1. Tale of two mobile interventions to improve quality of health care Oluwaseun Adeleke, Abt Assoc Odartei Lamptey, Abt Assoc CRS ICT4D Conference March 19 th to 21 st, 2013

2. Abt Associates Two unrelated projects using common “mhealth” approaches  Case study #1: Using smart phones for data-driven improvement at TB facilities in Nigeria  Case study #2: Evaluating impact of text messages on drug vendor treatment for diarrhea Ghana Shared themes Interventions designed to improve quality of care through data driven corrective actions Needs-based, government-led activities Technology rides on capacity to strengthen existing government systems Pilot directed at improvement of content/process and mentorship for skill acquisition Applications designed as M&E tool to assess gaps and outcomes Sustainability planning Contribute to mhealth evidence base

3. Abt Associates Case study #1 Using Smart Phones for Data Driven Improvements in Nigerian TB Clinics

4. Abt Associates | pg 4 Background High-Burden TB Countries – WHO Global TB Report  Nigeria (13th) rank among the highest Tuberculosis (TB) burden countries in the world.  Desk review revealed need for strengthening Supportive Supervision (SS) to improve performance and treatment outcomes  Nigeria was open to exploring new and innovative ways of improving quality through SS

5. Abt Associates | pg 5 Goals 1.Move away from long, paper-based checklists 2.Reduce time for data entry & analysis and human error 3.Concentrate on performance of clinical tasks and resolution of problems experienced by the health worker 4.Increase feedback from supervisors 5.Provide evidence for policy and planning (goal linked to online database)

6. Abt Associates | pg 6 Mobile ICT - Opportunities  Percentage of users accessing the web using mobile phones is increasing: Nigeria (63.9%)  Smartphones are getting cheaper (moving towards a retail price of $100 or less).  Today’s smartphones are essentially mini-computers – relevant not just for collecting data but also useful for analysis that will inform planning, policy direction & decision making

7. Abt Associates | pg 7 Innovation 1.Consolidated checklist loaded onto Smartphone 2.Forms programmed to do automatic calculations of critical indicators; reducing human error 3.Rapid review of critical indicators allows for immediate feedback and corrective action at the facility 4.Data sent immediately to an online database for State and Federal level analysis

8. Abt Associates | pg 8 Impact Community-based defaulter tracing Better record keeping Drug stock-outs decreased External quality control results obtained SIM cards independently purchased = sustainability indicator! Success recorded in Nigeria & Ethiopia has initiated increasing demand from other countries e.g. Malawi, South- Sudan … 8

9. Abt Associates | pg 9 Case study #2 Assessing Impact of Text Messages on Drug Vendor Treatment for Diarrhea

10. Abt Associates | pg 10 Background Information  Diarrhea Prevalence = 20% (2008 GDHS); diarrhea deaths represent 9% of all child deaths  WHO recommended treatment protocol zinc + ORS not widely followed  SHOPS Ghana program –Increase product supply through pharmaceutical partnerships –Conduct mass media communications campaign –Educate provider communities about protocols

11. Abt Associates | pg 11 Research to evaluate impact of text message reinforcement Control CONTROL (n=472) Training only TREAT M ENT TREATMENT (n=472) Training + 3 texts/week for 8 weeks ALL LCS RECEIVE MANDATORY ZINC/ORS TRAINING

12. Abt Associates | pg 12 Text message impact evaluation  Methodology  Both control and treatment groups interviewed about knowledge and practice: researchers blind to assignment arms  Mystery shopper visited each seeking treatment for baby’s diarrhea  Results (preliminary, analysis is ongoing):  Training + texts result in statistically significant difference in knowledge of zinc/ORS as appropriate treatment,  Training + texts did not show statistically significant difference in sales of (non-recommended) antibiotics though the trend was in the right direction

13. Abt Associates | pg 13 Implementation feedback: Messages received as welcome and helpful “The quizzes cast my mind back to the seminar” “Both tips & quizzes were very educative” Universal support for Pharmacy Council to continue use of reinforcing text education

14. Abt Associates | pg 14 Challenges: Unexpected problems with correct formatting  Failure to use key word SHOPS  Chatty replies: “SHOPS that is not the answer we learned”  Literal replies: “Respond SHOPS A, B, or C”  Other reasons responses not received –Don’t know how to open/send text –Too busy –Phone problems Majority non-responders said they read the texts (including correct quiz answers) Responders & non-responders did not vary in adherence to recommended treatment

15. Abt Associates | pg 15 Lessons learnt  RCT results: –Correct knowledge is necessary condition for behavior change, but not sufficient. Widely used “self-reports” from providers on their practices may not be truthful.  Text message implementation: –Texts are a valuable way to stay in touch with large numbers of trainees, reinforce treatment guidelines –Interactive assessments may have low response rate due to embarrassment about getting quiz wrong, need for practice –Spacing text messages throughout the year likely to improve results: difference in knowledge between intervention and control groups decreased over time

16. Thank You!