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MobileHealthcareInformationforAll

AssessmentofmHealthapplicationsfortheirpotentialtoprovide

essentialhealthcareinformationforcitizensinlowresourcesettings

January2017

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AboutHIFAHIFA(HealthcareInformationForAll)isaglobalsocialmovementtoimprovetheavailabilityanduseofhealthcareinformationinlow-andmiddle-incomecountries.Ithasmorethan16,000members(healthworkers,librarians,publishers,researchers,policymakers...)committedtotheprogressiverealisationofaworldwhereeverypersonhasaccesstothehealthcareinformationtheyneedtoprotecttheirownhealthandthehealthofothers.(seehttp://www.hifa.org/about-hifa/overview)AboutmobileHIFA(mHIFA)ThemHIFAWorkingGroupisleadingtheHIFAcommunityinachievingMobileHealthcareInformationForAll,withafocusoninformationforcitizens,parentsandchildren.Recentyearshaveseenanexplosionintheuseofmobilephonesinlowandmiddleincomecountries(LMICs).Thistransformationincommunication,especiallyinareaswhereelectricityandinfrastructureisscarce,representsauniqueopportunitytorevolutioniseaccesstohealthinformation.(seehttp://www.hifa.org/projects/mobile-hifa-mhifa)AboutthisreportThisreporthasbeenpreparedforHIFAbyDrGeoffRoyston,oneofmHIFA’sexpertadvisers,withadviceandassistancefromothermembersofthemHIFAWorkingGroup.Itdrawsfrom,andbuildson,apreviouspublication:EnsuringthatmHealthapplicationsprovideessentialhealthcareinformationforcitizensinlowresourcesettings(2015).

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1.IntroductionDuring2014,followingasurveyforHIFAbyKartzinelandHagar(ref1)furtherworkwascarriedouttodevelopandoperationalisecriteriatoassessmHealthapplications(mobile“apps”)fortheirpotentialtoputrelevant,reliablehealthcareinformationintothehandsofcitizens(includinghealthcareworkers)inlowresourcesettings,tobeusedasandwhentheyneeded.Thisworkproducedanassessmenttoolthatusedsimple“trafficlight”indicatorsshowingthestrongerandweakerpoints,fromaHIFAperspective,ofanymHealthinformationapplication.Fromthatworkitwaspossiblenotonlytoassessapplicationsbutalsotodrawsomeconclusionsaboutwhatappearedmostneededinintroducingnewapplicationsortoimproveexistingones.Thecriteria,the“trafficlight”tool,itsusetoassessapplications(mostlydrawnfromtheabove-mentionedsurvey),andtheconclusionsaboutdevelopmentalprioritieswereallsetoutinthepaper“EnsuringthatmHealthapplicationsprovideessentialhealthcareinformationforcitizensinlowresourcesettings”firstpublishedontheHIFAwebsitetowardstheendof2014andstillavailable(initsslightlyrevised2015version)at(ref2).AtaboutthesametimethemHIFAWorkingGrouppublishedapaperinLancetGlobalHealth(ref3)outliningtheopportunitiestotransformglobalhealthbyusingmobilephonestoempowercitizensinlow-resourcesettingswithessential,actionable,informationonbasichealthcare.Itchallengedcontentproviders,mobilephonemanufacturers,networkoperators,applicationdevelopers,andinternationalhealthorganisationstocollaboratetobringthisabout.Sincethentherehavebeensomeencouraging(andsomenotsoencouraging)developmentsonthisfront,particularlywithsomeofthemobileappsassessedtwoyearsago,andwiththeemergenceofnewapps.Therehasalsobeensomegrowthwithworkthatlooksfurther“downstream”-totheactualuseofmobileappsfocusedonprovidingessentialhealthcareinformationinlow-resourcesettings,and(toaverylimitedextent)ontheirimpactonknowledge,behaviourandhealthcare.Thisupdateconcentratesontheoriginalareaof“upstream”assessmentofapps,butitspenultimatesectioncontainssomebriefobservationsabouttheemergingpositionon“downstream”issues.TheissueofassessingmHealthapplicationsremainsofhigh-levelinterestintheglobalhealtharena.Animportantrecent(2016)reportbyJohnHopkinsUniversityfortheGlobalmHealthinitiative“MobiletechnologyinSupportofFrontlineHealthWorkers”(ref4)coversover140mHealthprojectsfromdevelopingcountriesandprovidesavaluableoverview,althoughtheprojectsrangedmuchmorebroadlythanprovisionofhealthcareinformationtohealthworkersandcitizens(e.g.thelargestgroupofprojectsconcernedtheuseofmobilephonesfordatacollection).Anotherrecent(May2016)report,fromtheWHOsecretariat,“mHealth:useofmobilewirelesstechnologiesforpublichealth”(ref5),highlighted,asakeyobstacletogreateradoptionofmHealth,the“Absenceofstandardsandtoolsforthecomparativeassessmentoffunctionality,scalabilityandcomparativevalueofmHealthsolutions,resultinginalackofevidencetoarticulatenormativeguidance”.

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Itseemstimelythentoupdateandextendtheoriginal2014assessment.Thisnewreportstandsbyitself,althoughitdoesnotreplicateallthebackgroundandreferencescontainedintheoriginal2014paper.Thisnewedition:

o reviewsthecriteriaand“trafficlight”indicatorsselectedforthe2014assessment

o updatesthe2014assessmentsofparticularhealthcareinformationappsinthelightofdevelopmentssincethen

o includesassessmentsofsomeadditionalappsparticularlysomethathaveappearedsince2014

o outlinestheemergingpictureon“downstream”issuesofuserengagementwithandimpactofapplications

2.Criteriaand“trafficlight”indicatorsThe2014papernotedthattheprovisionofessentialhealthcareinformationtocitizensisonepieceofacomplexjigsawforempoweringpeopletocarebetterforthemselvesandtheirfamilies.(ThejigsawhasbeencharacterisedbyHIFAbytheacronymSEISMIC-skills,equipment,information,structuralsupport,medicines,incentivesandcommunicationfacilities).Takingthatwiderpictureintoaccountisimportant,butforthe2014assessmentitwasfeltthattheinitialrequirementwastofocusonsomemoreproximatefactorsrelatedtothecomprehension,acceptanceanduseofinformation,includingnotonlytechnologicalbutalsocognitiveandbehaviouralfactors.VariousframeworksandcriteriaforassessingmHealthappshavebeenproposedseee.g.(refs6,7,8).ThesearehelpfulbuttypicallyfocusneitheronlowresourcesettingsnorexclusivelyonmHealthinformationapplications.Importantexceptionsaretheusefulevaluationguide(ref9)producedbytheMobileAllianceforMaternalAction(MAMA)andtheshort,incisive,paper(ref10)byTomlinsononimprovingtheevidencebaseformHealth.The2014paperdevelopedaninitialsetofcriteriaandtheirmaincomponents,withafocusoncriteriaofparticularrelevancetoachievementoftheHIFAaimsandvisioni.e.that“everypersonandeveryhealthworkerwillhaveaccesstothehealthcareinformationtheyneedtoprotecttheirownhealthandthehealthofthoseforwhomtheyareresponsible,assetoutintheboxbelow:

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CriteriaforassessingmobileappsforrelevancetoHIFAaims

Tooperationalisethesecriteriaforassessmentpurposesasimple“trafficlight”indicatorsystemwasused,asshowninthefigurebelow.Foreachcomponentofeachcriterion,attributesaredescribedthatbroadlyindicateincreasing“fit”ofanapplicationtotheachievementofHIFAaims.Theattributesarecodedred,amber,orgreen,withredindicatingpooralignmenttoHIFAaims,greenagoodfitandamberanintermediatematch.

• Significanceofthehealthproblem(s):Istheapplicationfocusedonasignificanthealthorhealthcareproblem-awidespreadseriouscondition,oranemergencyorurgentneed?

