Tag Archives: eHealth

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Using mobile technology to support vital registration and verbal autopsy in the community: Bonsaaso Millennium Villages Project, Ghana

Prior to the inception of the Ghana Bonsaaso Millennium Villages Project in 2006,  maternal mortality was as high as 345 deaths per 100,000 live births, child mortality was 110 deaths per 1000 live births, and the institutional delivery rate was as low as 32%. The challenge of accessing healthcare was identified as the main cause of poor health indicators in the area at that time.

The Millennium Villages Project (MVP) in Ghana initiated vital registration and verbal autopsy (VRVA) in 2008 to support the improvement of maternal and child health services, and, in turn, to reduce infant, child and maternal deaths. Vital registration ensured that all community members were properly identified and included in the denominator of measures being tracked by MVP. In 2011, verbal autopsy was strengthened to ensure that any death in the village was recorded and analysed for medical and social causes so that future deaths could be prevented.

The vital registration and verbal autopsy system

At the community level, community health workers (CHWs) registered household members within their community, making sure to include pregnant women and children under five. They also collected data on the following vital statistics: birth registration (indicating date and place of birth), pregnancy outcomes, and all deaths.

Prior to 2008, a paper-based system was used to collect this data. Multiple challenges were experienced from the paper-based system, including a large volume of information being gathered making it difficult to manage and data analysis very time-consuming.

In late 2009, mobile communications were established throughout the area and, in 2010, the mobile-phone based system called ChildCount+ (CC+) was introduced by the project to address the problems of the paper-based system. The open-source system, CC+, enabled CHWs to send data via SMS text messages to a central server, collecting data in real-time. This system was later migrated to a smartphone-based system called CommCare for general home visits.

A verbal autopsy specialist assists CHWs in conducting in-depth verbal investigations into the causes of each death in the community.  This investigation gathers information from the household and the health facilities of the catchment area where the death occurred to understand the circumstances behind the death.

This more extensive data collection by the verbal autopsy specialists required the use of a complementary electronic system known as Open Data Kit (ODK), where verbal autopsy data is inputted into smartphones using mobile forms.  Specialists visit homes, record the data on the phones and later return to an area with good coverage to send data to a central electronic medical record system – OpenMRS. The OpenMRS system then automatically uses this verbal autopsy data to generate reports on the social and medical causes of each death, which were reported back to local and remote teams. The mobile phone-based system integrated with Open MRS was also eventually migrated to run on the CommCare system in 2014.

How the data is used

The data is discussed during weekly MVP health team meetings comprising selected senior doctors, nurses and heads of public health programmes in the district. During these weekly meetings, vital statistics and verbal autopsy data is reviewed and analysed in order to identify solutions to the circumstances that led to the death and/or morbidity, and to prevent future occurrences.

On a monthly basis, a meeting with a larger stakeholder group takes place where issues on all deaths and morbidity trends are discussed. During these larger stakeholder meetings the verbal autopsy specialist presents on all cases of deaths that have been investigated. Participants of this monthly meeting comprise the MVP health team and multiple representatives from where the death occurred, including from the district referral hospital, from local facilities, from communities, and CHWs.  The meeting discusses the issues presented, finds solutions, and sets timelines for their implementation.

Examples of solutions implemented as a result of the verbal autopsy data include community health information sharing sessions and staff in-service training. These would be based on recommendations from the larger, monthly stakeholder meeting.

Achievements

The transition towards using these electronic data collection systems saw a greater volume of data reporting (see tables 1 and 2), which was in real-time and more accurate. This data collection has become an important monitoring and managerial tool, providing vital information in real-time, so that resources and staff performance gaps can be quickly identified and action taken immediately.  The programme has seen improvements in health staff performance, logistics provision and management. This implies that an effective data collection system provides the edge to improve performance for better results.

Table 1 and table 2Challenges and lessons learned

MVP has been successful in using effective data systems to improve performance and health outcomes. However, this was not achieved without challenges. Key challenges and lessons learned include:

