Effects of a Digital Health Literacy Intervention on Porcine Cysticercosis Prevalence and Associated Household Practices in Iringa District, Tanzania.

Digital health is considered an opportunity to engage a wider community in disease control for public health. It has been used in healthcare consultation, in medical treatments and in reporting emergencies. The current study developed digital health literacy content for public health education and assessed its effects on porcine cysticercosis prevalence, pig-keeping style and pig pen and latrine qualities. The intervention was designed and evaluated on the prevention and control of porcine cysticercosis in the Iringa District of southern Tanzania. A quasi-controlled field trial with pre-intervention and post-intervention assessments of porcine cysticercosis, pig-keeping style and pig pen and latrine qualities was conducted. A baseline cross-sectional study was followed immediately by digital health literacy intervention, which comprised educational messages on porcine cysticercosis shown on computer tablets or smartphones. Free internet access supported unsupervised community access. The 25-month post-intervention assessments revealed significantly increased pig confinement (20.1%) (p = 0.026) and pig pen quality (16.2%) (p = 0.025). However, the quality of household latrines (p = 0.453) was not improved, nor was there any significant effect on the prevalence of porcine cysticercosis (p = 0.231). The digital health literacy intervention suggests a strategy for wider and sustainable dissemination of educational messages for Taenia solium infection control.

Utilizing community InfoSpots for health education: perspectives and experiences in Migoli and Izazi, Tanzania.

Limited access to health education can be a barrier for reaching the Sustainable Development Goals, especially in rural communities in sub-Saharan Africa. We addressed this gap by installing community information spots (InfoSpots) with access to the internet and a locally stored digital health education platform (the platform) in Migoli and Izazi, Tanzania. The objective of this case study was to explore the perspectives and experiences of InfoSpot users and non-users in these communities. We conducted 35 semi-structured interviews with participants living, working or studying in Migoli or Izazi in February 2020 and subsequently analysed the data using content analysis. The 25 InfoSpot users reported variations in use patterns. Users with more education utilized the platform for their own health education and that of others, in addition to internet surfing. High school students also used the platform for practicing English, in addition to health education. Most InfoSpot users found the platform easy to use; however, those with less education received guidance from other users. Non-users reported that they would have used the InfoSpot with the platform if they had been aware of its existence. All participants reported a positive view of the digital health messages, especially animations as a health knowledge transfer tool. In conclusion, different and unintended use of the platform shows that the communities are creative in ways of utilizing the InfoSpots and gaining knowledge. The platform could have been used by more people if it had been promoted better in the communities.

Access to good-quality health education is crucial for reaching the Sustainable Development Goals. We installed community information spots (InfoSpots) with access to the internet and a locally stored digital health education platform (the platform) in two rural villages in Tanzania in November 2019. This qualitative case study was conducted in Migoli and Izazi in February 2020, and 35 people participated in semi-structured interviews. Content analysis was performed with the software NVivo, and quotations were used to illustrate the themes. Twenty-five participants were classified as InfoSpot users. Variations and creativity in use patterns were reported. Less educated users were guided by others, while users with more education used the platform for their own and for the education of others, in addition to internet surfing. The students who used the InfoSpot for health education and for practicing English demonstrated unintended use of the platform. All non-users reported that they would have used the InfoSpots if they had been aware of their existence. All participants, users and non-users, reported a positive view of the digital health messages, especially animations as a health knowledge transfer tool. The use of such platforms can be an important factor in disease prevention.

Improving Health Knowledge Through Provision of Free Digital Health Education to Rural Communities in Iringa, Tanzania: Nonrandomized Intervention Study.

