Publications by authors named "Martin Were"

65 Publications

Comparative analysis of competency coverage within accredited master's in health informatics programs in the East African region.

J Am Med Inform Assoc 2021 Jun 21. Epub 2021 Jun 21.

Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objective: As master of science in health informatics (MSc HI) programs emerge in developing countries, quality assurance of these programs is essential. This article describes a comprehensive comparative analysis of competencies covered by accredited MSc HI programs in the East African common labor and educational zone.

Materials And Methods: Two reviewers independently reviewed curricula from 7 of 8 accredited MSc HI university programs. The reviewers extracted covered competencies, coding these based on a template that contained 73 competencies derived from competencies recommended by the International Medical Informatics Association, plus additional unique competencies contained within the MSc HI programs. Descriptive statistics were used to summarize the structure and completion requirements of each MSc HI program. Jaccard similarity coefficient was used to compare similarities in competency coverage between universities.

Results: The total number of courses within the MSc HI degree programs ranged from 8 to 22, with 35 to 180 credit hours. Cohen's kappa for coding competencies was 0.738. The difference in competency coverage was statistically significant across the 7 institutions (P = .012), with covered competencies across institutions ranging from 32 (43.8%) to 49 (67.1%) of 73. Only 4 (19%) of 21 university pairs met a cutoff of over 70% similarity in shared competencies.

Discussion: Significant variations observed in competency coverage within MSc HI degree programs could limit mobility of student, faculty, and labor.

Conclusions: Comparative analysis of MSc HI degree programs across 7 universities in East Africa revealed significant differences in the competencies that were covered.
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http://dx.doi.org/10.1093/jamia/ocab075DOI Listing
June 2021

Effect of Mobile Phone Text Message Reminders on the Completion and Timely Receipt of Routine Childhood Vaccinations: Superiority Randomized Controlled Trial in Northwest Ethiopia.

JMIR Mhealth Uhealth 2021 06 15;9(6):e27603. Epub 2021 Jun 15.

Department of Health Informatics, Institute of Public Health, University of Gondar, Gondar, Ethiopia.

Background: Nonattendance at vaccination appointments is a big challenge for health workers as it is difficult to track routine vaccination schedules. In Ethiopia, 3 out of 10 children have incomplete vaccination and the timely receipt of the recommended vaccines is low. Thus, innovative strategies are required to reach the last mile where mobile technology can be effectively utilized to achieve better compliance. Despite this promising technology, little is known about the role of text message-based mobile health interventions in improving the complete and timely receipt of routine childhood vaccinations in Ethiopia.

Objective: This trial aimed to determine the effect of mobile phone text message reminders on the completion and timely receipt of routine childhood vaccinations in northwest Ethiopia.

Methods: A two-arm, parallel, superiority randomized controlled trial was conducted in 9 health facilities in northwest Ethiopia. A sample size of 434 mother-infant pairs was considered in this trial. Randomization was applied in selected health facilities during enrollment with a 1:1 allocation ratio by using sealed and opaque envelopes. Participants assigned to the intervention group received mobile phone text message reminders one day before the scheduled vaccination visits. Owing to the nature of the intervention, blinding of participants was not possible. Primary outcomes of full and timely completion of vaccinations were measured objectively at 12 months. A two-sample test of proportion and log-binomial regression analyses were used to compare the outcomes between the study groups. A modified intention-to-treat analysis approach was applied and a one-tailed test was reported, considering the superiority design of the trial.