  • Although the paper-based system cost less compared to the CommCare system, it was not cost-effective due to the limitations faced in using it:  time consuming to collect, numerous errors, risk of data loss, large costs for data entry, and lack of real-time data collection limiting rapid decision-making. Key costs to consider for the CommCare system include the smartphone and data bundle.
  • While the CC+ mobile phone-based system introduced in 2010 reduced data bulkiness, there were a number of challenges in using it, including CHWs having to type a lot of information into basic-feature phones, which led to significant errors, and CC+ requiring mobile service at the point of sending SMS text messages. Transferring to the CommCare system using smart phones in 2012 helped to address these problems. CommCare enabled CHWs to enter data on the smart phone anytime, anywhere with or without a mobile network service since data can be synchronized as soon as the CHW enters a network zone.  Also, CommCare can be designed to limit the amount of typing, and therefore reducing errors, by using drop down selection boxes and multiple choice selection options.
  • Training on using the technology takes time. It takes about three days to train someone in the technology and one to two months to become skilful in using it. Allocating time for this is important.
  • There will always be the challenge of the equipment, namely the phones getting lost, broken, or faulty. To address this challenge, the programme provides supervisors with back-up phones ready to be used until a permanent replacement is found.
  • We have not experienced families being concerned about using the mobile phones to collect the verbal autopsy data. Nevertheless, it is important to be culturally sensitive on when you conduct the interview (e.g. in our case, conduct the interview one week after the death) and explain to the family how the data is to be collected before the interview and that it will not be used for any wrong motive.

Future plans and the way forward

The success of the system has meant that the Ministry of Health and the Ghana Health Service have expressed interest in scaling up. MVP is currently working with the Ghana Government to look for both domestic and foreign support to scale-up the interventions.

Acknowledgments

This case study was written by Eric Akosah and Seth Ohemeng Dapaah from Millennium Villages Project, Bonsaaso-Ghana and reviewed by Dr Andrew S. Kanter, Columbia University.

Further information

Read more about this mHealth solution in the article ‘Combining vital events registration, verbal autopsy and electronic medical records in rural Ghana for improved health services delivery’ published by Studies in health technology and informatics and written by contributors to this case study and their colleagues – S., Ohemeng-Dapaah,  P., Pronyk, Akosa, E., Nemser, B., & Kanter, A.

Photo Credit: Danielle Goldman

How information and communication technologies can improve the quality of maternal and newborn care in low and middle income countries: a structured literature review

The Evidence for Action programme has developed a structured literature review of how information communication technology (ICT)/mobile technology have been used in low and middle income countries for monitoring and improving the quality of maternal and newborn healthcare in general, as well as in the context of vital event registration and/or maternal death reviews.

The review identified a total of 24 projects covering four thematic areas:

  • data management including collection, transmission, and analysis of information
  • point of care support by assisting decision-making and diagnosis
  • training and disseminating knowledge to healthcare workers (e.g. latest research and guidelines)
  • improving communication and networking between healthcare workers and health facilities, patients or other healthcare workers

The review found that these technologies could have greater potential in improving and monitoring quality of maternal and newborn care if the following factors are considered:

  • ensuring the deployment of technology that can be installed and maintained locally
  • deploying devices and infrastructure that is low cost and can be integrated within the health system
  • ensure the buy-in and commitment of key stakeholders

The paper concludes that the future of ICT to contributing to quality of care improvements is promising; however it must be complemented by other inputs such as adequate infrastructure and human resources to maximize its potential.

Early detection of maternal death in Senegal through household-based death notification integrating verbal and social autopsy: a community-level case study

The article by Mosa Moshabela and colleagues in the BMC Health Services Research presents a case study of community-level surveillance in Senegal as part of the Millennium Villages Project (MVP). The mobile technology based (mHealth) platform Childcare+ was used to identify pregnancies, births and deaths. Once this information is entered into the surveillance system, this then prompts a verbal and social autopsy to be conducted. Verbal Autopsy and Social Autopsy (VASA) data was collected using a standardised tool based on the WHO’s Verbal Autopsy questionnaire but with some modifications on questions related to social contributors to mortality (e.g. accessing transport). The VASA data was collected either by hand or using a mobile device and then uploaded to a central database where a pre-set algorithm was used to calculate the likely cause of death and any contributory social factors.

The case study highlights how the routine community-based surveillance system identified inefficiencies at a tertiary level of care as the main contributor to the five maternal deaths in the area. The study concludes that mHealth data collection tools are able to detect small changes in community-level mortality in real-time, can help facilitate rapid-cycle quality improvement interventions when linked with accountability structures such as mortality reviews.

Every Death Counts: Electronic Tracking Systems for Maternal Death Review in India

This article by Chittaranjan Purandare and colleagues in the International Journal of Gynecology and Obstetrics describes the process that led to the development of an electronic Maternal Death Review (MDR) system in India. Users were positive about the software, finding it simple to use, secure, and useful to generate reports for planning.  Key lessons learned include:

  • Ensure alignment of the country’s objectives and strategies into software development plans
  • Have a clear implementation road map and project management system to ensure that timelines are followed
  • Have an action plan for both intended and unintended problems that arise
  • Involve programme “champions” who will see implementation to its end
  • Establish public-private partnerships for guidance and support from key stakeholders
  • Share regular updates on progress to ensure help is provided when needed and that team-members are motivated to provide high-quality work