BACKGROUND: Community health education is one of the most effective measures to increase health literacy worldwide and can contribute to the achievement of specific targets of the Sustainable Development Goal 3. Digitalized health education materials can improve health knowledge as a dimension of health literacy and play an important role in disease prevention in rural sub-Saharan settings. OBJECTIVE: The objective of this research is to assess the effect of a digital health education intervention on the uptake and retention of knowledge related to HIV/AIDS, tuberculosis (TB), and Taenia solium (neuro)cysticercosis and taeniosis in rural communities in Iringa, Tanzania. METHODS: We conducted a nonrandomized intervention study of participants aged 15 to 45 years, randomly selected from 4 villages in Iringa, Tanzania. The intervention consisted of 2 parts. After the baseline assessment, we showed the participants 3 animated health videos on a tablet computer. After a period of 6 months, free access to community information spots (InfoSpots) with an integrated digital health education platform was provided to the intervention villages. Participants in the control group did not receive the intervention. The primary outcome was the difference in disease knowledge between the intervention and control groups, 12 months after baseline. Data were collected using an open-ended questionnaire, with correct or incorrect answers before and after intervention. RESULTS: Between April and May 2019, a total of 600 participants were recruited into the intervention (n=298, 49.7%) or control (n=302, 50.3%) groups. At baseline, no statistically significant differences in knowledge of the target diseases were observed. At 12 months after intervention, knowledge about HIV/AIDS, TB, and T. solium (neuro)cysticercosis and taeniosis was 10.2% (95% CI 5.0%-15.4%), 12% (95% CI 7.7%-16.2%), and 31.5% (95% CI 26.8%-36.2%) higher in the intervention group than in the control group, respectively. In all 4 domains (transmission, symptoms, treatment, and prevention), an increase in knowledge was observed in all the 3 diseases, albeit to varying degrees. The results were adjusted for potential confounders, and the significance of the primary results was maintained in the sensitivity analysis to assess dropouts. The participants who reported using the InfoSpots in the 12-month assessment further increased their knowledge about the target diseases by 6.8% (HIV/AIDS), 7.5% (TB), and 13.9% higher mean proportion of correct answers compared with the participants who did not use the InfoSpots. CONCLUSIONS: Digital health education based on animated health videos and the use of free InfoSpots has significant potential to improve health knowledge, especially in rural areas of low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT03808597; https://clinicaltrials.gov/ct2/show/NCT03808597. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/25128.

Safe Pregnancy intervention for intimate partner violence: a randomised controlled trial in Norway among culturally diverse pregnant women.

BACKGROUND: Intimate partner violence (IPV) during pregnancy is a global health problem with adverse consequences for mothers, infants and families. We hypothesise that information about IPV and safety behaviours during pregnancy has the potential to increase quality of life and the use of safety behaviours and prevent IPV. METHODS: A multicentre randomised controlled trial among culturally diverse pregnant women in Norway, to test the effect of a tablet-based video intervention about IPV and safety behaviours. Women attending routine antenatal check-ups alone (baseline) were screened for violence (Abuse Assessment Screen) by responding to questions on a tablet, and randomised (1:1) by computer to receive an intervention or a control video. The intervention video presented information about IPV and safety behaviours. The controls viewed a video promoting healthy pregnancy in general. Outcome measures were assessed three months post-partum: The World Health Organization Quality of Life-BREF, the Composite Abuse Scale on violence during the last 12 months and use of safety behaviours based on a 15-item checklist. A general linear model for repeated measures was used to examine the intervention's effect. The analyses were conducted by intention to treat. RESULTS: Among 1818 eligible women, 317 reported IPV and were randomised to an intervention (157) or a control group (160). A total of 251 (79.2%) women completed the follow-up questionnaire: 120 (76.4%) in the intervention group and 131 (81.9%) in the control group. At follow-up, 115 (45.8%) women reported a history of IPV. Few women (n = 39) reported IPV during the last 12 months. No differences in quality-of-life domains and overall quality of life and health were found between the intervention and the control groups. We detected no differences between the use of safety behaviours or IPV frequency and severity during the last 12 months. CONCLUSION: Our intervention did not improve women's quality of life, use of safety behaviours or exposure to violence. Nevertheless, a tablet-based tool may motivate women experiencing IPV to seek help and support. More research is needed regarding tablet-based interventions for women experiencing IPV, particularly culturally sensitive interventions. TRIAL REGISTRATION: NCT03397277 registered in clinicaltrials.gov on 11/01/2018.

Development of Digital Health Messages for Rural Populations in Tanzania: Multi- and Interdisciplinary Approach.

BACKGROUND: Health workers have traditionally delivered health promotion and education to rural communities in the Global South in paper leaflet formats or orally. With the rise of digital technologies, health promotion and education can be provided in innovative and more effective formats, which are believed to have a higher impact on disease prevention and treatment. OBJECTIVE: The aim of this tutorial is to illustrate how a multi- and interdisciplinary approach can be applied in the design process of digital health messages for use in the Global South. METHODS: The multi- and interdisciplinary team of the Non-discriminating access for Digital Inclusion (DigI) project digitalized and customized available government-approved paper-based health promotion messages into a screen-suitable format. The team worked closely together and used its diverse expertise to develop digital health messages with disease-specific content in Tanzania's national language (Swahili) as well as English. The development process included the following phases: a local needs assessment; identification of government-approved health promotion materials in a nondigital format; identification of key health messages; creation of a practical and engaging story, easy to understand for the general public; drafting of a storyboard for an animated video with review, feedback, and revisions; forward and backward translation; audio recording of the story in both languages; finalization and presentation of the animations; development of relevant questions related to the health messages in each domain; and development of web and mobile apps to access the digital health messages. RESULTS: Between 2017 and 2019, we developed key health messages, quizzes, and animated health videos to address HIV/AIDS, tuberculosis, Taenia solium cysticercosis and taeniasis, and anthrax, all of which are of public health importance in Tanzania. Feedback from local stakeholders and test users was included in various phases of the process. The 4 videos and other content are available in local information spots on a digital health platform (DigI platform), established by the DigI project, in both Tanzanian Swahili and English. CONCLUSIONS: Our methodological multi- and interdisciplinary approach ensures that the digital health messages for the public are clear, high quality, and align with the government's objectives for health promotion. It also demonstrates the diversity of scientific disciplines required when collaborating on a digital health project. We recommend this approach to be applied to the development of other digital health messages for a wide range of diseases. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/25128.