• Appropriatenessofthetargeting:istheapplicationaimedatuseinlowresourcesettingsorbylowincomeorotherprioritygroupse.g.motherandchild,healtheducators?

• Valueoftheinformation:Istheinformationrelevanttousers’needsforaddressingthehealthproblem;isitreliable;canitbeeasilyrelatedtopracticalaction?

• Easeofassimilationoftheinformation:istheinformationpresentedinanappealingandeasytounderstandwaysuchasavideoorvoiceclips;isitculturallyappropriateandavailableinlocallanguage(s)?

• Availabilityoftheapplication:istheapplicationavailableacrossseveralregionsorcountries;isitavailablefreetotheuser?

• Technologicalaccessibilityoftheapplication:doesithaveasimpleandintuitiveuserinterface,isitaccessibleonabasicorfeaturephone;willitwork“offline”;willitworkonmultipleoperatingsystems;isitpre-loaded?

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AtemplateforassessingmHealthapplicationsinrelationtoHIFAaims

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Sofar,theabovecriteriaandindicatorsappeartohavestoodupquitewell.Thereare,however,someissuesaboutthemwhicharebecomingincreasinglyimportant,notably:Criteriaandtheircomponents:Clearly,thereisscopetoaddtooramendthecriteria,forexample,somepeoplemightprefertotakefinancialcostasaseparatedimension.Thereareofcoursealsowider,moregeneric,criteria(suchasabilitytointegratewithotherhealthinformationsystems,capacityforscaling-up,anddatasecurity),asforexamplehelpfullyidentifiedinthegeneralsetof16broadcriteriaforuseinassessinganymHealthinterventionpublishedearlierthisyearbytheWHOmHealthTechnicalEvidenceReviewGroup,see(ref11).However,forthisupdatewecontinuetofocusonthosecriteriaparticularlyrelevanttoHIFAaims.Attributesandtheirtrafficlightindicators:The2014assessmentnotedthatthesixappsassesseddifferedinfocus:some,suchasHealthPhone,HesperianSafePregnancyandBirthandOppiaMobileappearedtobemainlyfocusedonhealthcareworkers,whileothers,suchasRedCrossFirstAidandMobiliumSmartHealth,appearedtobemainlyaimedatdirectusebycitizensontheirown.Thesegroupswillhavesomedifferentcharacteristics(forexample,healthcareworkersaremorelikelytohavehigherlevelsofliteracy,andtohavemoreadvancedphones–therecentJohnHopkinsoverviewmentionedearlierfoundthatnearly60%ofthephonesusedbycommunityhealthworkersCHWsweresmartphones,whileuseoffeaturephoneswasonly14%-andsomayhavesomewhatdifferentcapabilitiesandneeds,intermsofbothtechnologyandcontent,inusingmobilephonesinprovidinghealthcareinformation.Wehaveconsideredthereforedifferentiatingtheseusersintheassessment,whichwouldaffectparticularlytheindicatorsforinformationformat,userinterface,andmobileplatform.However,thiswouldconsiderablycomplicatetheassessments.Further,inpracticeuseisoftenmixed,withhealthcareworkersusingappstogetherwiththepublicinconsultationswiththeirpatientsorincommunitymeetings.Ouroriginalapproach,whichconsiderstherangeofgroupscovered(especiallyprioritygroupslikemothersandchildren)morethanwhethertheytypicallyinvolvedirectusebycitizensorusemediatedbyhealthworkers–stillseemsareasonablecompromise.Thecostreductionandrapidspreadofsmartphonesandthedropping-offinpopularityoffeaturephonesinmid-andlow-incomecountriescontinuesapace(seeillustrationsbelow).

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Similarly,therapidglobalspreadofinternetconnectivityandusers-inmanycountriesmainlyusingmobilephones-continues(seefigurebelow)MostmidincomeregionshavenowattainedEuropeanusagelevelsofjust8yearsback,andeventhelowincomeregionslikesub-SaharanAfricaareonlyabout13yearsbehind.

Thesetechnicaldevelopmentsraisethequestionofwhetheritwouldnowbeappropriatetorelaxtheindicatorratingforrequiringasmartphoneorforrequiringinternetconnectivityfroman“orange”toa“green”trafficlight.However,themHIFAWorkingGroupfeelthatthispointhasnotyetbeenreached,therearestillmanyplaceswheretheserequirementswouldremainobstacles,althoughthesituationisclearlychangingquiterapidlyandshouldbekeptunderreview.

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3.DevelopmentsofapplicationfeaturesThe2014assessmentlookedatsixmHealthapplications(mostlyidentifiedinthesurveyforHIFA)appearingmostlikelytobemostrelevanttotheneedsofusersinlowresourcesettingsforhealthcareinformation.Theseapplicationswere:HealthPhone;NewbornCareSeries;SafePregnancyandBirth;OppiaMobile;FirstAid(RedCross);andSmartHealth.(Thesewereallappswhereuserscan“pull”inInformationasandwhenneeded;appsthat“push”informationoutfromproviders,ofatypeandatatimeoftheirchoosing,notablyappsfocusedontextmessaging,werenotcovered,beingoutsidethemainmHIFAfocus.)Briefdetailsareshownintheboxbelow.

KeydevelopmentsoftheseappsfeatureshavebeenasfollowsHealthPhoneAswellasexpandingitscontent,soitnowcontainsover2,500videosinabout80languages,thiscuratedvideolibraryhasnowbeendistributedmorewidely(seepenultimatesectionofthispaper).HealthPhoneisalsonowproducingsome“truemobileapps”-3freeofflineappsonmaternalandchildnutritionarecurrentlyunderdevelopmentandwillbereleasedin2017inIndia.Allmedia(videosandimages)isincludedwithintheappandnoadditional

HealthPhone,aprojectoftheMotherandChildHealthEducationTrust,isapersonalvideoreferencelibraryandguidetobetterhealthandnutritionpractices,forfamiliesandcommunities,includingtheilliterate,intheirlanguage,distributedonmobilephones.www.healthphone.orgNewbornCareSeries,fromGlobalHealthMedia,aprimaryproducerofheathcareinformationvideosforfrontlinehealthworkersinlow-resourcesettings,isasuiteofvideosonlow-cost,low-techlifesavinginterventionsfornewborns,presentingclinicalguidelinesinavisualformfortrainingandreview.www.globalhealthmedia.org/newbornSafePregnancyandBirth,fromHesperian,isamobileappthatprovideshealthinformationthataimstosupportwomen,midwivesandhealthworkerstoensuresaferpregnancies.www.hesperian.org/books-and-resources/safe-pregnancy-and-birth-mobile-appOppiaMobile,fromDigitalCampus,isamobileappthatprovidesaplatformfordeliveringlearningcontent,largelyfocusedonkeyhealthtopicsforfrontlinehealthworkers,andincludesuseofvideos,quizzesandwithatext-to-voiceconversionfacility.https://oppia-mobile.orgFirstAid,fromtheRedCross,isamobileappthatprovidesadviceoneverydayfirstaidsituations,usingvideos,quizzesandstep-by-stepguides,plustipsforemergencypreparedness.InformationabouttheUKversioncanbefoundatwww.redcross.org.uk/What-we-do/First-aid/Mobile-appSmartHealth,aninitiativebyMobiliumGlobalandSamsung,isamobileappthatprovidesinformationmainlyonHIV/AIDS,TBandMalariaandalsoincorporatesamobilewebbasedsymptomchecker.Itisaimedatenhancingthehealth,healthmaintenance,healthbehaviorsofindividualsandtheircommunitiesacrossAfrica.http://mobilium.com/about-us/october-2013-mobilium-smart-health-app

