[This is a review of some of the exciting mHealth research presented at the recently concluded  mHealth Summit, held in Washington DC  December 3-5, 2012. This abstract and others are candidates for the iMedicalApps-mHealth Summit Research Award]

By: Christine Lasway, iMedicalApps-mHealth Summit Award Finalist

Due to a significant health crisis and vast infrastructure issues, many developing countries have had to rely on members of communities to bring health care close to the people. These trusted members of the community, called Community Health Workers (CHW), are usually volunteers without formalized healthcare training.

They serve as the frontline public health workers who serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. In fact, community health workers are deemed vital to accelerate the achievement of the UN Millennium Development Goals by 2015.

Community health workers, however, face numerous challenges: inadequate refresher training, weak performance incentives, a lack of supportive supervision, and insufficient real-time access to patient data and reference information.

Could a new app empower CHWs to provide quality service provision? A joint partnership between FHI 360, Pathfinder, D-Tree International and the Tanzanian government has developed an open-source mobile phone-based family planning (e-FP) application with an algorithm to enable CHWs to effectively counsel, screen, provide and refer clients for FP, HIV/AIDS, and Sexually transmitted infections (STI) services. This e-FP application utilizes GPRS to allow for the collection and reporting of data that will help to monitor service provision. Furthermore, it also utilizes SMS to send automated reminders to both CHWs and supervisors on weekly and monthly reports on service provision. The e-FP has several technological advantages including skip patterns, auto-data capture, real-time access to data, real-time data access, and portability.

The e-FP algorithm is based on a combination of proven evidence-based tools including the Balanced Counseling Strategy Plus (BCS+), the Decision-Making Toolkit, the pregnancy checklist, and the provider screening checklist for oral contraceptives.  The BCS+ is a family planning counseling framework developed and refined over a number of years by the Population Council. It was originally developed for use in a clinical setting rather than by community health workers. The heart of the BCS is an 11-step algorithm which choreographs a specific dialogue between provider and client, and which is supported by two kinds of materials for each method: a Counseling Card and a Brochure.

The development of this application, therefore, builds on what has already been developed and will continually be tested and further refined. The Provider Screening Checklists help providers determine if a woman is medically eligible to initiate use of any of four popular contraceptive methods: combined oral contraceptives (COCs), injectables (DMPA and NET-EN), the copper intrauterine device (IUD), and implants. A fifth checklist helps to rule out pregnancy among non-menstruating women.

Finally, the Decision Making Toolkit includes a decision-making aid for clients, a job-aid and reference manual for providers, and a training resource. Its format allows easy interaction with clients – one page faces the client (with simple information on key issues for the client to consider) and a corresponding page faces the provider (with key points and detailed reference information). Health-care providers can use it step-by-step to help clients make informed choices that suit their needs.

The e-FP application is being evaluated to assess the acceptability and feasibility of the application to improve quality of counseling by CHWs. The research study is a randomized control design which will compare the quality of FP service provision, including screening and referrals, and efficiency of data reporting, to a paper-based tool. Six health facilities in the Dar es Salaam region of Tanzania will be randomized to use either the mobile phone-based application (intervention group) or paper-based tools (control group). The post-test only control group design includes structured surveys with clients, in-depth interviews with CHWs and their supervisors, data abstraction from client records, field reports, and cost-effectiveness analysis. Results are expected in mid-2013.

Christine Lasway, MPH is a Senior Technical Officer for Research Utilization unit of the Global Health, Population & Nutrition Group at FHI 360. Lasway has over 10 years of experience providing technical assistance and management support to international health projects, in particular focusing on family planning, Reproductive health and HIV/AIDS. For the past six years, Christine has predominantly worked on efforts to translate research evidence into policy and practice in the area of FP/RH at country level in Tanzania, Kenya, Uganda, Nigeria and South Africa, as well as at the global level.