Digital Health Intervention to Increase Health Knowledge Related to Diseases of High Public Health Concern in Iringa, Tanzania: Protocol for a Mixed Methods Study.

BACKGROUND: Traditionally, health promotion and health education have been provided to communities in the global south in the form of leaflets or orally by health care workers. Digital health interventions (DHIs) such as digital health messages accessed by smartphones have the potential to reach more people at a lower cost and to contribute to strengthening of health care systems. The DHI in this study focuses on disseminating digital health education regarding 3 disease complexes of high public health concern: HIV/AIDS, tuberculosis, and Taenia solium (neuro)cysticercosis or taeniasis, a parasitic zoonotic disease that requires a One Health approach. The DHI presents the participants with animated health videos (animations) and provides access to information spots (InfoSpots) with a free-of-charge digital health platform containing messages about health to rural Tanzanian communities. OBJECTIVE: The objective of this study is to measure the effect of the DHI on health knowledge uptake and retention over time in the rural communities. METHODS: This is a mixed methods study including a nonrandomized controlled trial and qualitative interviews conducted in rural Tanzania. A health platform containing digital health messages for the communities was developed prior to the study. The health messages consist of text, pictures, quizzes, and animations of everyday stories, aimed at disease prevention and early treatment. The baseline and immediate postintervention assessments were completed in Iringa, Tanzania in May 2019. The participants were interviewed by enumerators and completed questionnaires regarding health knowledge. Participants in the intervention group were exposed to 3 different health animations once on a tablet device. The participants' health knowledge was assessed again immediately after the exposure. The first follow-up survey was undertaken in August 2019. The InfoSpots with the digital health platform were thereafter launched in the intervention villages in November 2019. Qualitative interviews were undertaken in February 2020. The second follow-up was completed in June 2020. RESULTS: A total of 600 participants have been enrolled in the trial. We will assess (1) the difference in knowledge scores between baseline and the immediate postintervention assessments in the intervention group and (2) the difference in knowledge scores between the intervention and control groups at baseline, 3 and 6 months post-DHI rollout. Since a randomized design did not prove feasible, potential confounders (eg, age, gender, education, and time of exposure) may be introduced, and results will be adjusted. Data analysis for the 35 qualitative interviews is currently ongoing, and perspectives and experiences related to use and nonuse of the InfoSpots are being explored. CONCLUSIONS: The data have been collected, and the analysis is ongoing in this digital health study, aimed at evaluating the effects of a DHI based on relevant health messages. The publications of results can be expected this year. TRIAL REGISTRATION: ClinicalTrials.gov NCT03808597; https://clinicaltrials.gov/ct2/show/NCT03808597. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/25128.

Estimating PQoS of Video Streaming on Wi-Fi Networks Using Machine Learning.

Video on demand (VoD) services such as YouTube have generated considerable volumes of Internet traffic in homes and buildings in recent years. While Internet service providers deploy fiber and recent wireless technologies such as 802.11ax to support high bandwidth requirement, the best-effort nature of 802.11 networks and variable wireless medium conditions hinder users from experiencing maximum quality during video streaming. Hence, Internet service providers (ISPs) have an interest in monitoring the perceived quality of service (PQoS) in customer premises in order to avoid customer dissatisfaction and churn. Since existing approaches for estimating PQoS or quality of experience (QoE) requires external measurement of generic network performance parameters, this paper presents a novel approach to estimate the PQoS of video streaming using only 802.11 specific network performance parameters collected from wireless access points. This study produced datasets comprising 802.11n/ac/ax specific network performance parameters labelled with PQoS in the form of mean opinion scores (MOS) to train machine learning algorithms. As a result, we achieved as many as 93-99% classification accuracy in estimating PQoS by monitoring only 802.11 parameters on off-the-shelf Wi-Fi access points. Furthermore, the 802.11 parameters used in the machine learning model were analyzed to identify the cause of quality degradation detected on the Wi-Fi networks. Finally, ISPs can utilize the results of this study to provide predictable and measurable wireless quality by implementing non-intrusive monitoring of customers' perceived quality. In addition, this approach reduces customers' privacy concerns while reducing the operational cost of analytics for ISPs.

