore the nuances of these findings across different technologies and settings in the SSA region and implications on health and health care equity, capitalizing on mixed-methods research, including the use of real-world quantitative data to understand patient health needs. The promise of digital health will only be realized when informed by studies that incorporate patient perspective at every stage of the research cycle.

SERIES: eHealth in primary care. Part 6: Global perspectives: Learning from eHealth for low-resource primary care settings and across high-, middle- and low-income countries.

BACKGROUND: eHealth offers opportunities to improve health and healthcare systems and overcome primary care challenges in low-resource settings (LRS). LRS has been typically associated with low- and middle-income countries (LMIC), but they can be found in high-income countries (HIC) when human, physical or financial resources are constrained. Adopting a concept of LRS that applies to LMIC and HIC can facilitate knowledge interchange between eHealth initiatives while improving healthcare provision for socioeconomically disadvantaged groups across the globe. OBJECTIVES: To outline the contributions and challenges of eHealth in low-resource primary care settings. STRATEGY: We adopt a socio-ecological understanding of LRS, making LRS relevant to LMIC and HIC. To assess the potential of eHealth in primary care settings, we discuss four case studies according to the WHO 'building blocks for strengthening healthcare systems'. RESULTS AND DISCUSSION: The case studies illustrate eHealth's potential to improve the provision of healthcare by i) improving the delivery of healthcare (using AI-generated chats); ii) supporting the workforce (using telemedicine platforms); iii) strengthening the healthcare information system (through patient-centred healthcare information systems), and iv) improving system-related elements of healthcare (through a mobile health financing platform). Nevertheless, we found that development and implementation are hindered by user-related, technical, financial, regulatory and evaluation challenges. We formulated six recommendations to help anticipate or overcome these challenges: 1) evaluate eHealth's appropriateness, 2) know the end users, 3) establish evaluation methods, 4) prioritise the human component, 5) profit from collaborations, ensure sustainable financing and local ownership, 6) and contextualise and evaluate the implementation strategies.

Digital health for all: How digital health could reduce inequality and increase universal health coverage.

Digital transformation in health care has a lot of opportunities to improve access and quality of care. However, in reality not all individuals and communities are benefiting equally from these innovations. People in vulnerable conditions, already in need of more care and support, are often not participating in digital health programs. Fortunately, numerous initiatives worldwide are committed to make digital health accessible to all citizens, stimulating the long-cherished global pursuit of universal health coverage. Unfortunately initiatives are not always familiar with each other and miss connection to jointly make a significant positive impact. To reach universal health coverage via digital health it is necessary to facilitate mutual knowledge exchange, both globally and locally, to link initiatives and apply academic knowledge into practice. This will support policymakers, health care providers and other stakeholders to ensure that digital innovations can increase access to care for everyone, leading towards Digital health for all.

Target women: Equity in access to mHealth technology in a non-communicable disease care intervention in Kenya.

BACKGROUND: Non-Communicable Diseases (NCDs) constitute 40 million deaths annually. Eighty-percent of these deaths occur in Low- and Middle-Income Countries. MHealth provides a potentially highly effective modality for global public health, however access is poorly understood. The objective of our study was to assess equity in access to mHealth in an NCD intervention in Kenya. METHODS: This is a secondary analysis of a complex NCD intervention targeting slum residents in Kenya. The primary outcomes were: willingness to receive SMS, whether SMS was received, and access to SMS compared to alternative health information modalities. Age, sex, level of education, level of income, type of work, number of hours worked, and home environment were explanatory variables considered. Multivariable regression analyses were used to test for association using likelihood ratio testing. RESULTS: 7,618 individual participants were included in the analysis. The median age was 44 years old. Majority (75%, n = 3,691/ 4,927) had only attended up to primary (elementary) school. Majority reported earning "KShs 7,500 or greater" (27%, n = 1,276/ 4,736). Age and level of income had evidence of association with willingness to receive SMS, and age, sex and number of hours work with whether SMS was received. SMS was the health information modality with highest odds of being accessed in older age groups (OR 4.70, 8.72 and 28.89, for age brackets 60-69, 70-79 and 80 years or older, respectively), among women (OR = 1.86, 95% CI 1.19-2.89), and second only to Baraazas (community gatherings) among those with lowest income. CONCLUSION: Women had the greatest likelihood of receiving SMS. SMS performed equitably well amongst marginalized populations (elderly, women, and low-income) as compared to alternative health information modalities, though sensitization prior to implementation of mHealth interventions may be needed. These findings provide guidance for developing mHealth interventions targeting marginalized populations in these settings.