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downloadisrequired.Eachappwillbein18Indianlanguages.Astheseappsarestillunderdevelopmenttheyhavenotbeenincludedinthisupdate,butwillbeconsideredforanyfutureedition.FirstAidFromoriginallybeingavailableonlyinEnglish,thisappisnowavailableinover35languages.Over80nationalRedCross/RedCrescentsocietieshavenowproducedatailoredversionfortheirowncountry.(TheInternationalRedCross/RedCrescentsupplyanappdevelopmenttoolkitincludingaplatformapp–the“UniversalApp”-toenablethenationalsocietiestodothistailoring.)Therehasalsobeensomeevaluationofitsimplementation(seepenultimatesectionofthispaper).NewbornCareSeries/GlobalHealthMediaProjectTheNewbornCareSeriescomprisedvideosavailableon,andfreelydownloadablefrom,theGlobalHealthMediawebsite-notanappassuch).TheGHMprojecthascontinuedtoexpanditsnumberandrangeofvideos(nowexceeding60,inuptoeightlanguages)whichcovernewborncare,childbirth,breastfeeding–butnowalsosomeacuteconditions(choleraandEbola).Giventhisexpansion,wehavenowassessedthewholewebsiteandre-labelledaccordinglyas“GlobalHealthMediaProject”.SafePregnancyandBirthThisappdoesnotappeartohavebeendevelopedfurthersince2014(orindeedsinceitsoriginalproductionin2012).ItremainstheonlypartofHesperian’sextensiveandhighlyregardedsetofguidanceonhealthcareinlow-resourcesettingsthatisavailableasamobileapp.OppiaMobileTherehavebeenanumberofothertrainingprogrammesforhealthworkersinmed/lowresourcesettingsdevelopedforthisplatformapp;downloadableappsinclude:

• Bright Future (Pakistan) - https://play.google.com/store/apps/details?id=org.bright.future.oppia.mobile.learning&hl=en (note that this app is being updated)

• Gyan Jyoti (India) - https://play.google.com/store/apps/details?id=org.ujjwal.saathi.oppia.mobile.learning&hl=en

• NURHI (Nigeria) - https://play.google.com/store/apps/details?id=org.nurhi.oppia&hl=en

Astheyallhaveaverysimilarlookandfeeltheyhavenotbeenassessedindividually,buttheoverallassessmentfortheOppiaMobileplatformhasbeenupdatedtoreflectthedevelopments.SmartHealthTherehasbeensomedevelopmentofSmartHealth,forexample,aFrenchlanguageversionbecameavailableshortlyafterourinitialassessmentandthereisnowaSwahiliversion.However,itisunderstoodthattherearenoplanstoproduceanoff-lineversion,orforittoproducemoreaction-orientedguidanceforcitizensoncareofarangeofcommonconditions.

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4.Somenew“apps”Ofcourse,sincetheworkonthe2014assessment,othermobileappshavesurfacedorbeenintroduced.Acomprehensivesurveyhasnotbeenattempted,butafewofthemorerelevant“apps”arenotedbelow:ORB(seehttp://health-orb.org)This,introducedinJune2015bymPoweringFrontlineHealthworkers,islikeHealthPhoneinbeingawebsiteforacuratedvideo-libraryratherthanastandardmobileapp.Itcomprisesanextensiveset(some400items)ofquality-assuredandmobile-optimisedmultimediatrainingmaterials(fromseveralcontentproviderssuchasGHMandMAF)forfrontlinehealthworkers.Itisfocusedonmaternalandchildheath,coveringfamilyplanning,antenatalnatalandnewborncare,childhealth,andnutrition(and,shortly,Zika).AllmaterialscanbefreelydownloadedunderaCreativeCommonslicense(thoughseeminglynotanopenversionoftheCClicense,sonotallowingtranslationoradaptation)toamobileortablet,afterwhichinternetaccessisnolongerrequired.Muchofthematerialhasversionsinarangeoflanguages.OnerecentdevelopmentisthepartnershipofORBwiththeGlobalHealthMediaProject:GHMPprovidesvideosforORB,whileORBhelpsdistributesthemandhelpshealthworkersusethemmoreeffectively,withtheirvideosbeingincorporatedintonewtrainingprogramsbeingintroducedinseveralAfricancountries.TheZeroMothersDieApp(seewww.zeromothersdie.org),oneofthenewer(June2016)apps,isproducedbytheglobalpartnershipinitiativeofthesamename.Ithasseparatesectionsforfrontlinehealthworkersandfornewmothersandmothers-to-be.Theformerareasubsetofthevideos,coursesetc.availablethroughORB.Thelattersectionscontainextensiveinformation(thoughentirelyintext)aboutstagesofpregnancyandthefirstyearoflife.EnglishandFrenchversionsareavailable.SafeDelivery(seehttp://maternity.dk/the-safe-dilevery-appNBthisspellingis“correct”)Thisapp,fromtheMaternityFoundation,supportsskilledbirthattendants’capabilityandconfidenceinprovidingrespectful,evidence-basedbasicemergencyobstetriccare.Thecontentoftheappisbasedonglobalclinicalguidelinesandhasbeenvalidatedwithaninternationalgroupofglobalhealthexperts.Itcontainsfourbasicfeatures:10animatedinstructionvideos,actioncards,druglistandpracticalprocedureinstructions.Allfeaturesandfunctionsaredesignedforlow-literacy,low-incomesettingsandworkcompletelyofflineoncedownloaded.Afieldevaluationoftheimpactofthisapphasbeenpublished(seelater).MedicalAidFilms(MAF)isanotherprimaryproducerofhealthcareinformationvideosforcommunityhealtheducationorfortraininghealthworkersinlow-resourcesettings.LikeGHMP,MAFhasawebsite(www.medicalaidfilms.org)fromwhichabouttwohundredsuchvideos(coveringnutrition,maternalhealth,newbornandchildhealth,sexualandreproductivehealth,emergencyobstetricsandneonatalcareandEbola)inupto20languagescanbefreelydownloaded,inamobile-friendlyformat.Assomeofitsvideosare

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inHealthPhoneitwasobliquelycoveredinthe2014assessmentbutitwasnotassessedseparately.GivenitssimilarscopetoGHMPthereseemagoodargumentforincludingitinitsownright.AsimilarargumentappliestoSAWBO,(ScientificAnimationswithoutBorders)whichmaintainsamobilefriendlyvideolibrary(http://sawbo-animations.org/home/),especiallyasitnowhasanassociatedAndroidandiOSmobileapp(SAWBOdeployer)toassistdownloadingofthevideostoamobilephone(NBoneofthedeployerbrowsingfilters(topic)needsattention–currentlyitsusecancauseacrash;theothertwofilters(languageandcountry)operatewell).Moregenerally,inafollow–uptotheoriginalsurveyofmHealthinformationapps,aHIFA–commissionedsurvey(againconductedbySanJoseUniversity)todeterminewhatvideoinformationwasavailableforcitizensinlowandmiddleincomecountriesthroughmobiledevices,identifiedadditionalsuchproviders/librariessuchthoseofAliveAndThrive(http://aliveandthrive.org/types/videos)andiHeed(www.iheed.orgalsowww.iheedcrowd.org)(NBitisnotclearwhatthecurrentstatusofiHeedisinregardtovideoproductionorcurating,andtheirproductionpartnerMobentoappearstobenolongeroperating).OtherrelevantvideodevelopersitesincludeChocolateMooseMedia(www.chocmoose.com)MobileKunji(andasisterappMobileAcademy)isfromtheBBCMediaActionproject(seehttp://downloads.bbc.co.uk/mediaaction/policybriefing/bbc_media_action_health_on_the_move.pdf).MobileKunjiisverydifferentfromalltherestoftheappsconsideredhere(andisnotbeingincludedinthetrafficlightassessment)buthassomeuniquefeaturesthatmerititsinclusioninthispaper.Itinvolveshealthcareworkers,whencounsellingruralfamilies,usingbasicmobilephonestoringaseriesoftoll-freenumbers(identifiedfrompicturecardsrelatingtoavarietyofessentialhealthtopics)toaccessaninteractivevoicerecordinggivinghealthcareinformationtothemandthefamilieson40differenttopicscoveringessentialinformationonpregnancyandnewbornhealth.Themessagesaredeliveredinthevoiceofawomandoctorcharacter,designedtobebothengagingandconversationalandtoreinforcethehealthmessageillustratedonthecard.MobileAcademyissimilarbutprovesalongerprogrammeoftrainingcoursematerialforhealthcareworkers.Thereareofcourseothernewappsthatcouldbeconsidered,suchastheWHOZikaapp(seehttp://www.who.int/risk-communication/zika-virus/app/en/)ortheMeTooapp.(seehttp://apk-dl.com/metoo/com.uriosweb.appidays.metoo)Howevertheformerisanexampleofaspecific“niche”appforhealthcareworkers,andthelatterleansheavilytowardsbeingadiagnosticapp(usingthecameraphone).Suchapps,innovativeandimportantthoughtheymaybe,seemoutsidethescopeofanassessmentfocusingonmHIFAgoalsforcitizenaccesstoessentialhealthcareinformation.(Similarly,wedonotconsidertheraftofavailablemHealthappsthatareaimedatsupportingtaskssuchashealthcareadministrationormanagement).