Effect of the Pregnant+ smartphone application in women with gestational diabetes mellitus: a randomised controlled trial in Norway.

OBJECTIVE: To assess the effect of the Pregnant+ app on the 2-hour glucose level of the routine postpartum oral glucose tolerance test (OGTT) among women with gestational diabetes mellitus (GDM). The Pregnant+ app was designed to provide information about GDM, and promote physical activity and a healthy diet. DESIGN: A multicentre, non-blinded randomised controlled trial. SETTING: Five diabetes outpatient clinics in the Oslo region. PARTICIPANTS: Women ≥18 years old with a 2-hour OGTT blood glucose level ≥9 mmol/L who owned a smartphone; understood Norwegian, Urdu or Somali; and were <33 weeks pregnant. A total of 238 women were randomised; 158 women completed the OGTT post partum. INTERVENTION: The Pregnant+ app and usual care, the control group received usual care. PRIMARY AND SECONDARY OUTCOMES: The primary outcome was the 2-hour blood glucose level of the routine postpartum OGTT. Secondary outcomes reported were mode of delivery, induction of labour, Apgar score, birth weight, transfer to the neonatal intensive care unit and breast feeding practice. Blood glucose levels during pregnancy, knowledge of diabetes, diet and physical activity are not reported. RESULTS: No difference was found for the 2-hour blood glucose level of the postpartum OGTT, with 6.7 mmol/L (95% CI 6.2 to 7.1) in the intervention group and 6.0 mmol/L (95% CI 5.6 to 6.3) in the control group. The significant difference in the proportion of emergency caesarean sections between the intervention group, 10 (8.8%) and the usual care group, 27 (22.1%), disappeared when adjusted for parity. There were no differences in birth weight, breast feeding practice, obstetric complications or transfer to the intensive neonatal care unit. No adverse events were registered. CONCLUSION: The Pregnant+ app had no effect on 2-hour glucose level at routine postpartum OGTT. After controlling for parity, the difference in emergency caesarean section was not statistically significant. TRIAL REGISTRATION NUMBER: NCT02588729.

The Safe Pregnancy study - promoting safety behaviours in antenatal care among Norwegian, Pakistani and Somali pregnant women: a study protocol for a randomized controlled trial.

BACKGROUND: Intimate partner violence (IPV) around the time of pregnancy is a recognized global health problem with damaging consequences. However, little is known about the effect of violence assessment and intervention during pregnancy. We hypothesise that routine enquiry about IPV during pregnancy, in combination with information about IPV and safety behaviours, has the potential to increase the use of these behaviours and prevent and reduce IPV. METHODS: The Safe Pregnancy study is a randomised controlled trial (RCT) to test the effectiveness of a tablet-based intervention to promote safety behaviours among pregnant women. Midwives include women who attend routine antenatal care. The intervention consists of a screening questionnaire for violence and information about violence and safety behaviours through a short video shown on a tablet. The materials are available in different languages to ensure participation of Norwegian, Urdu, Somali and English-speaking women. Eligible women answer baseline questions on the tablet including the Abuse Assessment Scale (AAS). Women who screen positive on the AAS will be randomized to an intervention video that contains information about violence and safety behaviours and women in the control group to a video with general information about a healthy and a safe pregnancy. All women receive information about referral resources. Follow up will be at three months post-partum, when the woman attends the maternal and child health centre (MCHC) for the baby's check-up. Outcome measures are: Use of safety behaviours and quality of life (primary outcomes), prevalence of violence, mental health measures and birth outcomes (secondary outcomes). Intention to treat analysis will be performed. DISCUSSION: The project will provide evidence on whether enquiry about violence and a short video intervention on a tablet is effective and feasible to prevent or reduce harm from IPV among women who attend antenatal care. TRIAL REGISTRATION: This study is registered in ClinicalTrials.gov. Identifier: NCT03397277 (Registered 11th January 2018).

Health Care Professionals' Attitudes Toward, and Experiences of Using, a Culture-Sensitive Smartphone App for Women with Gestational Diabetes Mellitus: Qualitative Study.