Results: A total of 426 participants were included for the analysis. We found that a higher proportion of infants in the intervention group received Penta-3 (204/213, 95.8% vs 185/213, 86.9%, respectively; P<.001), measles (195/213, 91.5% vs 169/213, 79.3%, respectively; P<.001), and full vaccination (176/213, 82.6% vs 151/213, 70.9%, respectively; P=.002; risk ratio 1.17, 95% lower CI 1.07) compared to infants in the usual care group. Similarly, a higher proportion of infants in the intervention group received Penta-3 (181/204, 88.7% vs 128/185, 69.2%, respectively; P<.001), measles (170/195, 87.1% vs 116/169, 68.6%, respectively; P<.001), and all scheduled vaccinations (135/213, 63.3% vs 85/213, 39.9%, respectively; P<.001; risk ratio 1.59, 95% lower CI 1.35) on time compared to infants in the usual care group. Of the automatically sent 852 mobile phone text messages, 764 (89.7%) were delivered successfully to the participants.

Conclusions: Mobile phone text message reminders significantly improved complete and timely receipt of all recommended vaccines. Besides, they had a significant effect in improving the timely receipt of specific vaccines. Thus, text message reminders can be used to supplement the routine immunization program in resource-limited settings. Considering different contexts, studies on the implementation challenges of mobile health interventions are recommended.

Trial Registration: Pan African Clinical Trial Registry PACTR201901533237287; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5839.
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http://dx.doi.org/10.2196/27603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277338PMC
June 2021

Acceptability, Barriers and Facilitators of Mobile Text Message Reminder System Implementation in Improving Child Vaccination: A Qualitative Study in Northwest Ethiopia.

J Multidiscip Healthc 2021 9;14:605-616. Epub 2021 Mar 9.

Department of Health Informatics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.

Background: Mobile phone text message-based mHealth interventions have shown promise in improving health service delivery. Despite the promising findings at a small scale and few contexts, implementing new technologies as part of changes to health care services is inherently challenging. Though there is a potential to introduce mHealth initiatives to health systems of developing countries, existing evidence on the barriers and facilitators of implementation in different contexts is not adequate. Therefore, this study aimed to explore the acceptability, barriers and facilitators of implementing mobile text message reminder system for child vaccination in Ethiopia.

Methods: This study applied a phenomenological study design. The study was conducted in north-west, Ethiopia between July 28 and August 19, 2020. A total of 23 participants were purposively selected for the in-depth and key informant interviews. We used an interview guide to collect data and audio-records of interviews were transcribed verbatim. Coding was done to identify patterns and thematic analysis was conducted using ATLAS ti7 software.

Results: The findings indicated that mothers were receptive to mobile text message reminders for their child's vaccination. Low mobile phone ownership, access to mobile network, access to electricity and illiteracy among the target population were identified as barriers that would affect implementation. Confidentiality and security-related issues are not barriers to implementation of text message reminders for child vaccination service. Facilitators for implementation include stakeholder collaboration, providing orientation/training to users, and willingness to pay by clients.

Conclusion: In this study, using mobile phone text message reminders for child vaccination services are acceptable by clients. Barriers identified were related to inadequate ICT infrastructure and other technical issues. Addressing the potential barriers and leveraging the existing opportunities could optimize the implementation in resource-limited settings. Before actual implementation, program implementers should also consider providing orientation to users on the proposed mHealth program.
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http://dx.doi.org/10.2147/JMDH.S298167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955748PMC
March 2021

Mothers intention and preference to use mobile phone text message reminders for child vaccination in Northwest Ethiopia.

BMJ Health Care Inform 2021 Feb;28(1)

Department of Health Informatics, Institute of Public Health,College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.

Objectives: With the unprecedented penetration of mobile devices in the developing world, mHealth applications are being leveraged for different health domains. Among the different factors that affect the use of mHealth interventions is the intention and preference of end-users to use the system. This study aimed to assess mother's intention and preference to use text message reminders for vaccination in Ethiopia.

Methods: A cross-sectional study was conducted among 460 mothers selected through a systematic random sampling technique. Initially, descriptive statistics were computed. Binary logistic regression analysis was also used to assess factors associated with the outcome variable.

