IMPLEMENTATION OF HEALTH-RELATED SMARTPHONE APPLICATIONS IN LOW- AND MIDDLE- INCOME COUNTRIES: SCOPING REVIEW AND LEARNINGS FROM THE CHILDSAFE APPLICATION IN MALAYSIA

While digital technologies such as smartphone apps have become an increasingly popular way to deliver health interventions, implementation and scale up remains a recognized challenge. Recently, the Johns Hopkins International Injury Research Unit and the Institute for Public Health in Malaysia collaborated in the development of a smartphone app for child injury prevention called ChildSafe that was piloted in Malaysia. The aim of this dissertation was to better understand the implementation of health apps in low- and middle-income countries to identify opportunities and gaps for future research, as well as to strengthen the design, implementation, and dissemination of the ChildSafe app. We had three objectives: 1) to better understand the current state of the peer-reviewed literature on the use and implementation of health apps in low- and middle-income countries; 2) to assess the adoption, fidelity, acceptability, and process of user engagement through the ChildSafe app; and 3) to examine the facilitators and barriers to implementation of the ChildSafe app from the perspective of caregivers of children under five. This dissertation comprises of three manuscript-oriented chapters, each presenting the results from one of these objectives. The first manuscript, “Use and Implementation of Health-Related Smartphone Apps in Low- and Middle-Income Countries” presents the results of a scoping review that identified gaps in the literature on the implementation of health apps in low- and middle-income countries. Building on these learnings, the second manuscript, “Adoption, Fidelity, and Acceptability of a Smartphone App for Child Injury Prevention” assessed the implementation of the ChildSafe app from multiple dimensions to generate insight to strengthen its design, implementation, and dissemination that may be relevant to other similar health apps. Finally, the third manuscript, “Facilitators and Barriers to Use and Implementation of a Smartphone App for Child Injury Prevention in Malaysia” applied an established implementation framework to identify facilitators and barriers to use and implementation of the ChildSafe app to contribute to a broader conceptual understanding of the implementation of health apps. Together, these manuscripts make the case for and demonstrate the value of considering implementation from the early stages of digital development through implementation and scale up

Hubris, humility and humanity: expanding evidence approaches for improving and sustaining community health programmes

Community-based approaches are a critical foundation for many health outcomes, including reproductive, maternal, newborn and child health (RMNCH). Evidence is a vital part of strengthening that foundation, but largely focuses on the technical content of what must be done, rather than on how disparate community actors continuously interpret, implement and adapt interventions in dynamic and varied community health systems. We argue that efforts to strengthen evidence for community programmes must guard against the hubris of relying on a single approach or hierarchy of evidence for the range of research questions that arise when sustaining community programmes at scale. Moving forward we need a broader evidence agenda that better addresses the implementation realities influencing the scale and sustainability of community programmes and the partnerships underpinning them if future gains in community RMNCH are to be realised. This will require humility in understanding communities as social systems, the complexity of the interventions they engage with and the heterogeneity of evidence needs that address the implementation challenges faced. It also entails building common ground across epistemological word views to strengthen the robustness of implementation research by improving the use of conceptual frameworks, addressing uncertainty and fostering collaboration. Given the complexity of scaling up and sustaining community RMNCH, ensuring that evidence translates into action will require the ongoing brokering of relationships to support the human creativity, scepticism and scaffolding that together build layers of evidence, critical thinking and collaborative learning to effect change

Assessing the effectiveness of intervention strategies to address home injuries among children in Malaysia: a cluster randomized trial evaluation of evidence

Background Malaysia is facing an increasing burden of childhood injuries, not unlike many other low- and middle-income countries (LMICs). Across the globe, more than 95 percent of total child injury mortality occurs in LMICs. A considerable proportion of these injuries occur in and around the home. Effective approaches to prevention include home safety education, parenting education and home modification. Through this study, we aim to evaluate the effectiveness of two intervention strategies in reducing in-home hazards for unintentional injuries among children. Methods We conducted a prospective cluster randomized controlled trial (cRCT) to compare the effectiveness of an in-home safety tutorial program and an educational pamphlet intervention in reducing safety hazards to child injuries. The study randomized 39 clusters to two study arms (home safety tutorial vs educational pamphlet), with around 30 households per cluster. Our exposure and outcome were assessed using a household survey instrument with self-reported and observer-reported components. Results Our initial analysis is a comparison of overall safety scores across the baseline arm that found a mean safety score of 30 of a maximum possible 45 (translating to a mean percentage of 66.7%), with improvement on average in both intervention arms. The overall safety score mean for educational pamphlets was 32.3 with a mean percentage of 71.7%, and the corresponding numbers for the in-home tutorial were 31.8 and 71%. Discussion This study compares a labor-intensive and ‘active’ intervention, the in-home safety tutorial, with a more passive intervention through handing out educational pamphlets. In our preliminary findings from the cRCT, we see an improvement in the mean safety scores between baseline and follow-up measurement in both intervention arms; between the two intervention arms, the safety scores are comparable. We believe that educational pamphlets can be an effective intervention to reduce child injuries, with particular relevance to resource constrained settings

How can the use of data within the immunisation programme be increased in order to improve data quality and ensure greater accountability in the health system? A protocol for implementation science study

Abstract Background Immunisation remains one of the most important and cost-effective interventions to reduce vaccine-preventable child morbidity, disability and mortality. Health programmes like the Expanded Program of Immunization rely on complex decision-making and strong local level evidence is important to effectively and efficiently utilise limited resources. Lack of data use for decision-making at each level of the health system remains the main challenge in most developing countries. While there is much evidence on data quality and how to improve it, there is a lack of sufficient evidence on why the use of data for decision-making at each level of the health system is low. Herein, we describe a comprehensive implementation science study that will be conducted to identify organisational, technical and individual level factors affecting local data use at each level of the Ethiopian health system. Methods We will apply a mixed methods approach using key informant interviews and document reviews. The qualitative data will be gathered through key informant interviews using a semi-structured guide with open- and closed-ended questions with four categories of respondents, namely decision-makers, data producers, data users and community representatives at the federal, regional, zonal, woreda and community levels of the health system. The document review will be conducted on selected reports and feedback documented at different levels of the health system. Data will be collected from July 2017 to March 2018. Descriptive statistics will be analysed for the quantitative study using SPSS version 20 software and thematic content analysis will be performed for the qualitative part using NVivo software. Discussion Appropriate and timely use of health and health-related information for decision-making is an essential element in the process of transforming the health sector. The findings of the study will inform stakeholders at different levels on the institutionalisation of evidence-based practice in immunisation programmes

Embedding research to improve program implementation in Latin America and the Caribbean

ABSTRACT In the last 10 years, implementation research has come to play a critical role in improving the implementation of already-proven health interventions by promoting the systematic uptake of research findings and other evidence-based strategies into routine practice. The Alliance for Health Policy and Systems Research and the Pan American Health Organization implemented a program of embedded implementation research to support health programs in Latin America and the Caribbean (LAC) in 2014–2015. A total of 234 applications were received from 28 countries in the Americas. The Improving Program Implementation through Embedded Research (iPIER) scheme supported 12 implementation research projects led by health program implementers from nine LAC countries: Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, Panama, Peru, and Saint Lucia. Through this experience, we learned that the “insider” perspective, which implementers bring to the research proposal, is particularly important in identifying research questions that focus on the systems failures that often manifest in barriers to implementation. This paper documents the experience of and highlights key conclusions about the conduct of embedded implementation research. The iPIER experience has shown great promise for embedded research models that place implementers at the helm of implementation research initiatives