BACKGROUND: The increasing prevalence of gestational diabetes mellitus (GDM) among women of different ethnic backgrounds provides new challenges for health care professionals, who often find it difficult to provide information about the management of this disease to such individuals. Mobile health (mHealth) may act as a useful tool for blood sugar control and care process enhancement. However, little is known about health care professionals' experiences and attitudes toward the use of mHealth for women with GDM. OBJECTIVE: The aim of this study was to explore how health care professionals perceived the provision of care to pregnant women who managed their GDM using the culture-sensitive Pregnant+ app in a randomized controlled trial. METHODS: Individual interviews with 9 health care professionals providing care for women with GDM were conducted. Braun and Clark's method of thematic content analysis inspired the analysis. This study included health care professionals who were primarily responsible for providing care to participants with GDM in the Pregnant+ randomized controlled trial at 5 diabetes outpatient clinics in Oslo, Norway. RESULTS: Health care professionals perceived mHealth, particularly the Pregnant+ app, as an appropriate tool for the care of women with GDM, who were described as individuals comprising a heterogeneous, motivated group that could be easily approached with health-related information. Some participants reported challenges with respect to provision of advice to women with different food cultures. The advantages of the Pregnant+ app included provision of information that women could access at home, the information provided being perceived as trustworthy by health care professionals, the culture sensitivity of the app, and the convenience for women to register blood sugar levels. Technical problems, particularly those associated with the automatic transfer of blood glucose measurements, were identified as the main barrier to the use of the Pregnant+ app. Strict inclusion criteria and the inclusion of participants who could not speak Norwegian were the main challenges in the recruitment process for the randomized controlled trial. CONCLUSIONS: The findings of this study suggest that mHealth is a useful tool to enhance the care provided by health care professionals to women with GDM. Future mobile apps for the management of GDM should be developed by a trustworthy source and in cooperation with health care professionals. They should also be culture sensitive and should not exhibit technical problems.

Smartphone application for women with gestational diabetes mellitus: a study protocol for a multicentre randomised controlled trial.

INTRODUCTION: The promotion of a healthy diet, physical activity and measurement of blood glucose levels are essential components in the care for women with gestational diabetes mellitus (GDM). Smartphones offer a new way to promote health behaviour. The main aim is to investigate if the use of the Pregnant+ app, in addition to standard care, results in better blood glucose levels compared with current standard care only, for women with GDM. METHODS AND ANALYSIS: This randomised controlled trial will include 230 pregnant women with GDM followed up at 5 outpatient departments (OPD) in the greater Oslo Region. Women with a 2-hour oral glucose tolerance test (OGTT) ≥9 mmol/L, who own a smartphone, understand Norwegian, Urdu or Somali and are <33 weeks pregnant, are invited. The intervention group receives the Pregnant+ app and standard care. The control group receives standard care only. Block randomisation is performed electronically. Data are collected using self-reported questionnaires and hospital records. Data will be analysed according to the intention-to-treat principle. Groups will be compared using linear regression for the main outcome and χ2 test for categorical data and Student's t-test or Mann-Whitney-Wilcoxon test for skewed distribution. The main outcome is the glucose level measured at the 2-hour OGTT 3 months postpartum. Secondary outcomes are a change in health behaviour and knowledge about GDM, quality of life, birth weight, mode of delivery and complications for mother and child. ETHICS AND DISSEMINATION: The study is exempt from regional ethics review due to its nature of quality improvement in patient care. Our study has been approved by the Norwegian Social Science Data Services and the patient privacy protections boards governing over the recruitment sites. Findings will be presented in peer-reviewed journals and at conferences. TRIAL REGISTRATION NUMBER: NCT02588729, Post-results.

Designing and Developing a Mobile Smartphone Application for Women with Gestational Diabetes Mellitus Followed-Up at Diabetes Outpatient Clinics in Norway.

The prevalence of Gestational Diabetes Mellitus (GDM) is increasing worldwide. Controlling blood sugar levels is fundamental to the management of GDM. Current practice in Norway includes patients registering blood sugar levels in a booklet and receiving verbal and/or written health information. A smartphone application may provide patients individually targeted and easily available advice to control blood sugar levels. The aim of this paper is to document the process of designing and developing a smartphone application (the Pregnant+ app) that automatically transfers blood sugar levels from the glucometer and has information about healthy eating and physical activity. This formative research included expert-group discussions among health professionals, researchers and experts in data privacy and security. User-involvement studies were conducted to discuss prototypes of the app. Results indicated that the content of the application should be easy to understand given the varying degree of patients' literacy and in line with the information they receive at clinics. The final version of the app incorporated behavior change techniques such as self-monitoring and cues to action. Results from the first round of interactions show the importance of involving expert groups and patients when developing a mobile health-care device.