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Scott C. Ratzan MD, MPA Journal of Health Communication: International Perspectives; Columbia University

Mailman School of Public Health; and Anheuser-Busch InBev

Elizabeth S. Higgs, MD, MIA, DTMH Division of Clinical Research, NIAID, NIH, USG DHHS

U.S. Government Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change

June 3-4, 2013

Chair: Scott Ratzan, Journal of Health Communication: International Perspectives; Columbia University, Mailman School of Public Health; AB InBev

Co-Chair: Elizabeth S. Higgs, Division of Clinical Research, NIAID, NIH, USG DHHS

Facilitator: Allison Goldberg, Columbia University

Coordinator: Wendy Meltzer, Journal of Health Communication: International Perspectives

Kristian Olson, Harvard Medical School

Raj Pannu, McCann Health*

John Parrish-Sprowl, Indiana University*

Ryan Phelps, USAID

Pamela Riley, Abt Associates*

Rajiv Rimal, George Washington University

Christine Saba, Columbia University

Carina Schmid, PCI Media Impact

Leslie Snyder, University of Connecticut

Sean Southey, PCI Media Impact

Charlotte Cole, Sesame Workshop*

Shannon Dorsey, University of Washington

Brianna Ferrigno, McCann Health

Dennis Israelski, InSTEDD

Ada Kwan, mHealth Alliance

Alain Labrique, Johns Hopkins University

Patricia Mechael, Columbia University

David Milestone, USAID

Anand Narasimhan, Simha Foundation

Rafael Obregon, UNICEF

* These individuals led the sub-teams to conduct the reviews of each category of evidence – mHealth, social-trans media, health literacy, and other health technology – on child survival in LMICs.

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Approach to focal question within STI

Findings from each of four subgroups(mHealth, Health Technologies, Health Literacy, Social Media and Transmedia)

Description of additional literature identifcation methods

Summary of findings

What are the effective and sustainable interventions that utilize communication-based science and technology innovatively, to promote and support behavior and social changes that are needed to accelerate reductions in under-five mortality, and optimize health and protective child development to age 5?

ERT 6 divided into four STI sub-

1. mHealth—defined as mobile technologies in health

2. Health Technologies—defined as diagnostic, therapeutic, and assistive medical devices seeking to prevent child mortality

3. Health Lteracy—the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions;

4. Trans and Social Media—defined as technology used to facilitate interactions and exchanges between individuals and virtual communities across different media forms and platforms in order to improve health.

Each sub-group identified literature in addition to the Evidence Summit literature review and Call for Evidence as described in their respective sections below.

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Summit Literature Identification (3 studies inclusion criteria)

Inclusion

-mobile phones as communications devices

-conducted in LMICs

-targeted health behaviors with child survival outcome data

-used a comparison group

ERT Members Add Studies (15 studies)

-7 systematic reviews were manually assessed to identify further studies meeting inclusion criteria

-Total of 15 studies that had outcome data and a comparison group.

Approach to evidence & context

-Analyzed for evidence

-Studies Rates for quality

-Programmatic and theoretical reports reviewed and included in the bibliography to provide context for the role of mobiles as a mediating factor in the development of population-level behavior change.

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Workflow Management Systems

Decisions Support Systems

On-Demand Training/Assessment

Real-time Data Access/PHR

Vital Statistics Reporting

Disease Surveillance

Point-of-care Diagnostics

Remote Monitoring

Remote Consultation

Logistics monitoring and tracking

Financing (Banking, Insurance)

Client reporting of quality/performance

Electric Medical Records

Enhanced Counseling

Appointment Scheduling

Client Education

On-demand Information/Helplines

mHealth Strategy

Improved Dem./Hlth. Data Appropriate Resource Alloc. Policy

Adjustments

Supply Chain Integrity Accuracy of Information

Continuity of Care Affordability of Care

Provider Competence, Accountability, Effectiveness

Client Knowledge and Self-Efficacy

Responsive Health System

Improved Efficiency/ Coverage

Improved Quality of Care

Improved Health Behaviors

Improved Population Health

Improved Health Outcomes

Intermediate Outcome Outcome/Impact

HEA

LT

H S

YST

EM

PR

OV

IDER

C

LIE

NT

Our focus on behavioral interventions (with outcome data) did not address the context within which families and providers make child health decisions based on service quality, access and use. Important factors that influence behavior include:

◦ Better equipped service delivery points

◦ Well-trained providers

◦ More timely, higher quality, lower cost data collection

◦ More efficient tracking of essential supplies

◦ Real-time data analysis for improved decision-making and resource allocation

mHealth applications which address these factors result in stronger health systems

◦ Increased trust in the system contributes to behavior change

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Intervention Impact Strength of Evidence

1. Provider messages to improve treatment adherence

Mixed: improved provider care (not viral load in maternal population)

Moderate with few studies

2. Clinic appointment reminders Improved clinic attendance Strong

3. Medication adherence support Mixed: one study did not detect impact, two detected impact on adherence, and one resulted in viral suppression

