The potential use of digital health technologies in the African context: a systematic review of evidence from Ethiopia

The World Health Organization (WHO) recently put forth a Global Strategy on Digital Health 2020–2025 with several countries having already achieved key milestones. We aimed to understand whether and how digital health technologies (DHTs) are absorbed in Africa, tracking Ethiopia as a key node. We conducted a systematic review, searching PubMed-MEDLINE, Embase, ScienceDirect, African Journals Online, Cochrane Central Registry of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform databases from inception to 02 February 2021 for studies of any design that investigated the potential of DHTs in clinical or public health practices in Ethiopia. This review was registered with PROSPERO (CRD42021240645) and it was designed to inform our ongoing DHT-enabled randomized controlled trial (RCT) (ClinicalTrials.gov ID: NCT04216420). We found 27,493 potentially relevant citations, among which 52 studies met the inclusion criteria, comprising a total of 596,128 patients, healthy individuals, and healthcare professionals. The studies involved six DHTs: mHealth (29 studies, 574,649 participants); electronic health records (13 studies, 4534 participants); telemedicine (4 studies, 465 participants); cloud-based application (2 studies, 2382 participants); information communication technology (3 studies, 681 participants), and artificial intelligence (1 study, 13,417 participants). The studies targeted six health conditions: maternal and child health (15), infectious diseases (14), non-communicable diseases (3), dermatitis (1), surgery (4), and general health conditions (15). The outcomes of interest were feasibility, usability, willingness or readiness, effectiveness, quality improvement, and knowledge or attitude toward DHTs. Five studies involved RCTs. The analysis showed that although DHTs are a relatively recent phenomenon in Ethiopia, their potential harnessing clinical and public health practices are highly visible. Their adoption and implementation in full capacity require more training, access to better devices such as smartphones, and infrastructure. DHTs hold much promise tackling major clinical and public health backlogs and strengthening the healthcare ecosystem in Ethiopia. More RCTs are needed on emerging DHTs including artificial intelligence, big data, cloud, cybersecurity, telemedicine, and wearable devices to provide robust evidence of their potential use in such settings and to materialize the WHO’s Global Strategy on Digital Health.

Mobile Ecological Momentary Assessment and Intervention and Health Behavior Change Among Adults in Rakai, Uganda: Pilot Randomized Controlled Trial

Background:
An extraordinary increase in mobile phone ownership has revolutionized the opportunities to use mobile health approaches in lower- and middle-income countries (LMICs). Ecological momentary assessment and intervention (EMAI) uses mobile technology to gather data and deliver timely, personalized behavior change interventions in an individual’s natural setting. To our knowledge, there have been no previous trials of EMAI in sub-Saharan Africa.

Objective:
To advance the evidence base for mobile health (mHealth) interventions in LMICs, we conduct a pilot randomized trial to assess the feasibility of EMAI and establish estimates of the potential effect of EMAI on a range of health-related behaviors in Rakai, Uganda.

Methods:
This prospective, parallel-group, randomized pilot trial compared health behaviors between adult participants submitting ecological momentary assessment (EMA) data and receiving behaviorally responsive interventional health messaging (EMAI) with those submitting EMA data alone. Using a fully automated mobile phone app, participants submitted daily reports on 5 different health behaviors (fruit consumption, vegetable consumption, alcohol intake, cigarette smoking, and condomless sex with a non–long-term partner) during a 30-day period before randomization (P1). Participants were then block randomized to the control arm, continuing EMA reporting through exit, or the intervention arm, EMA reporting and behavioral health messaging receipt. Participants exited after 90 days of follow-up, divided into study periods 2 (P2: randomization + 29 days) and 3 (P3: 30 days postrandomization to exit). We used descriptive statistics to assess the feasibility of EMAI through the completeness of data and differences in reported behaviors between periods and study arms.

Results:
The study included 48 participants (24 per arm; 23/48, 48% women; median age 31 years). EMA data collection was feasible, with 85.5% (3777/4418) of the combined days reporting behavioral data. There was a decrease in the mean proportion of days when alcohol was consumed in both arms over time (control: P1, 9.6% of days to P2, 4.3% of days; intervention: P1, 7.2% of days to P3, 2.4% of days). Decreases in sex with a non–long-term partner without a condom were also reported in both arms (P1 to P3 control: 1.9% of days to 1% of days; intervention: 6.6% of days to 1.3% of days). An increase in vegetable consumption was found in the intervention (vegetable: 65.6% of days to 76.6% of days) but not in the control arm. Between arms, there was a significant difference in the change in reported vegetable consumption between P1 and P3 (control: 8% decrease in the mean proportion of days vegetables consumed; intervention: 11.1% increase; P=.01).