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5.Theupdated“trafficlight”assessmentsWehaveextendedthetrafficlightassessmentstoalsocoverfiveofthesenew“apps”,almostdoublingthenumberof“apps”coveredinourassessment.Notethat,aswellasvaryingintheirfocus(onhealthworkers,oncitizensoronboth,asoutlinedabove)these“apps”fallintothreeforms:- truemobileapps-appsthatcanbedownloaded,usuallyfromanappstorelikeGoogle

Play.(Thesecouldinturn,thoughforsimplicitywehavenotdoneso,besub-dividedintothosebeingorhavinga“platform”apptoassistproductionofversionstailoredtodifferenttopics,targetgroupsorcountries(OppiaMobile,FirstAid),andthosethatare“standard”singleversionapps(SafePregnancyandBirth,SafeDelivery,ZeroMothersDie,SmartHealth))

- websitesofcuratedlibrariesofdownloadableresources(particularlyvideos)fromvarioussources(HealthPhone,ORB)

- websitesofprimarycontent(videos)producers(MedicalAidFilms,GlobalHealthMediaProject,ScientificAnimationswithoutBorders)

Wehaveusedtheabovegroupingsinthefollowingassessments.Eachgrouphasacorrespondingtrafficlightassessmentasbelow.Thetruemobileappsareincoveredintwosections,thefirstcomprisingfairlybroadlyfocusedappsandthesecondbeingonappsfocusingspecificallyonmaternityandnewborncare,thethirdandfourthsectionsrespectivelycoverwebsitesofcuratedlibrariesandwebsitesofprimarycontentproducers.Attheendofthesetoffourtrafficlighttablesthereisasinglepageof”radarplots”summarisingtheresults(thebettertheassessmentscoresare,themorecompletelyshadedarethecircularplots).Note,asinthe2014paper,thattheassessmentsarefromtheparticular(mHIFA)perspectiveofhowfartheappshavepotentialtoputessentialhealthcareinformationintothehandsofhealthcareworkersandcitizensinlowresourcesettings,tobeusedasandwhenneeded,anddonotimplyanymoregeneralviewoftheirmeritsorotherwise.

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2 Focusedonemergencycare/firstaid 2 Mostlyfocusedonacute;notmuchonemergency 1

None(afterdownload)

Smartphonerequired

Android,iOS

None(materialdownloadablebutnotpreloaded)

Videosandsymptomcheckerbothrequireonlineaccess

MOBILEAPPS

Broadanddeepcoverageofmanyhealthproblems Focusedonarangeofmoderateandseriousproblems Focusedonmajorconditionsbutlimitedtojustthreeofthese(HIV,tuberculosis,malaria)

TARGETAUDIENCE

SEVERITY

URGENCY

COUNTRY(IES)OFUSE

2

Nowavaialbleinover80countries,includingmanylowandmiddleincomeones

2

2

2

EASEOFASSIMILATIONOFTHEINFORMATION

2

Nowavailableinover35languages 2

COMMUNICATIONREQUIREMENTS 2

Rating2016

Informationorientedtolowandmiddleincomecountries

Mobileapp,menueasytonavigate

PreloadedonSamsungphonesandtabletsinAfrica,downloadableelsewhere

Materialveryvariableinpointingtoaction

Informationrathergeneral;thesymptomchecker("isabel")onlysignpoststoelsewhere

English,French,Portuguese,Swahili

Pan-African

GeneralPublic?Nothingfocussedonmotherandchild

1

1

2

Appisfree(butmaybedatachargesforonlineuse)

Smartphoneortablet

Android

SmartHealth(Mobilium)

1

1

2

1

0

1

2

Appistext-heavy;therearelinkstoafewYouTubevideos

RedCross/CrescentFirstAidRating-2016

2

2

2

2

2

Stronglinkagetoaction

MainlyEnglish,somecoursesininHindiandUrdu

2

1

Largelytext,butwithtexttospeechconversionfacility.Somediagrams.Quizzes.Afewvideos.

OppiaMobile(DigitalCampus)

Stronglinkagetoaction 2

MOBILEPLATFORM

None(afterdownload)exceptforprogressfeedbacktotrainers

1

2

2

2

EASEOFRELATINGTOACTION

INFORMATIONFORMAT

LANGUAGE(S)

GEOGRAPHICALPROVISION

COSTTOUSER

USERINTERFACE

ADDITIONALPHYSICALMEDIANEEDS

2

TECHNOLOGICALACCESSIBILITYOFTHEAPPLICATION

2

1Smartphoneortablet

AVAILABILITYOFTHEAPPLICATION

2

1 1None(materialdownloadablebutnotpreloaded)

Android

Tailoredmoblieapp,easytonavigate

Appisfree,(exceptpossibledatachargeforone-offdownload?)

Generic,plusspecifcapplicationsforEthiopia,Pakistan,India,Nigeria

2

OPERATINGSYSTEM

2

1

Tailoredversionsnowavailableforover80countries 2

Tailoredmobileapp,easytonavigate

Appisfree,(exceptpossibledatachargeforone-offdownload?)

ApprovedinsomesensebyGlobalFund

1

2

1

2

0

CRITERION COMPONENTS

SIGNIFICANCEOFTHEHEALTHPROBLEM(S)

Coversmanyaspectsofcommunicableandnon-communcablediseasesandcare(includingantenatalcare)andenvironmentalhealth

VALUEOFTHEINFORMATION

EssentialinformationEssentialinformation

Generalpublic,andthereisacompanionappfocusedonbabiesandchidren(forUKversion)

Healthworkersonly-allmaterialisinformoftrainingcoursesAPPROPRIATENESS

OFTHETARGETING

Lowandmiddleincome

WellaccreditedsourceSourcesappearwellaccreditedRELIABILITY

RELEVANCETOUSERS'NEEDS

Rating2016

2

Shortvideosformostitems

15

Smartphoneortablet 1

AndroidoriOS 2

None-appdownloadablethoughnotpreloaded 1

Manyofthevideosandtrainingcoursesrequireaninternetconnection,othersrequireadditionalappssuchasVimeotodownloadorrun

MOBILEAPPS(CTD)

1

Non-specific 1

Appisfree(exceptpossibledatachargeforinitialdownload)

2

Mobleapp,menuveryeasytonavigate 2

Worksoffline 2

Healthworkersinvolvedinmaternitycare 1

Informationorientedtolowincomecountries 2

Authoritative 2

Coverskeyhealthissuesandconcernsofusergroup

2

Stronglyaction-oriented 2

Rating2016

SafeDelivery(MaternityFoundation/CopenhagenUniversity)

Rating2016

SafePregnancyandBirth(Hesperian)

Rating2016

Includesemergencies 2

Moderate/emergencyproblemsinpregnancyandchildcare,(bydefinition,nootherareascovered)

1

Informationorientedtolowincomecountries 2



URGENCY

ZeroMothersDie(ZeroMothersDiePartnership))

Fullrangeofurgencycovered 2 Fullrangeofurgencycovered 2

SEVERITY Moderate/emergencyproblemsinpregnancyandchildcare,(bydefinition,nootherareascovered)

1 1

APPROPRIATENESSOFTHETARGETING

TARGETAUDIENCE 2 "Skilledbirthattendants" 1

COUNTRY(IES)OFUSE


RELIABILITY Wellaccreditedsources 2

Lowandmiddleincome 2

"Validatedbyinternationalexpertsanddoctorswithinobstetricsandpediatrics"

2

RELEVANCETOUSERS'NEEDS Essentialinformation.Containsinstructionalvideosandonlinecourses.