Health disparities across the counties of Kenya and implications for policy makers, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.

BACKGROUND: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provided comprehensive estimates of health loss globally. Decision makers in Kenya can use GBD subnational data to target health interventions and address county-level variation in the burden of disease. METHODS: We used GBD 2016 estimates of life expectancy at birth, healthy life expectancy, all-cause and cause-specific mortality, years of life lost, years lived with disability, disability-adjusted life-years, and risk factors to analyse health by age and sex at the national and county levels in Kenya from 1990 to 2016. FINDINGS: The national all-cause mortality rate decreased from 850·3 (95% uncertainty interval [UI] 829·8-871·1) deaths per 100 000 in 1990 to 579·0 (562·1-596·0) deaths per 100 000 in 2016. Under-5 mortality declined from 95·4 (95% UI 90·1-101·3) deaths per 1000 livebirths in 1990 to 43·4 (36·9-51·2) deaths per 1000 livebirths in 2016, and maternal mortality fell from 315·7 (242·9-399·4) deaths per 100 000 in 1990 to 257·6 (195·1-335·3) deaths per 100 000 in 2016, with steeper declines after 2006 and heterogeneously across counties. Life expectancy at birth increased by 5·4 (95% UI 3·7-7·2) years, with higher gains in females than males in all but ten counties. Unsafe water, sanitation, and handwashing, unsafe sex, and malnutrition were the leading national risk factors in 2016. INTERPRETATION: Health outcomes have improved in Kenya since 2006. The burden of communicable diseases decreased but continues to predominate the total disease burden in 2016, whereas the non-communicable disease burden increased. Health gains varied strikingly across counties, indicating targeted approaches for health policy are necessary. FUNDING: Bill & Melinda Gates Foundation.

Outcomes and costs of implementing a community-based intervention for hypertension in an urban slum in Kenya.

OBJECTIVE: To describe the processes, outcomes and costs of implementing a multi-component, community-based intervention for hypertension among adults aged > 35 years in a large slum in Nairobi, Kenya. METHODS: The intervention in 2012-2013 was based on four components: awareness-raising; improved access to screening; standardized clinical management of hypertension; and long-term retention in care. Using multiple sources of data, including administrative records and surveys, we described the inputs and outputs of each intervention activity and estimated the outcomes of each component and the impact of the intervention. We also estimated the costs associated with implementation, using a top-down costing approach. FINDINGS: The intervention reached 60% of the target population (4049/6780 people), at a cost of 17 United States dollars (US$) per person screened and provided access to treatment for 68% (660/976) of people referred, at a cost of US$ 123 per person with hypertension who attended the clinic. Of the 660 people who attended the clinic, 27% (178) were retained in care, at a cost of US$ 194 per person retained; and of those patients, 33% (58/178) achieved blood pressure control. The total intervention cost per patient with blood pressure controlled was US$ 3205. CONCLUSION: With moderate implementation costs, it was possible to achieve hypertension awareness and treatment levels comparable to those in high-income settings. However, retention in care and blood pressure control were challenges in this slum setting. For patients, the costs and lack of time or forgetfulness were barriers to retention in care.

A community-based intervention for primary prevention of cardiovascular diseases in the slums of Nairobi: the SCALE UP study protocol for a prospective quasi-experimental community-based trial.