Conclusions:
Preliminary estimates suggest that EMAI may be a promising strategy for promoting behavior change across a range of behaviors. Larger trials examining the effectiveness of EMAI in LMICs are warranted.

Trial Registration:
ClinicalTrials.gov NCT04375423; https://www.clinicaltrials.gov/ct2/show/NCT04375423

Public Awareness Knowledge of Availability And Willingness to Use Neurosurgical Care Services in Africa: A CrossSectional ESurvey Protocol

Background: Barriers to care cause delays in seeking, reaching, and getting care. These delays affect low-and middle-income countries (LMICs), where 9 out of 10 LMIC inhabitants have no access to basic surgical care. Knowledge of healthcare utilization behavior within underserved communities is useful when developing and implementing health policies. Little is known about the neurosurgical health-seeking behavior of African adults. This study evaluates public awareness, knowledge of availability, and readiness for neurosurgical care services amongst African adults.

Methodology: The cross-sectional study will be run using a self-administered e-survey hosted on Google Forms (Google, CA, USA) disseminated from 10th May 2021 to 10th June 2021. The Questionnaire would be in two languages, English and French. The survey will contain closed-ended, open-ended, and Likert Scale questions. The structured questionnaire will have four sections with 42 questions; Sociodemographic characteristics, Definition of neurosurgery care, Knowledge of neurosurgical diseases, practice and availability, and Common beliefs about neurosurgical care. All consenting adult Africans will be eligible. A minimum sample size of 424 will be used. Data will be analyzed using SPSS version 26 (IBM, WA, USA). Odds ratios and their 95% confidence intervals, Chi-Square test, and ANOVA will be used to test for associations between independent and dependent variables. A P-value <0.05 will be considered statistically significant. Also, a multinomial regression model will be used.

Dissemination: The study findings will be published in an academic peer-reviewed journal, and the abstract will be presented at an international conference.

Highlights

The burden of neurosurgical diseases is enormous in low- and middle-income countries, especially in Africa.
Unfortunately, most neurosurgical needs in Africa are unmet because of delays in seeking, reaching, and getting care.
Most efforts aimed at reducing barriers to care have focused on improving the neurosurgical workforce density and infrastructure. Little or no efforts have been directed towards understanding or reducing the barriers to seeking care.
We aimed to understand public awareness, willingness to use, and knowledge of the availability of neurosurgical care in Africa.
The study findings can inform effective strategies that promote the utilization of neurosurgical services and patient education in Africa.

Synthesizing postpartum care pathways, facilitators, and barriers for women after cesarean section: a qualitative analysis from rural Rwanda

Background
In low- and middle-income countries (LMICs), c-section is the most commonly performed operation, and surgical site infection (SSI) is the most common post-operative complication following all surgical procedures performed. Whilst multiple interventions have been rolled out to address high SSI rates, strategies for optimal care of patients at risk of developing SSIs need to include an understanding of the general care seeking behaviors, facilitators, and barriers among high-risk groups, including mothers delivering via c-section. This study explores the healthcare experiences of women who delivered by c-section section, from giving birth through recovery, and their associated decision-making, perceptions of care, and social and financial supports.

Methods
We conducted protocol-guided interviews in rural Kirehe District, Rwanda with twenty-five mothers who delivered by c-section at Kirehe District Hospital between February-April 2018, exploring their experience with delivery, hospitalization, recovery, and complications. Coded interviews were analyzed using the Grounded Theory approach to identify emergent themes. Thematic saturation was achieved.

Results
Overall, women largely followed the tiered referral system, as it was designed. A majority faced financial barriers to returning to care, and a majority were not able to describe the reason for their c-section, the complications experienced, or the treatment prescribed. We constructed a process map to summarize key steps where interventions should be designed to promote facilitators, to reduce barriers, and to identify and target the women being diverted from this designated path.

Conclusions
Understanding the existing healthcare pathway and the associated facilitators and barriers among postpartum women is critical to designing appropriate interventions that properly serve their needs. Our findings strongly suggest that moving or complimenting post-operative wound assessments from the health center into home-based care, and ensuring unified messaging around c-section indications, care, and complications at the community-level are two of the areas that may improve utilization of existing healthcare infrastructure for women who deliver by c-section in rural districts in Rwanda.

Cerebral aneurysms in Africa: A scoping review

Introduction
The epidemiology, management, and prognosis of cerebral aneurysms in Africa remain poorly understood. Most data to date has been from modeling studies. The authors aimed to describe the landscape of cerebral aneurysms in Africa based on published literature.