Strong

4. Message encouraging uptake of services

Mixed: impact in urban setting, not rural

Moderate with few studies

5. Messages targeting other maternal behaviors

Reduced anxiety in pregnancy, oral care for children

Weak

Intervention category Application to Health Areas Relevant to Child Survival

Application Strongest Promising Areas for

Extrapolating

Provider messages to improve health worker adherence to treatment guidelines

Malaria treatment including counseling on medication management

HIV/PTMTC (one study, showed no decrease in viral loads but increased provider satisfaction)

Reminder messages for clinic appointments

Clinic based services including antenatal care, outpatient

Time sensitive interventions including immunizations, IPTp

Medication adherence messages

HIV (messages on ART can reduce viral load, support PTMTC)

Repeat dose medications such as ARTs for malaria, zinc for diarrhea, Vitamin A

Messages encouraging uptake of services

Uptake HIV testing & counseling, skilled birth attendance

Antenatal care, immunizations, family planning

Messages targeting maternal behavior

Prenatal support, impact on attitudes and satisfaction but not outcomes

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Adherence-Service Uptake-Training

Provider training and support messages for: ◦ pregnancy

◦ neonatal care

◦ Nutrition

◦ Pneumonia

◦ diarrhea

Messages to mothers on home behaviors or service demand: ◦ family planning

◦ antenatal care

◦ breast-feeding pneumonia

◦ diarrhea management

◦ malaria

Many RCTs underway in MCH, but results not yet available ◦ mHealth is relatively new field, with rapidly changing

technology, and commercially driven applications

◦ Evidence on long-term impact will take time

Some qualitative literature exists suggesting benefits of mHealth ◦ CHWs reported increased community confidence when they

use phone tools

◦ More efficient case management

◦ Patients feeling cared for

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Objective: To analyze evidence-based approaches to design and implementation of diagnostic, therapeutic, and assistive medical devices that seek to prevent child mortality in LMICs.

Consulted electronic databases, online journals, and published literature from leading global health sources

41 articles reviewed, 12 selected

Grey literature such as WHO reports and guidelines were also consulted

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Global health technology market for new and existing technology products intended to address health demands in the developing world.

Approximately 1.5 million different medical devices, ranging from simple low-cost items such as thermometers to complex and expensive diagnostic equipment (WHO, 2010).

Three potential problem areas in the global health technology sector:

1. Demand-side

2. Supply-side

3. Government

These shortcomings increase the complexity of the global health market and the difficulty in grasping and engaging with its structure.

Opportunity exists for LMIC governments in the global health technology market –but how to support their interactions with this market?

Propose viewing national governments as consumers of global health technology products.

Nearly 40% of all medical equipment is out of service in resource poor settings (Malkin & Perry, 2011).

THE WHO Health System Conceptual Framework

Health Workforce

Service Delivery

Information

Medical Products & Technologies

Financing

Leadership/Governance

System Building Blocks

Improved Health

Responsiveness

Social and Financial Risk Protection

Improved Efficiency

Overall Goals/Outcomes

Access

Coverage

Quality

Safety

Sources: WHO Health System Strengthening Strategy 2007

The Six Building Blocks of a Health System: Aims and Desirable Attributes

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Malaria:

Insecticide-treated bed nets are a proven intervention that have scaled remarkably with an estimated 250,000 infant deaths prevented from malaria in sub-Saharan Africa between 2002 and 2008 (Howitt, 2012). Studies have shown that demand for bed nets are sensitive to price. In Kenya, demand for bed nets dropped to nearly zero at the subsidized price ( ~0.75 USD) (Cohen et al). When the experiment was replicated in different market towns, giving people time to go home and collect cash (and not have to buy the nets immediately) the demand went up significantly (Cohen & Dupas, 2007; Dupas, 2007).

Nutrition:

One case of a therapeutic nutrition intervention reported to result in behavior change beyond the technology itself was a color-gradated feeding bowl for caregivers. It was evaluated by PROCOSI in Latin America (Vivas de Alvarado, 2009). The evaluation however included only 82 mothers and no evidence of scale has been forthcoming.

Early Infant Diagnosis:

The Ethiopian Health and Nutrition Research Institute (EHNRI) implemented SMS-printers to decrease turnaround time of early infant diagnosis (EID) test results in 4 health facilities from one regional laboratory (RL). Preliminary findings indicate a two-week average reduction in turn around time, with the most dramatic reduction observed being 50 days. (Theiss-Nyland et al., 2011)

Water:

Oral rehydration solution (ORS) and Chlorine Dispenser System (CDS)

Proven interventions to improve child survival and decrease morbidity from diarrheal illness has stagnated since 1995 (Santhosham et al., 2010). An example of a promising technological advance that has combined novel packaging and distribution networks is the ColaLife project. ColaLife is utilizing innovative packaging to leverage private sector distribution of bottled products to facilitate large-scale distribution of ORS, zinc, and other life saving products (Colalife).

Chlorine dispensers, in combination with the paid promoters, in Kenya increased adoption of chlorinated water by 53%. Use of the chlorine dispensers was sustained for 30 months into the program, with continued use even after promoters were no longer paid. (Poverty Action Lab, n.d.)