2 Coverskeyhealthissuesandconcernsofusergroup 2


INFORMATIONFORMAT 1 Manyinstructionalvideos,plusquickreferenceactioncards

2

LANGUAGE(S)

EASEOFRELATINGTOACTION Stronglinkagetoaction 2 Stronglyaction-oriented,withdetailsonkeyproceduresandinformationondrugs

Appistext-heavybuthassimpleillustrativediagrams

1

EnglishandSpanish


USERINTERFACE Mobileapp,easytonavigatethemenu 2

MOBILEPLATFORM

Non-specific 1

COSTTOUSER Appisfree(exceptpossibledatachargeforinitialdownload)

2 Appisfree(exceptpossibledatachargeforinitialdownload)

2


GEOGRAPHICALPROVISION Non-specific 1

Mobleapp,menuextremelyeasytonavigate 2

COMMUNICATIONREQUIREMENTS 0 Allvideosandothermaterialworkoffline 2


Informationforpatientsistext-onlythoughhealthworkerinformationhasagoodsetofvideos(asubsetofthecuratedvideolibraryonORB).

Pregnantwomen,newmothersandhealthworkerscaringforthesegroups.

Moderate/emergencyproblemsinpregnancyandneonatalcare,(bydefinition,nootherareascovered)

2

None-butseecommunicatonrequirments 1 None-appdownloadablethoughnotpreloaded 1

OPERATINGSYSTEM Android 2 Android

SmartphoneortabletSmartphoneortablet 1 1

EnglishandFrench 1 Englishonly 0

2

16

ORB(mPoweringFrontlineHealthWorkers)

Rating2016

Coversmanyaspectsofchronicandacutecare,especiallyonmaternityandchildhealth

2

Broadanddeepcoverageofmanyhealthproblems 2

Focusisontrainingfrontlinehealthworkers,onlyalittlematerialidentifiedasforcitizenuse

1

Focusonlowincomecountries 2

Allmaterialhastogothroughanexpertcontentreviewteam 2

Requiresinternetaccesstoviewordownloadanyitem.

Focusisonessentialinformationneeds. 2

Mostmaterialisstronglyactionrelated 2

2

2 Manyregionsandabout20specificcountriescovered 2

Free,(exceptpossibledatachargeforone-offdownload?) 2


COMMUNICATIONREQUIREMENTS

MOBILEPLATFORM

Allmaterialcanbedownloaded,andwhileitisnotpreloadeditisalsoavailableonmicroSD

1

2

2

2 Multilingual(about25languagesintotal) 2

Verylargecuratedlibrayofvideos(nearly200),slides,documentsandotherresourcesdrawnfrommultipleprimarysources



APPROPRIATENESSOFTHETARGETING

Focusonlowincomecountries

Indiaandothercountries

Focusisonessentialinformationneedsespeciallyforprevention.

Multilingual(around80languagesintotal,including15Indianlanguages)



Mostmaterialisstronglyactionrelated

Notan"app"assuch,websitehasanitemselectionmenu,navigationmaybedifficultforsome

1

Free,(exceptpossibledatachargeforone-offdownload?)

2

2

1

Multiple

2

Smartphonesortabletsneededformostmaterial,featurephonesOKforsome.

1

Multiple 2

None-materialcanbedownloaded,althoughitisnotpreloaded.Viewingsomevideosrequiresdownloadingadditionalapps(Vimeo)

1

Notan"app"assuch,butwebsitehasafairlyeasilysearchableitemselectionmenu,thoughnavigationmaybedifficultforsome

2

1

CURATEDCOLLECTIONS

LANGUAGE(S)

GEOGRAPHICALPROVISION

COSTTOUSER

2

2

2

2

2

Rating2016

CRITERION COMPONENTSHealthPhone

(MotherandChildHealthEducationTrust)

Coversmanyaspectsofchronicandacutecare,includingmaternityandchildhealth


2

USERINTERFACE

OPERATINGSYSTEM

Widerangeofdevicetypes.Sometextforbasicphones,featurephonesufficeforothermaterials.

Materialavailableon-lineand(viamicroSDcard)off-line

URGENCY

SEVERITY

TARGETAUDIENCE

COUNTRY(IES)OFUSE

RELIABILITY

RELEVANCETOUSERS'NEEDS

EASEOFRELATINGTOACTION

INFORMATIONFORMAT

Approvedbyvariousofficlaibodies;drawsonUNFactsforLifepublication.

Verylargecuratedvideolibrary(hundredsofvideos)drawnfrommultipleprimarysources

Broadanddeepcoverageofmanyhealthproblems

Healthworkersandproritygroups-'providesfamilieswiththeirownpersonalreferencelibraryandguidetobetterhealthpractices'.

17

CONTENTPROVIDERS

Rating

2016ScientifcAnimationsWithoutBorders

Rating

2016

Focusonafewselectedacuteconditions(e.g.Chagas,

ebola,cholera,dengue)andprevention(eghandwashing,

TB,malaria)

SAWBOwebsitehaslargemenuofvideodownloads,the

SAWBOdeployerappallowseasysearch&access (NBtheratingassumesaminorsearchbugwillbefixed!)

Smartphone,tabletorfeaturephone

Broadanddeepcoverageofmanyhealthproblems

Notan"app"assuch,websitehashugemenuofvideo

downloads,menunavigationmaybedifficultforsome

Particularlyforhealthcareworkerscaringforpregnant

womenandmothersofyoungchildren,butalsowider

communityeducation

Mostlyonmoderate/emergencyproblemsin

pregnancyandchildcare,butalsosomematerialon

choleraandebola


SIGNIFICANCEOF

THEHEALTH

PROBLEM(S)

URGENCY Coversmanyaspectsofchronicandacutecare 2

MedicalAidFilmsRating

2016GlobalHealthMediaProject

Fullrangeofurgencycovered 2 Coversaspectsofchronicandacutecare(thoughnot

maternityornewborn)1

SEVERITY 2 1

Focusonlowincomecountries 2

1

APPROPRIATENESS

OFTHETARGETING

TARGETAUDIENCE"Skiiledhealthworkersandcommunityeducation

groups".2 2 Healthworkersandproritygroups. 2

COUNTRY(IES)OFUSE

VALUEOFTHE

INFORMATION

RELIABILITY Clinicalexpertsfullyinvolvedinproduction 2 Wellaccreditedsources 2

Focusonlowincomecountries 2 Lowincome 2

Expertvalidationprocess 2

RELEVANCETOUSERS'NEEDS Essentialinformation. 2 Essentialinformation. 2 Focusisonessentialinformationneeds 2

Multilingual(over30languagesintotal) 2

2

EASEOF

ASSIMILATIONOF

THEINFORMATION

INFORMATIONFORMATAll(bydefinition!)materialinvideoform--extensive

libraryof(about200)videos2 Largevideolibrary(nowover60videos) 2 Libraryofvideos(notonlyonhealth,butabout30areon

healthtopics)2

LANGUAGE(S)

EASEOFRELATINGTOACTION Mostvideosstronglyactionrelated 2 Stronglinkagetoaction 2 Mostvideosstronglyactionrelated

