Tale of two mobile
interventions to
improve quality of
health care
Oluwaseun Adeleke, Abt Assoc
Odartei Lamptey, Abt Assoc
CRS ICT4D Conference
March 19th to 21st, 2013
Two unrelated projects using
common “mhealth” approaches
 Case study #1: Using smart phones for data-driven improvement at
TB facilities in Nigeria
 Case study #2: Evaluating impact of text messages on drug vendor
treatment for diarrhea Ghana
Shared themes
• Interventions designed to improve quality of care through data driven corrective actions
• Needs-based, government-led activities
• Technology rides on capacity to strengthen existing government systems
• Pilot directed at improvement of content/process and mentorship for skill acquisition
• Applications designed as M&E tool to assess gaps and outcomes
• Sustainability planning
• Contribute to mhealth evidence base
Abt Associates
Case study #1
Using Smart Phones for Data Driven
Improvements in Nigerian TB Clinics
Abt Associates
Background
 Nigeria (13th) rank among
the highest Tuberculosis
(TB) burden countries in the
world.
High-Burden TB Countries
– WHO Global TB Report
 Desk review revealed need
for strengthening Supportive
Supervision (SS) to improve
performance and treatment
outcomes
 Nigeria was open to
exploring new and
innovative ways of improving
quality through SS
Abt Associates | pg 4
Goals
1.
Move away from long,
paper-based checklists
2.
Reduce time for data entry
& analysis and human
error
3.
Concentrate on
performance of clinical
tasks and resolution of
problems experienced by
the health worker
4.
Increase feedback from
supervisors
5.
Provide evidence for
policy and planning (goal
linked to online database)
Abt Associates | pg 5
Mobile ICT - Opportunities
 Percentage of users accessing the
web using mobile phones is
increasing: Nigeria (63.9%)
 Smartphones are getting cheaper
(moving towards a retail price of $100
or less).
 Today’s smartphones are essentially
mini-computers – relevant not just for
collecting data but also useful for
analysis that will inform planning,
policy direction & decision making
Abt Associates | pg 6
Innovation
1. Consolidated checklist
loaded onto Smartphone
2. Forms programmed to do
automatic calculations of
critical indicators; reducing
human error
3. Rapid review of critical
indicators allows for
immediate feedback and
corrective action at the
facility
4. Data sent immediately to an
online database for State
and Federal level analysis
Abt Associates | pg 7
Impact
 Community-based defaulter
tracing
 Better record keeping
 Drug stock-outs decreased
 External quality control results
obtained
 SIM cards independently
purchased = sustainability
indicator!
 Success recorded in Nigeria &
Ethiopia has initiated
increasing demand from other
countries e.g. Malawi, SouthSudan …
Abt Associates | pg 8
8
Case study #2
Assessing Impact of Text Messages on
Drug Vendor Treatment for Diarrhea
Abt Associates | pg 9
Background Information
 Diarrhea Prevalence = 20% (2008 GDHS); diarrhea
deaths represent 9% of all child deaths
 WHO recommended treatment protocol zinc + ORS
not widely followed
 SHOPS Ghana program
– Increase product supply through pharmaceutical
partnerships
– Conduct mass media communications campaign
– Educate provider communities about protocols
Abt Associates | pg 10
Research to evaluate impact of text
message reinforcement
ALL LCS RECEIVE
MANDATORY ZINC/ORS
TRAINING
Control
TREAT
M
ENT
• CONTROL
(n=472)
Training only
• TREATMENT
(n=472)
Training + 3
texts/week for
8 weeks
Abt Associates | pg 11
Text message impact evaluation
 Methodology

Both control and treatment groups interviewed about knowledge
and practice: researchers blind to assignment arms

Mystery shopper visited each seeking treatment for baby’s diarrhea
 Results (preliminary, analysis is ongoing):

Training + texts result in statistically significant difference in
knowledge of zinc/ORS as appropriate treatment,

Training + texts did not show statistically significant difference
in sales of (non-recommended) antibiotics though the trend was in
the right direction
Abt Associates | pg 12
Implementation feedback: Messages
received as welcome and helpful
“The quizzes
cast my mind
back to the
seminar”
“Both tips &
quizzes were
very educative”
Universal support for Pharmacy Council to continue use of
reinforcing text education
Abt Associates | pg 13
Challenges: Unexpected problems
with correct formatting
 Failure to use key word SHOPS
 Chatty replies: “SHOPS that is
not the answer we learned”
 Literal replies: “Respond
SHOPS A, B, or C”
 Other reasons responses
not received
– Don’t know how to
open/send text
– Too busy
Responders & non-responders did
not vary in adherence to
recommended treatment
said they
–Majority
Phonenon-responders
problems
read the texts (including correct quiz
answers)
Abt Associates | pg 14
Lessons learnt
 RCT results:
– Correct knowledge is necessary condition for behavior change, but
not sufficient. Widely used “self-reports” from providers on their
practices may not be truthful.
 Text message implementation:
– Texts are a valuable way to stay in touch with large numbers of
trainees, reinforce treatment guidelines
– Interactive assessments may have low response rate due to
embarrassment about getting quiz wrong, need for practice
– Spacing text messages throughout the year likely to improve
results: difference in knowledge between intervention and control
groups decreased over time
Abt Associates | pg 15
Thank You!