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Design:

Three main causes for this technology failure: 1) Lack of training, 2) health technology management, and 3) infrastructure (Malkin & Perry, 2011). Recipients and donors need to actively manage the process through a proactive approach to identifying and filling needs (Howie, 2008).

Development:

Public-private partnerships for product development, or product development partnerships (PDPs), have increasingly become the drivers of R&D for addressing global burden of disease. Nearly 75% of all identified R&D projects in 2005 involved PDPs of both large and small private-sector partners (Moran, 2005).

For new products to impact the health status of target countries, their health systems need to adopt the products for use by intended populations. Advocacy, research, and technical assistance for adoption of innovative products by countries also needed.

Implementation, Scale, and Evaluation:

Approaches, processes, and pathways for adoption of innovative technologies at scale are weak and under resourced. At present, national governments are understandably cautious, in the absence of data on safety, effectiveness, and value for money, to adopt and integrate these newer products into their health systems. (WHO, 2011a; PATH, 2012). The WHO report Health Technology Assessment of Medical Devices (2011b) provides a systematic evaluation process for the properties, effects, and/or impacts of health technologies.

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United Nations Ministerial Declaration: “We stress that health literacy is an important factor in ensuring significant health outcomes and in this regard call for the development of appropriate action plans to promote health literacy.” (July 9, 2009)

World Health Organization Preamble to the Constitution: “Informed opinion and active cooperation on the part of the public are of the utmost importance in the improvement of health of the people.”

Of the 61 studies included in the original literature search, 0 were relevant.

Key search terms (health literacy, ehealth, mHealth, literacy, LMICs, child health, maternal) were used to conduct an additional search for relevant literature in the following databases: ◦ PubMed

◦ ProQuest Public Health

◦ CIOS

◦ Google Scholarly Articles

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Checklists and scorecards can have major global impacts for patients and consumers – including reduction of:

◦ Chronic, non-communicable diseases (NCDs)

◦ Maternal and child mortality

◦ Infectious diseases

Better access/use of information through new technologies:

◦ Contributes to expanded health literacy globally

◦ Helps relieve burden on strained health systems/workforces

New Promise: Use of mobile health communication (m-health)

Sources: United Nations Economic and Social Council (ECOSOC) 2010 ‘Healthy Literacy and the Millennium Development Goals: United Nations Economic and Social Council (ECOSOC) Regional Meeting Background Paper (Abstracted)’, Journal of Health Communication, 15: 1, 211-223

Again, no studies that cross-cut the terms maternal or child health, health literacy, technology , behavior change , and LMICs was generated from this search.

Four studies were close (below), but did meet all of the search criteria (e.g. conducted in a high-income country; not directly related to child survival behavior changes)

◦ Donelle, L. and Hoffman-Goetz, L. (2008). An Exploratory Study of Canadian Aboriginal Online Health Care Forums. Health Communication 23 270-281.

◦ Endres, L., Sharp, L., Haney, K., E., Dooley, S. L (2004). Health Literacy and Pregnancy Preparedness in Pregestational Diabetes. Diabetes Care; Feb 2004; 27, 2; 331-334.

◦ Ginossar, T.and Nelson, S. (2010). La Comunidad Habla: Using Internet Community-Based Information Interventions to Increase Empowerment and Access to Health Care of Low Income Latino/a Immigrants, Communication Education, 59:3, 328-343.

◦ Kirigia, J.M., Seddoh, A., Gatwiri, D., Muthuri, L. HK, Seddoh, J. (2005). E-health: Determinants, opportunities, challenges and the way forward for countries in the WHO African Region. BMC Public Health, 5, 137-149.

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Objective: Examine the effectiveness of the emerging use of social media and transmedia to foster population-level behavior change in the area of child health.

For the purpose of the review we employed the following operational conceptions:

◦ Transmedia:

A related group of media content with linkages across media forms and platforms which may or may not have a narrative component, including transitional and new media technologies.

◦ Social Media:

The interactions and exchanges among and between individuals and virtual communities through a variety of different platforms, including blogs, wikis, podcasts, forums, message boards, review and opinion sites, and social networking.

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0 Relevant

Initial

Search:

61 Docs

•17 Published

Experiments

•11 Published

Reports

•6 Unpublished

Experiments

•5 Unpublished

Reports

Broader

Search*:

39 Docs

*Conducted by NIH Library

0

1

2

3

4

5

6

7

8

9

10

Nu

mber

of

Rep

ort

s

Health Domain

gray: other

gray: experimental

pub: other

pub: experimental

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Currently available for trans & social media interventions demonstrating causal improved impact on child survival or child health outcomes. ◦ A number of interventions incorporated the use of media

platforms to change health behaviors.

◦ However, this review shows a paucity of evidence that supports the impact of media on child health outcomes specifically.

◦ Either too few of the studies assessed the independent effect of media platforms on child health, or failed to isolate how, or what type, of media actually influenced the outcomes under investigation.