AVAILABILITYOF

THEAPPLICATION

GEOGRAPHICALPROVISIONSomeofthevideosarecountryspecific(MAFhas

partnershipsin19countries)2 Supernational 2

Multilingual-about20languagesintotal 2 Mulitilingual-about10languagesintotal-including

English,Spanish,French,Swahili,Nepali,andKhmer

2

Over50countriescovered 2

COSTTOUSER Free,(exceptpossibledatachargeforone-offdownload?) 2 Free(exceptpossibledatachargeforinitialdownload) 2 Free,(exceptpossibledatachargefordownloads) 2

2

COMMUNICATION

REQUIREMENTSInternetaccessrequiredtodownloadeachitem 1 Internetaccessrequiredtodownloadeachitem 1 Internetaccessrequiredtodownloadeachitem;though

deployerappallowsvideosharingviaBluetooth1

TECHNOLOGICAL

ACCESSIBILITYOF

THEAPPLICATION

USERINTERFACE 1 Notan"app"assuch",websitehaslargemenuofvideo

downloads,menunavigationmaybedifficultforsome.1

MOBILEPLATFORMSmartphone,tabletorfeaturephone 1 Smartphone,tabletorfeaturephone 1 1

ADDITIONALPHYSICALMEDIA

NEEDS

2

None-allvideoscanbedownloaded1

None-allvideosdownloadable.1

None-allvideoscanbedownloaded1

OPERATINGSYSTEM Multiple 2 1 Any(thoughSAWBOdeployerappnotcompatiblewith

iOS)

Any?However,Androidphonesmayrequire

downloadinganapp(suchasVLCforAndroid)toplay

thevideoswhichareinmov.(Quicktime)format

18

Radarplotsummariesoftheassessments

19

Somecommentsontheassessments- thetruemobileapps.ThedevelopmentoftheRedCrossFirstAidapphasimprovedits

ratingandithasnowbecomeoneofthetwotopscoringapps.OppiaMobilealsocontinuestorateverywell.SmartHealthcontinuestolagwellbehindduetolackofactionableinformationandneedforonlineaccessformuchofitscontent.Allthreeoftheassessedapps(SafePregnancyandBirth,SafeDelivery,ZeroMothersDie)thatarefocusedexclusivelyonmaternityandchildcarescorequitewell,andtheassessmentsshowhowtheycouldquiteeasilybefurtherimprovedby,forexample,increasingthenumberoflanguagestheysupport.

- thewebsitesofcuratedlibraries(HealthPhone,ORB)ofdownloadableresources(particularlyvideos)fromvarioussourcesscorehighly,withHealthPhonehavingtheedgeandindeed,acrossalltheassessedtools,sharingtopplace(withtheRedCrossFirstAidapp).However,bothlosemarksfromnotbeing“truemobileapps”providingauserfriendlyinterfacetotheirlibraries.ORB’sinvolvementwiththeZeroMother’sDieapp,andHealthPhone’scurrentworkondevelopingsome“true”appstobereleasedshortly,suggeststheycouldbothreadilyproducesuchaninterface;thesewouldbevaluableenhancements.

- websitesofprimarycontent(videos)producers(MedicalAidFilms,GlobalHealthMediaProject,ScientificAnimationswithoutBorders).Perhapssurprisingly,giventhesearesingleproviderwebsites,ratherthantrueappsorcuratedmulti-sourcelibraries,theseallscoredverywell.Oneofthem(SAWBO)hasproducedacompanionappthatprovidesauser-friendlyinterfaceforthelibrary,adevelopmentthat,asnotedabove,othersmightusefullyconsider.

6.EvaluatingtheactualuseandimpactoftheappsTheabove(andtheearlier2014)assessmentisofthepotentialofappstodeliverrelevant,reliablehealthcareinformationintothehandsofcitizens,tobeusedasandwhenneeded.Itdidnotextendintolookingattheactualtake-up,useandimpactofsuchapps,partlybecausethatwouldrequireassociatedfieldinvestigations,oratleastreportsfromfieldinvestigations,ofwhichatthattimethereappearedtohavebeenveryfew.Remarkably,thislimitationprovedlessofadrawbackthanexpected,asagreatdealofinsightintothelikelyvalueofhealthcareinformationappsprovedtobeobtainablefromtheexaminationoftheirinternalcharacteristics.(Indeedonebenefitofsuchexaminationisthatitshouldavoidwastedeffortonfieldinvestigationofapplicationswhoseassessmentofpotentialalreadyshowsthemlikelytobeofverylimitedvalue).However,“downstream”assessmentofactualuseandimpactisclearlyimportant,notleasttofurthertestandrefinethemorepromisingapplications.Informationonthis,whilestillverypatchy(andnotyetsufficienttomeritextendingour“trafficlight”tool),isnowbeginningtobecomeavailable,asshownbrieflybelow.ThetakeupandusageofmHealthinformationappsthatarecoveredinourassessmentsGoogleAnalyticsshowsdownloadsrangingfrom100Kormore(HesperianSafePregnancy,RedCrossFirstAidappinseveralmid-incomecountries)toafewhundred(SmartHealthin

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anycountry;RedCrossFirstAidinmostlow-incomecountriescovered).However,thesefiguresareoflimiteduse,astheyexcludepre-loadingandpeer-to-peertransfersofapps,soforexampletheactualnumberofphoneswhichhavehadSmartHealthloadedmustbenothundredsbutmillionsasitisreportedasbeingpre-loadedonallSamsungsmartphonessoldinAfrica–runningattensofmillionsayear!Moreusefulinformationishoweveravailableforsomeoftheappscovered,asshownbelow.HealthPhonehasnowbeendisseminatedwidelytobeavailabletomillionsofpeople:

- inMaharashtra,India(pop118m)thegovernment,withsupportfrom UNICEF,isprovidingeveryhealthworker(180,000)withamicroSDcardcontainingtheHealthPhonevideolibrary.

- theIAPHealthPhoneprogramme,launchedinJune2015,isadigitalmasseducationprogrammetotacklethechallengeofmalnutritioninwomenandchildrenatthenational-levelinIndia.Itisapublic/privatepartnershipbetweenTheIndianAcademyofPediatrics(IAP),HealthPhone,MWCD,UNICEFandVodafone.Fourvideos,jointlyproducedbyMWCDandUNICEFin18Indianlanguages,aredownloadableandviewable,freeofdatacharges,toapproximately200millionVodafonecustomersinIndia.Thevideosaddressissuesofstatusofwomen,thecareofpregnantwomenandchildrenundertwo,breastfeedingandtheimportanceofbalanceddiet,healthandsimplechangesinnutritionalcarepractices

TheRedCrossFirstAidApp,whichisnowavailableincountry-specificversionstohundredsofmillionsofpeopleinover80countries,hashadsomedetailedinvestigationontake-upandusage.Anevaluationofitsimplementationineight(fivehigh-andthreemid-income)countrieswascarriedoutin2015.TheveryhelpfulreportonthisevaluationisavailableonaRedCrosswebsite(ref12)andthereisalsoapublishedacademicpaper(ref13).Thepercentageofthestudycountrypopulationswhohaddownloadedtheapprangedfrom0.01%(5,000peopleinMyanmar)to4%(13,000peopleinIceland),thoughthis,especiallythelowerfigure,willbeanunderestimateasthefiguresarefromGoogleanalytics(seeabove).Highertake-upappearedtobeassociatedwithinternetandsmartphonepenetration,mediaexposure,andpopulationdensity.Typicalusageoftheappwasinsessionsaveragingtwotothreeminutes.Themostcommontopicaccessedwasburns.Over85%ofusers(self-selected)whoofferedfeedbackgavepositivecomments.