Methods
Articles on cerebral aneurysms in Africa from inception to June 9, 2020, were pulled from multiple databases (Medline, World Health Organization (WHO) Global Health Library/Global Index Medicus African Journals Online, and Google Scholar). The search results were merged, uploaded into Rayyan. After deduplication, titles and abstracts were screened independently by four reviewers (FDT, USK, IN, NDAB) based on the pre-defined inclusion and exclusion criteria. A full-text review was conducted, followed by data extraction of study, patient, neuroimaging, therapeutic, and prognostic characteristics.

Results
Thirty-three articles were included in the full-text retrieval. These studies were published across 13 (24.0%) countries, notably in Morocco (30.3%, n = 10) and South Africa (15.2%, n = 5), and 14 (42.4%) of them were published on or after 2015. Together, the studies totaled 2289 patients; there was a female predominance in 18 (54.5%) study cohorts, and the most frequently cited aneurysms were located in the internal carotid (12.1%, n = 352) and anterior cerebral arteries (9.5%, n = 275). Open surgery (27.3%, n = 792) was the most widely used option in these studies ahead of coiling (3.2%, n = 94). The reported mortality rate following surgical intervention was 7.9%.

Conclusion
There are few peer-reviewed reports of aneurysm practice and variability in access to cerebral aneurysm care in Africa.

Access to care solutions in healthcare for obstetric care in Africa: A systematic review

Background
Emergency Medical Services (EMS) systems exist to reduce death and disability from life-threatening medical emergencies. Less than 9% of the African population is serviced by an emergency medical services transportation system, and nearly two-thirds of African countries do not have any known EMS system in place. One of the leading reasons for EMS utilization in Africa is for obstetric emergencies. The purpose of this systematic review is to provide a qualitative description and summation of previously described interventions to improve access to care for patients with maternal obstetric emergencies in Africa with the intent of identifying interventions that can innovatively be translated to a broader emergency context.

Methods
The protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371. We searched the following electronic databases for all abstracts up to 10/19/2020 in accordance to PRISMA guidelines: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. Articles were included if they were focused on a specific mode of transportation or an access-to-care solution for hospital or outpatient clinic care in Africa for maternal or traumatic emergency conditions. Exclusion criteria included in-hospital solutions intended to address a lack of access. Reference and citation analyses were performed, and a data quality assessment was conducted. Data analysis was performed using a qualitative metasynthesis approach.

Findings
A total of 6,457 references were imported for screening and 1,757 duplicates were removed. Of the 4,700 studies that were screened against title and abstract, 4,485 studies were excluded. Finally, 215 studies were assessed for full-text eligibility and 152 studies were excluded. A final count of 63 studies were included in the systematic review. In the 63 studies that were included, there was representation from 20 countries in Africa. The three most common interventions included specific transportation solutions (n = 39), community engagement (n = 28) and education or training initiatives (n = 27). Over half of the studies included more than one category of intervention.

Interpretation
Emergency care systems across Africa are understudied and interventions to improve access to care for obstetric emergencies provides important insight into existing solutions for other types of emergency conditions. Physical access to means of transportation, efforts to increase layperson knowledge and recognition of emergent conditions, and community engagement hold the most promise for future efforts at improving emergency access to care.

Views from Multidisciplinary Oncology Clinicians on Strengthening Cancer Care Delivery Systems in Tanzania

Background
In response to the increasing burden of cancer in Tanzania, the Ministry of Health Community Development, Gender, Elderly and Children launched National Cancer Treatment Guidelines (TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care in the country. At Ocean Road Cancer Institute (ORCI), we developed a theory-informed implementation strategy to promote guideline-concordant care. As part of the situation analysis for implementation strategy development, we conducted focus group discussions to evaluate clinical systems and contextual factors that influence guideline-based practice prior to launching of TNCTG.

Methods
In June 2019, three focus group discussions were conducted with a total of 21 oncology clinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogue about facilitators and barriers to delivery of guideline concordant care. Discussions were audio recorded, transcribed, translated, and analyzed using thematic framework analysis.

Results
Participants identified factors both within the inner context of ORCI clinical systems and outside of ORCI. Themes within the clinical systems included: capacity and infrastructure, information technology, communication, efficiency and quality of services provided. Contextual factors external to ORCI included: inter-institutional coordination, oncology capacity in peripheral hospitals, public awareness and beliefs, and financial barriers. Participants provided pragmatic suggestions for strengthening cancer care delivery in Tanzania.

Conclusion
Our results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broader guideline implementation strategy, in effort to improve uptake of the TNCTGs at ORCI.

Starting and Operating a Public Cardiac Catheterization Laboratory in a Low Resource Setting: The Eight-Year Story of the Uganda Heart Institute Catheter Laboratory

Abstract
Background: Low- and-middle-income-countries (LMICs) currently bear 80% of the world’s cardiovascular disease (CVD) mortality burden. The same countries are underequipped to handle the disease burden due to critical shortage of resources. Functional cardiac catheterization laboratories (cath labs) are central in the diagnosis and management of CVDs. Yet, most LMICs, including Uganda, fall remarkably below the minimum recommended standards of cath lab:population ratio due to a host of factors including the start-up and recurring costs.