Results: In this study, of the 456 mothers included for analysis, 360 (78.9%) of mothers have intention to use text message reminders for vaccination. Of these, 270 (75%) wanted to receive the reminders a day before the vaccination due date. Mothers aged 35 years or more (AOR=0.35; 95% CI: 0.15 to 0.83), secondary education and above (AOR=4.43; 95% CI: 2.05 to 9.58), duration of mobile phone use (AOR=3.63; 95% CI: 1.66 to 7.94), perceived usefulness (AOR=6.37; 95% CI: 3.13 to 12.98) and perceived ease of use (AOR=3.85; 95% CI: 2.06 to 7.18) were predictors of intention to use text messages for vaccination.

Conclusion: In conclusion, majority of mothers have the intention to use text message reminders for child vaccination. Mother's age, education, duration of mobile phone use, perceived usefulness and perceived ease of use were associated with intention of mothers to use text messages for vaccination. Considering these predictors and user's preferences before developing and testing text message reminder systems is recommended.
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http://dx.doi.org/10.1136/bmjhci-2020-100193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898827PMC
February 2021

Development of standard indicators to assess use of electronic health record systems implemented in low-and medium-income countries.

PLoS One 2021 11;16(1):e0244917. Epub 2021 Jan 11.

Institute of Biomedical Informatics, Moi University, Eldoret, Kenya.

Background: Electronic Health Record Systems (EHRs) are being rolled out nationally in many low- and middle-income countries (LMICs) yet assessing actual system usage remains a challenge. We employed a nominal group technique (NGT) process to systematically develop high-quality indicators for evaluating actual usage of EHRs in LMICs.

Methods: An initial set of 14 candidate indicators were developed by the study team adapting the Human Immunodeficiency Virus (HIV) Monitoring, Evaluation, and Reporting indicators format. A multidisciplinary team of 10 experts was convened in a two-day NGT workshop in Kenya to systematically evaluate, rate (using Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) criteria), prioritize, refine, and identify new indicators. NGT steps included introduction to candidate indicators, silent indicator ranking, round-robin indicator rating, and silent generation of new indicators. 5-point Likert scale was used in rating the candidate indicators against the SMART components.

Results: Candidate indicators were rated highly on SMART criteria (4.05/5). NGT participants settled on 15 final indicators, categorized as system use (4); data quality (3), system interoperability (3), and reporting (5). Data entry statistics, systems uptime, and EHRs variable concordance indicators were rated highest.

Conclusion: This study describes a systematic approach to develop and validate quality indicators for determining EHRs use and provides LMICs with a multidimensional tool for assessing success of EHRs implementations.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244917PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799790PMC
May 2021

Evaluating performance of health care facilities at meeting HIV-indicator reporting requirements in Kenya: an application of K-means clustering algorithm.

BMC Med Inform Decis Mak 2021 01 6;21(1). Epub 2021 Jan 6.

Department of Information Science and Media Studies, University of Bergen, Bergen, Norway.

Background: The ability to report complete, accurate and timely data by HIV care providers and other entities is a key aspect in monitoring trends in HIV prevention, treatment and care, hence contributing to its eradication. In many low-middle-income-countries (LMICs), aggregate HIV data reporting is done through the District Health Information Software 2 (DHIS2). Nevertheless, despite a long-standing requirement to report HIV-indicator data to DHIS2 in LMICs, few rigorous evaluations exist to evaluate adequacy of health facility reporting at meeting completeness and timeliness requirements over time. The aim of this study is to conduct a comprehensive assessment of the reporting status for HIV-indicators, from the time of DHIS2 implementation, using Kenya as a case study.

Methods: A retrospective observational study was conducted to assess reporting performance of health facilities providing any of the HIV services in all 47 counties in Kenya between 2011 and 2018. Using data extracted from DHIS2, K-means clustering algorithm was used to identify homogeneous groups of health facilities based on their performance in meeting timeliness and completeness facility reporting requirements for each of the six programmatic areas. Average silhouette coefficient was used in measuring the quality of the selected clusters.