MobileAcademyanda“sister”toMobileKunji,MobileKilkari(a“push”appforexpectantandnewmothers,sooutsidethescopeofthispaper’sassessments)arenowbeingrolledoutnationallybytheIndianMinistryofHealthandFamilyWelfare,withfundingfromtheIndiangovernment,theGatesFoundation,USAIDandtheBarrFoundation.Thisisaverylargemobilehealthprogramme–itaimstotrainonemillioncommunityhealthworkersandhelpnearly10millionnewandexpectingmothers.(Kilkariisnowmakingcallsto850,000familiesinsixstates,andwillscaletoreach9.5millionnewandexpectingmothersayear.)

ForMobileKunji,RebaRani,acommunityhealthworkerinBiharnoted:“NowthatIhaveMobileKunji,everytimeawomanasksmeforinformation,IlookattheindexcardoftheMobileKunjideckofcardsandchooseanappropriatemessage.AllIhavetodoisexplaintheinformationonthecardanddialthenumber“

21

MobileAcademyisnowaccessibleto150,000healthworkersacrossfourstates,andwillscaletoreachnearlyamillionhealthworkers.Sofar,21,500havecalledtheservice(despiteitnotbeingfree).Twentytwopercentofusershavealreadycompletedthecourse.Justover4,700healthworkersareeligibleforcertificatesforpassingthecourseandtraineeshaveaccessedmorethan1.7millionminutesoftrainingcontent.ImpactevaluationofthemHealthinformationappscoveredinourassessmentsSofar,therehasbeenverylimitedfield-basedevaluationofimpactonknowledge,behaviourorhealthfortheappscoveredinourassessments.Importantexceptionsinclude:

HealthPhone.Althoughsofarlargelyanecdotaltherearereports(ref14)ofassociatedimprovementsinincreaseduseofORSandZincduringdiarrhoeaepisodes,andofincreasedfrequencyofhandwashing,breastfeedingandimmunization.ORB.Thereisareport(ref15)ontrainingof200healthcareworkersin18clinicsviapartnershipwiththeORBpilotinOndoState,Nigeria,inMay2016,usingatabletwithpre-loadedORBtrainingmaterial.Althoughtheevidenceagainappearstobelargelyanecdotal,itisstatedthatasaresultofwatchingtheORBtrainingvideos,midwivesandcommunityhealtheducationworkerswerebetterabletounderstandtheoptimalantenatalcare,toschedulepatientvisitsandtobuildrapportwithpatients.Forexample,twomidwivesreportedthatanORBvideoondeliveryoftheplacentachangedthepracticeintheirclinic.ORBwasconsideredsimilartobutbetterthanMAMAConnectbecauseitdeliveredlearningmoreeffectivelyandcouldbeusedoff-line.Oneinterestingobservationwasthat“asORBwaspositionedforhealthworkersithadnotoccurredtomosttoshareitwithwomenintheclinicorthecommunity;howevermosthealthcarestaffagreethatsomeofthecontentwouldbereallyusefulfornew/expectingmothers…becausethevideosareinterestingandeasytounderstand…thoughalargerscreenwouldbemoreeffectiveforgroupviewing”.RedCrossFirstAidAlthoughthereviewnotedabovefocusedonimplementationandusageratherthanimpact,thereviewbriefingpaperreferstoexampleswheretheapphadbeensuccessfullyusedtomanageahealthemergencye.g.auserfromIrelandreported“Hadasituationofunconsciousnessandnotbreathingyesterdayinmyhomewithmysister.Alotofpeoplepanicked,butrememberingIhadtheapphandyforawhilenow,whippeditoutandhadaquickfewsecondvideoonexactlywhattodo,gotherbreathingundertheinstructions,liftedhertothecar,satinthebackwithherandgottoA&E,andshewasoktoleavebymorning.”MobileKunjiandMobileAcademyTheBBCbriefingpaper(seetheMediaActionwebsitelinkinSection4)reportsemerginganecdotalevidenceonthehealthimpactoftheseservices.Forexample,oneseniorsupervisorofcommunityhealthworkersinthedistrictofGopalganjreportedaspikeinwomencomingtothehealthfacility.

22

TheteamhasalsoseenanecdotalevidenceinthefieldthatwomenareheedingtheadvicefoundinMobileKunji.Onepregnantwomanspoke,forexample,ofhowshewasconvincedbyherhealthworker–andMobileKunji–toregisterforfreegovernmenthealthproductsandservices,suchasironfolicacidtabletsandtetanustoxoid.

Hesperian/SafePregnancyandBirthHesperianhaveadoptedanoutcomemappingapproachtomeasuringtheimpactofthehealthinformationtheyprovide,whichshouldbeapplicabletotheirapp.SafeDeliveryThisappisnoteworthyinhavinghadarandomisedcontroltrialonimpact.Thefirstfourfilmsoftheapp(activemanagementofthirdstagelabour,post-partumhaemorrhage,manualremovalofretainedplacenta,andneonatalresuscitation)weretestedinaone-yearrandomizedcontrolledtrialin73facilitiesinEthiopiatoassesstheimpacton176healthworkerslife-savingskillsandknowledge.Keyresultsrevealedastatisticallysignificantincreaseintheskillsandknowledgelevelofthehealthworkersusingapp,e.g.:at12monthshealthworkersabilitytohandlepost-partumhaemorrhage(PPH)andtoresuscitateanewborn(NR)morethandoubled.Useofthesafedeliveryappwasassociatedwithalowerperinatalmortalityof14per1000birthsininterventionclusterscomparedwith23per1000birthsincontrolclusters,thoughthisdidnotreachconventionalstatisticalsignificancelevels.See(ref16)

MedicalAidFilmsTherehavebeensomestudiesintotheimpactoffilmsfromMAF(seeref17),showingforexample“anaverage44%improvementinknowledgeandpracticeafterwatchingourfilms”.

7.ConclusionsThemainconclusionsofthe2014assessmentwere:- themorepromisingapplicationsshouldbefurtherdeveloped,especiallyinregardto

addingcontentandlanguagesappropriatefordirectusebycitizensandinawiderrangeofcountriesandcultures,takenupbymobilephoneenterprises,androlledoutasfarandasfastaspossible;

- Inthelongertermtheneedwastodevelopapplications,purposebuiltforuseinlowresourcesettings,thatcombinethepositivefeaturesofapplicationssuchasthosethathadbeenassessed,thisimplieddevelopingappsthatwouldworkoff-lineandwith(particularly)thefollowingfeatures:

o healthcontent–couldprioritisehealtheducation,maternalandreproductivehealth,childhealth,andfirstaid

o formatofmaterial–shouldmakefulluseofpictorialandvideo-basedmaterialandwithaudio(voiceclipsandautomatedtext–to–speechconversion)forusewhereliteracyislowand/orphonesthatcanshowvideoarenotavailable

o userinterface–needasimpleandintuitive“frontend”,witheasynavigationandiconsforuseinlowliteracysettings;

23

o technicalplatform–feature/smartphonesortabletscouldprobablybeassumedavailableforapplicationsaimedathealthworkers;applicationsfordirectusebycitizensandpatientswouldincreasinglybeabletodoassuchdevicesrapidlybecamelessexpensiveandmorewidespread.

- developingsuchapplicationsshouldbeaco-productioninvolvingcitizens,patients,carers,healthworkers,mobilephoneenterprisesandotherstakeholders–includinginternationalbodiessuchastheWHO.

Theseconclusionsstillstand,and,asthisupdateshows,therehasbeensomeencouragingprogress(forexamplemorelanguages,morevideocontentandmorematerialonfirstaidandhealtheducation)butsomeconsiderablewaystilltogoonoff-lineaccessanduser-friendlyinterfaces).Inadditiontothesepointsthisupdatehashighlightedorreinforcedanumberofkeyissuesbothfordevelopingappsandalsoinregardtoimproving“downstream”use:• appdevelopment–platformappssuchasOppiaMobileandtheRedCross“Universal

App”canmaketheappdevelopmentprocessmucheasier,andeasiertodevolvetonationalorregionalbodiestoensureappsaretailoredtolocalneeds.(AnexampleofworktosystematisedevelopmentanddeploymentismPoweringFrontlineHealthWorkers’“OpenDeliver”approach,whichcombinesexisting,opensourcetechnologiesintoanintegratedprocessfor“app”design,contentmodification/production,deploymenttomobiles,andusagemonitoring.Thesetechnologiesinclude:ORB,forsharingmobiletrainingcontent;Moodle,asystemforcoursecreation;andOppiaMobile,fordeliveryofcoursecontentinappform.)