Objectives: To review the performance, challenges and solutions employed, lessons learned, and projections for the future for a single cath lab that has been serving the Ugandan population of 40 million people in the past eight years.

Methods: A retrospective review of the Uganda Heart Institute cath lab clinical database from 15 February 2012 to 31 December 2019 was performed.

Results: In the initial two years, this cath lab was dependent on skills transfer camps by visiting expert teams, but currently, Ugandan resident specialists independently operate this lab. 3,542 adult and pediatric procedures were conducted in 8 years, including coronary angiograms and percutaneous coronary interventions, device implantations, valvuloplasties, and cardiac defect closures, among others. There was a consistent expansion of the spectrum of procedures conducted in this cath lab each year. The initial lack of technical expertise and sourcing for equipment, as well as the continual need for sundries present(ed) major roadblocks. Government support and leveraging existing multi-level collaborations has provided a platform for several solutions. Sustainability of cath lab services remains a significant challenge especially in relation to the high cost of sundries and other consumables amidst a limited budget.

Conclusion: A practical example of how centers in LMIC can set up and sustain a public cardiac catheterization laboratory is presented. Government support, research, and training collaborations, if present, become invaluable leverage opportunities.

Mortality during and following hospital admission among school-aged children: a cohort study

Background: Far less is known about the reasons for hospitalization or mortality during and after hospitalization among school-aged children than among under-fives in low- and middle-income countries. This study aimed to describe common types of illness causing hospitalisation; inpatient mortality and post-discharge mortality among school-age children at Kilifi County Hospital (KCH), Kenya.
Methods: A retrospective cohort study of children 5−12 years old admitted at KCH, 2007 to 2016, and resident within the Kilifi Health Demographic Surveillance System (KHDSS). Children discharged alive were followed up for one year by quarterly census. Outcomes were inpatient and one-year post-discharge mortality.
Results: We included 3,907 admissions among 3,196 children with a median age of 7 years 8 months (IQR 74−116 months). Severe anaemia (792, 20%), malaria (749, 19%), sickle cell disease (408, 10%), trauma (408, 10%), and severe pneumonia (340, 8.7%) were the commonest reasons for admission. Comorbidities included 623 (16%) with severe wasting, 386 (10%) with severe stunting, 90 (2.3%) with oedematous malnutrition and 194 (5.0%) with HIV infection. 132 (3.4%) children died during hospitalisation. Inpatient death was associated with signs of disease severity, age, bacteraemia, HIV infection and severe stunting. After discharge, 89/2,997 (3.0%) children died within one year during 2,853 child-years observed (31.2 deaths [95%CI, 25.3−38.4] per 1,000 child-years). 63/89 (71%) of post-discharge deaths occurred within three months and 45% of deaths occurred outside hospital. Post-discharge mortality was positively associated with weak pulse, tachypnoea, severe anaemia, HIV infection and severe wasting and negatively associated with malaria.
Conclusions: Reasons for admissions are markedly different from those reported in under-fives. There was significant post-discharge mortality, suggesting hospitalisation is a marker of risk in this population. Our findings inform guideline development to include risk stratification, targeted post-discharge care and facilitate access to healthcare to improve survival in the early months post-discharge in school-aged children.

Neglected tropical diseases activities in Africa in the COVID-19 era: the need for a “hybrid” approach in COVID-endemic times

With the coronavirus disease 2019 (COVID-19) pandemic showing no signs of abating, resuming neglected tropical disease (NTD) activities, particularly mass drug administration (MDA), is vital. Failure to resume activities will not only enhance the risk of NTD transmission, but will fail to leverage behaviour change messaging on the importance of hand and face washing and improved sanitation—a common strategy for several NTDs that also reduces the risk of COVID-19 spread. This so-called “hybrid approach” will demonstrate best practices for mitigating the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by incorporating physical distancing, use of masks, and frequent hand-washing in the delivery of medicines to endemic communities and support action against the transmission of the virus through water, sanitation and hygiene interventions promoted by NTD programmes. Unless MDA and morbidity management activities resume, achievement of NTD targets as projected in the WHO/NTD Roadmap (2021–2030) will be deferred, the aspirational goal of NTD programmes to enhance universal health coverage jeopardised and the call to ‘leave no one behind’ a hollow one. We outline what implementing this hybrid approach, which aims to strengthen health systems, and facilitate integration and cross-sector collaboration, can achieve based on work undertaken in several African countries.