Results: Based on percentage average facility reporting completeness and timeliness, four homogeneous groups of facilities were identified namely: best performers, average performers, poor performers and outlier performers. Apart from blood safety reports, a distinct pattern was observed in five of the remaining reports, with the proportion of best performing facilities increasing and the proportion of poor performing facilities decreasing over time. However, between 2016 and 2018, the proportion of best performers declined in some of the programmatic areas. Over the study period, no distinct pattern or trend in proportion changes was observed among facilities in the average and outlier groups.

Conclusions: The identified clusters revealed general improvements in reporting performance in the various reporting areas over time, but with noticeable decrease in some areas between 2016 and 2018. This signifies the need for continuous performance monitoring with possible integration of machine learning and visualization approaches into national HIV reporting systems.
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http://dx.doi.org/10.1186/s12911-020-01367-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789797PMC
January 2021

mHealth spectroscopy of blood hemoglobin with spectral super-resolution.

Optica 2020 Jun;7(6):563-573

Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana 47907, USA.

Although blood hemoglobin (Hgb) testing is a routine procedure in a variety of clinical situations, noninvasive, continuous, and real-time blood Hgb measurements are still challenging. Optical spectroscopy can offer noninvasive blood Hgb quantification, but requires bulky optical components that intrinsically limit the development of mobile health (mHealth) technologies. Here, we report spectral super-resolution (SSR) spectroscopy that virtually transforms the built-in camera (RGB sensor) of a smartphone into a hyperspectral imager for accurate and precise blood Hgb analyses. Statistical learning of SSR enables us to reconstruct detailed spectra from three color RGB data. Peripheral tissue imaging with a mobile application is further combined to compute exact blood Hgb content without personalized calibration. Measurements over a wide range of blood Hgb values show reliable performance of SSR blood Hgb quantification. Given that SSR does not require additional hardware accessories, the mobility, simplicity, and affordability of conventional smartphones support the idea that SSR blood Hgb measurements can be used as an mHealth method.
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http://dx.doi.org/10.1364/optica.390409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755164PMC
June 2020

International Comparison of Six Basic eHealth Indicators Across 14 Countries: An eHealth Benchmarking Study.

Methods Inf Med 2020 12 18;59(S 02):e46-e63. Epub 2020 Nov 18.

Clinical Informatics Center, Department of Pediatrics, Bioinformatics, and Population and Data Sciences, University of Texas Southwestern, Dallas, Texas, United States.

Background: Many countries adopt eHealth applications to support patient-centered care. Through information exchange, these eHealth applications may overcome institutional data silos and support holistic and ubiquitous (regional or national) information logistics. Available eHealth indicators mostly describe usage and acceptance of eHealth in a country. The eHealth indicators focusing on the cross-institutional availability of patient-related information for health care professionals, patients, and care givers are rare.

Objectives: This study aims to present eHealth indicators on cross-institutional availability of relevant patient data for health care professionals, as well as for patients and their caregivers across 14 countries (Argentina, Australia, Austria, Finland, Germany, Hong Kong as a special administrative region of China, Israel, Japan, Jordan, Kenya, South Korea, Sweden, Turkey, and the United States) to compare our indicators and the resulting data for the examined countries with other eHealth benchmarks and to extend and explore changes to a comparable survey in 2017. We defined "availability of patient data" as the ability to access data in and to add data to the patient record in the respective country.

Methods: The invited experts from each of the 14 countries provided the indicator data for their country to reflect the situation on August 1, 2019, as date of reference. Overall, 60 items were aggregated to six eHealth indicators.

Results: Availability of patient-related information varies strongly by country. Health care professionals can access patients' most relevant cross-institutional health record data fully in only four countries. Patients and their caregivers can access their health record data fully in only two countries. Patients are able to fully add relevant data only in one country. Finland showed the best outcome of all eHealth indicators, followed by South Korea, Japan, and Sweden.