BACKGROUND: The burden of cardiovascular disease is rising in sub-Saharan Africa with hypertension being the main risk factor. However, context-specific evidence on effective interventions for primary prevention of cardiovascular diseases in resource-poor settings is limited. This study aims to evaluate the feasibility and cost-effectiveness of one such intervention--the "Sustainable model for cardiovascular health by adjusting lifestyle and treatment with economic perspective in settings of urban poverty". DESIGN: A prospective quasi-experimental community-based intervention study. SETTING: Two slum settlements (Korogocho and Viwandani) in Nairobi, Kenya. STUDY POPULATION: Adults aged 35 years and above in the two communities. INTERVENTION: The intervention community (Korogocho) will be exposed to an intervention package for primary prevention of cardiovascular disease that comprises awareness campaigns, household screening for cardiovascular diseases risk factors, and referral and treatment of people with high cardiovascular diseases risk at a primary health clinic. The control community (Viwandani) will continue accessing the usual standard of care for primary prevention of cardiovascular diseases in Kenya. DATA: Demographic and socioeconomic data; anthropometric and clinical measurements including blood pressure. Population-based data will be collected at the baseline and endline--12 months after implementing the intervention. These data will be collected from a random sample of 1,610 adults aged 35 years and above in the intervention and control sites at both baseline and endline. Additionally, operational (including cost) and clinic-based data will be collected on an ongoing basis. MAIN OUTCOMES: (1) A positive difference in the change in the proportion of the intervention versus control study populations that are at moderate or high risk of cardiovascular disease; (2) a difference in the change in mean systolic blood pressure in the intervention versus control study populations; (3) the net cost of the complete intervention package per disability-adjusted life year gained. ANALYSIS: Primary outcomes comparing pre- and post-, and operational data will be analyzed descriptively and "impact" of the intervention will be calculated using double-difference methods. We will also conduct a cost-effectiveness analysis of the intervention using World Health Organization guidelines. DISCUSSION: The outcomes of the study will be disseminated to local policy makers and health planners. TRIAL REGISTRATION: Current controlled trials ISRCTN84424579.

Introducing a model of cardiovascular prevention in Nairobi's slums by integrating a public health and private-sector approach: the SCALE-UP study.

INTRODUCTION: Cardiovascular disease (CVD) is a leading cause of death in sub-Saharan Africa (SSA), with annual deaths expected to increase to 2 million by 2030. Currently, most national health systems in SSA are not adequately prepared for this epidemic. This is especially so in slum settlements where access to formal healthcare and resources is limited. OBJECTIVE: To develop and introduce a model of cardiovascular prevention in the slums of Nairobi by integrating public health and private sector approaches. STUDY DESIGN: Two non-profit organizations that conduct public health research, Amsterdam Institute for Global Health and Development (AIGHD) and African Population and Health Research Center (APHRC), collaborated with private-sector Boston Consulting Group (BCG) to develop a service delivery package for CVD prevention in slum settings. A theoretic model was designed based on the integration of public and private sector approaches with the focus on costs and feasibility. RESULTS: The final model includes components that aim to improve community awareness, a home-based screening service, patient and provider incentives to seek and deliver treatment specifically for hypertension, and adherence support. The expected outcomes projected by this model could prove potentially cost effective and affordable (1 USD/person/year). The model is currently being implemented in a Nairobi slum and is closely followed by key stakeholders in Kenya including the Ministry of Health, the World Health Organization (WHO), and leading non-governmental organizations (NGOs). CONCLUSION: Through the collaboration of public health and private sectors, a theoretically cost-effective model was developed for the prevention of CVD and is currently being implemented in the slums of Nairobi. If results are in line with the theoretical projections and first impressions on the ground, scale-up of the service delivery package could be planned in other poor urban areas in Kenya by relevant policymakers and NGOs.

Review of community-based interventions for prevention of cardiovascular diseases in low- and middle-income countries.

BACKGROUND: An increasing burden of cardiovascular disease (CVD) is occurring in low- and middle-income countries (LMICs) as a result of urbanisation and globalisation. Low rates of awareness and treatment of risk factors worsen the prognosis in these settings. Prevention of CVD is proven to be cost effective and should be the main intervention. Insight into prevention programmes in LMIC is important in addressing the rising levels of these diseases. OBJECTIVE: To evaluate the effectiveness of the community-based interventions for CVD prevention programmes in LMIC. DESIGN: A literature review with searches in the databases of PubMed, EMBASE, CINAHL, LILACS, African Index Medicus and Google Scholar between 1990 and May 2012. RESULTS: Twenty-six studies involving population-based and high-risk interventions have been included in this review. The content of the population intervention was mainly health promotion through media and health education, and the high-risk approach focused often on education of patients, training of health care providers and implementing treatment guidelines. A few studies had a single intervention on exercising or salt reduction. Most studies showed a significant reduction of cardiovascular risk ranging from lifestyle changes on diet, smoking and alcohol to biomedical outcomes like blood pressure, glucose levels or weight. Some studies showed improved management of risk factors like increased control of hypertension or adherence to medication. CONCLUSION: There have been effective community-based programmes aimed at reducing cardiovascular risk factors in LMIC but these have generally been limited to the urban poor. Health education with a focus on diet and salt, training of health care providers and implementing treatment guidelines form key elements in successful programmes.