• appavailability–thisclearlyremainsaproblem.Althoughmanyoftheassessedapps

areinprincipleavailabletomillions,evenhundredsofmillions,ofpeoplethroughnationalappstoresorotherwise,inpracticetheactualavailabilityislikelytobemuchless.Inparticular,therecanbedifficultieswherethereislimitedinternetaccess,especiallyofcourseforappsthatarenotfullydownloadableandsorequiremorethanaone-offonlineconnection.Therearevariousstepsthatcouldhelp,including:

o Continuingtotrytoincreaseavailabilitybyvoluntarycooperationwithmobile

phonecompaniesonpre-loadingappsonphonesorSDcards-asalreadydoneforthehigh-ratedHealthPhoneinIndia(andthelower-ratedSmartHealthinAfrica)

o Usingtechnicalinnovationssuchas”medicalinternet-in-abox”(see

http://internet-in-a-box.org)toovercometheneedforonlineaccess.(Theseboxeshavewifihotspotsandwillallowcitizensuptoseveralhundredmetresdistanttodownloadstoredhealthcareinformationcontent(suchasHealthPhonevideos),freeofcharge,totheirmobilephonesorotherdevices.Theycanrunonabatteryandthereforecangoanywhere.)

o Seekingtopersuade(perhapsonhumanrightsandpublichealthgrounds)oneor

moregovernmentstomakeinstallationofanapprovedapponessentialhealthcareinformationalegalrequirementformobilephonecompanies.(Thereissomeprecedentforthissortofaction-intheNetherlands,where,whenintroducingits

24

NL-Alertdisasterwarningservice,theDutchgovernmentrequiredmobilephonemanufacturerstopre-configureallnewcellularphonessothattheycouldautomaticallyreceivecellbroadcastsissuedbythisservice.)

Anotheravailabilityproblemthathasbeenreportedisindistinguishinganappfromanaccreditedsourcefromotheravailableapps,someofwhichcanlookdeceptivelysimilar(thishasforexamplebeenaproblemwiththeRedCrossapp).Atitsworst,thisisthemHealthequivalentofcounterfeitbrandedpharmaceuticals.ThismightbemitigatediftherewasoneplaceanLMICusercouldgotodownloadsomereputablehealthcareinformationapps,suchasacollectivesitethatdescribed,rated(usingmHIFA’swork)andprovidedeasyaccesstosuchapps(ref18)

• apptakeupanduse-thepenetrationandutilisationofappsprovidingessentialhealthcareinformation,evenwhentheyareavailable,isatinyfractionofwhatitcouldbe,especiallyinlower-incomecountries,andparticularlyfor“directtocitizen”apps.Someofthisobviouslyisduetotheasyetlimitedavailabilityofsmartphonesandinternetaccess,thoughthatisquiterapidlybecominglessofabarrier.Butevenwhenahealthcareinformationappisreadilyavailable,peoplestillmaynottakeituporuseit.Thisproblemcouldbetackledby:

o increasingawarenessthoughe.g.mediapublicity,althoughthatcanbeexpensive.

o increasingincentivesfortakeup,forexamplebyseekingandpublicisingcompellingexamplesofsuccessfuluse

o greateruseofintermediationbyhealthworkersi.e.healthworkershavingmaterialsuitableforusebycitizensontheirmobiledevicesandsharingitwiththem-andindeed,whereappropriate,thentransferringtheapptotheirphones.(Afurtheradvantageofthisapproachisthatitoffersatleastsomeaccesstosuchmaterialtopeoplewithoutamobilephone(seeegref19).

25

References1HagarC,KartzinelH,HealthcareInformationforAllby2015:Preliminaryfindingsandfuture2original2014paperonHIFAwebsite3Royston,G.;Hagar,C.;Long,L.-A.;McMahon,D.;Pakenham-Walsh,N.Mobilehealthcareinformationforall:aglobalchallenge.TheLancetGlobalHealth3(2015)7,pp.e356-e3574AgarwalS,RosenblumL,GoldschmidtT,CarrasM,GoalNandLabriqueA,MobileTechnologyinSupportofFrontlineHealthWorkers:Acomprehensiveoverviewofthelandscape,knowledgegapsandfuturedirections.JohnsHopkinsUniversity,GlobalmHealthInitiative,2016.5WHOSecretariat,mHealth:useofmobilewirelesstechnologiesforpublichealth,EB139/8,27May2016(accessedNov12016)6StoyanovSR,HidesL,KavanaghDJ,ZelenkoO,TjondronegoroD,ManiM.;MobileAppRatingScale:ANewToolforAssessingtheQualityofHealthMobileApps.EysenbachG,ed.; JMIRmHealthanduHealth;2015;3(1).7ThemHealthEvidenceWorkshop;MobileHealthTechnologyEvaluation;AmJPrevMed;August2013;45(2):228–236.8TLLewis;JCWyatt;mHealthandMobileMedicalApps:A FrameworktoAssessRiskandPromoteSaferUse;JMedicalInternetResearch,Sept201416(9) 9MAMAGlobalMonitoringandEvaluationFramework;July2012availableathttp://mobilemamaalliance.org/sites/default/files/MAMA_Global_MEPlan_FINAL_all.pdf10TomlinsonMetal,“ScalingUpmHealth:whereistheevidence?”PLOSMedicineFeb201310(2)

11AgarwalS,LeFevreAE,LeeJ,L’EngleK,MehlG,SinhaC,LabriquA;fortheWHOmHealthTechnicalEvidenceReviewGroup,Guidelinesforreportingofhealthinterventionsusingmobilephones:mobilehealth(mHealth)evidencereportingandassessment(mERA)checklistBMJ2016;352:i1174

12 TrilateralResearchLtd,FraunhoferInstituteforOpenCommunicationSystems,AsianDisasterPreparednessCenterandUtahStateUniversity,ComparativereviewoftheFirstAidApp,26february2016 http://preparecenter.org/ar/resources/comparative-review-first-aid-app(accessedOctober2016)13KlafftM,SaidM,AnsonS,WatsonH,HughesA,LukauE,ChallengesinDesigningandDistributingaNotForProfitFirstAidAppWorldwide,In:HeinrichC.Mayr,MartinPinzger(Eds.):INFORMATIK2016.LectureNotesinInformatics,VolumeP-259,Bonn:GesellschaftfürInformatik,pp.1745-175814YadavSandRawaiG,TheHIFAandtheHealthPhone:LayingtheFoundationforCombatingMalnutritioninIndia,InternationalJournalofHealthScienceandResearch,5(7),July2015368-37115HealthWorkerTrainingviapartnershipwiththeORBpilotinOndoState.https://www.ghdonline.org/uploads/ORB_evaluation_in_Nigeria.pdf(accessedNov12016)16LundS,BoasIM,BedesaT,FekedeW,NielsenHS,SørensenBL.AssociationBetweentheSafeDeliveryAppandQualityofCareandPerinatalSurvivalinEthiopiaARandomizedClinicalTrial.JAMAPediatr.2016;170(8):765-771.doi:10.1001/jamapediatrics.2016.068717http://www.medicalaidfilms.org/learn/how-we-make-a-difference/AccessedDec62016)18asuggestionfromChrisZielinski19Larsen-CooperE,BancroftE,O’TooleMandJezmanZ.Wherethereisnophone:ThebenefitsandlimitationsofusingintermediariestoextendthereachofmHealthtoindividualswithoutpersonalphonesinMalawi.AfricanPopulationStudies,29(1):1628-1642,June2015.doi:http://dx.doi.org/10.11564/29-1-714.

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