Conclusion: Advancement in eHealth depends on contextual factors such as health care organization, national health politics, privacy laws, and health care financing. Improvements in eHealth indicators are thus often slow. However, our survey shows that some countries were able to improve on at least some indicators between 2017 and 2019. We anticipate further improvements in the future.
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http://dx.doi.org/10.1055/s-0040-1715796DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7728164PMC
December 2020

Data cleaning process for HIV-indicator data extracted from DHIS2 national reporting system: a case study of Kenya.

BMC Med Inform Decis Mak 2020 11 13;20(1):293. Epub 2020 Nov 13.

Department of Information Science and Media Studies, University of Bergen, Bergen, Norway.

Background: The District Health Information Software-2 (DHIS2) is widely used by countries for national-level aggregate reporting of health-data. To best leverage DHIS2 data for decision-making, countries need to ensure that data within their systems are of the highest quality. Comprehensive, systematic, and transparent data cleaning approaches form a core component of preparing DHIS2 data for analyses. Unfortunately, there is paucity of exhaustive and systematic descriptions of data cleaning processes employed on DHIS2-based data. The aim of this study was to report on methods and results of a systematic and replicable data cleaning approach applied on HIV-data gathered within DHIS2 from 2011 to 2018 in Kenya, for secondary analyses.

Methods: Six programmatic area reports containing HIV-indicators were extracted from DHIS2 for all care facilities in all counties in Kenya from 2011 to 2018. Data variables extracted included reporting rate, reporting timeliness, and HIV-indicator data elements per facility per year. 93,179 facility-records from 11,446 health facilities were extracted from year 2011 to 2018. Van den Broeck et al.'s framework, involving repeated cycles of a three-phase process (data screening, data diagnosis and data treatment), was employed semi-automatically within a generic five-step data-cleaning sequence, which was developed and applied in cleaning the extracted data. Various quality issues were identified, and Friedman analysis of variance conducted to examine differences in distribution of records with selected issues across eight years.

Results: Facility-records with no data accounted for 50.23% and were removed. Of the remaining, 0.03% had over 100% in reporting rates. Of facility-records with reporting data, 0.66% and 0.46% were retained for voluntary medical male circumcision and blood safety programmatic area reports respectively, given that few facilities submitted data or offered these services. Distribution of facility-records with selected quality issues varied significantly by programmatic area (p < 0.001). The final clean dataset obtained was suitable to be used for subsequent secondary analyses.

Conclusions: Comprehensive, systematic, and transparent reporting of cleaning-process is important for validity of the research studies as well as data utilization. The semi-automatic procedures used resulted in improved data quality for use in secondary analyses, which could not be secured by automated procedures solemnly.
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http://dx.doi.org/10.1186/s12911-020-01315-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7664027PMC
November 2020

Coverage of IMIA-recommended Competencies by Masters in Health Informatics Degree Programs in East Africa.

Int J Med Inform 2020 11 1;143:104265. Epub 2020 Sep 1.

Vanderbilt University Medical Center, 2525 West End Avenue, Suite 11000, Nashville, TN, 37203, United States. Electronic address:

Objective: The International Medical Informatics Association (IMIA) has provided recommendations on Education in Biomedical and Health Informatics (BMHI) as guidance on competencies relevant to education of BMHI specialists. However, it remains unclear how well these competencies have been adopted to guide emerging degree programs in low- and middle-income countries (LMICs). We evaluated comprehensiveness of IMIA-recommended competency coverage by Masters in Health Informatics (MSc HI) programs in East Africa.

Materials And Methods: Two investigators independently reviewed curricula for seven accredited MSc HI university programs in the East Africa region to extract covered competencies using an instrument based on the IMIA education recommendations. Descriptive statistics were used to determine competency coverage by institution and across institutions and by IMIA-defined competency domains. Duplication of competency coverage in courses within each curriculum was also evaluated. Multivariable logistic regression was used to test whether coverage of IMIA-recommended competencies differed between institutions.

Results: Cohen's Kappa for coding competencies within courses was 0.738 (95% CI, 0.713-0.764). Coverage of the 40 recommended required IMIA competencies by institutional curricula ranged from 25 (62.5%) to 39 (97.5%) (p < 0.0001), with only 18 (45%) of these competencies covered by all seven institutions. No significant variations in competency coverage were observed between the domains of information sciences (83.7%), health sciences (71.4%), and core BMHI competencies (83.5%) (p = 0.13). On average, each competency was covered by 3.06 courses in each curriculum (range 0 - 14). Curricula also contained 25 additional competencies not part of the IMIA recommendations, 15 of which were found only within the curriculum of a single institution.

Discussion: There is significant variability in coverage of IMIA-recommended competencies across MSc HI curricula evaluated, with observed duplication of competency coverage within each curriculum. The additional competencies uncovered that were not part of the IMIA-recommendations were not universally shared across institutions.

Conclusion: The IMIA education recommendations provide a relevant, comprehensive reference guide for developing and improving health informatics degree programs within LMIC settings. Variability in competency coverage needs to be addressed for institutions within similar educational and labor regions.
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http://dx.doi.org/10.1016/j.ijmedinf.2020.104265DOI Listing
November 2020

Assessment of HIV Data Reporting Performance by Facilities During EMR Systems Implementations in Kenya.

Stud Health Technol Inform 2020 Jun;272:167-170

Vanderbilt University Medical Center, US.

There is little evidence that implementations of Electronic Medical Record Systems (EMRs) are associated with better reporting completeness and timeliness of HIV routine data to the national aggregate system. We analyzed the reporting completeness and timeliness of HIV reports to Kenya's national aggregate reporting system from District Health Information Software 2 (DHIS2) for the period 2011 to 2018. On average, reporting completeness improved to 97% whilst timeliness increased to 83% in 2017 with similar performance for the facilities under study that implemented either KenyaEMR or IQCare. However, in 2018, the reporting rates dropped by 13% for completeness and 11% for timeliness most likely due to changed reporting procedures. This suggests that besides EMRs, there are other factors influencing reporting such as reporting routines, which need to be assessed separately. Nonetheless, the EMRs have facilitated the collection of HIV data for submission to the DHIS2, which in turn facilitates the reporting process for the data officers.
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http://dx.doi.org/10.3233/SHTI200520DOI Listing
June 2020

K-Means Clustering in Monitoring Facility Reporting of HIV Indicator Data: Case of Kenya.

Stud Health Technol Inform 2020 Jun;272:143-146

Vanderbilt University Medical Center, US.

Health management information systems (HMISs) in low- and middle-income countries have been used to collect large amounts of data after years of implementation, especially in support of HIV care services. National-level aggregate reporting data derived from HMISs are essential for informed decision-making. However, the optimal statistical approaches and algorithms for deriving key insights from these data are yet to be fully and adequately utilized. This paper demonstrates use of the k-means clustering algorithm as an approach in supporting monitoring of facility reporting and data-informed decision-making, using the case example of Kenya HIV national reporting data. Results reveal four homogeneous cluster categories that can be used in assessing overall facility performance and rating of that performance.
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http://dx.doi.org/10.3233/SHTI200514DOI Listing
June 2020

Health Facility Ownership Type and Performance on HIV Indicator Data Reporting in Kenya.

Stud Health Technol Inform 2020 Jun;270:1301-1302

Vanderbilt University Medical Center, USA.

In low- and middle-income countries, private and public facilities tend to have highly variable characteristics, which might affect their performance in meeting reporting requirements mandated by ministries of health. There is conflicting evidence on which facility type performs better across various care dimensions, and only few studies exist to evaluate relative performance around nationally-mandated indicator reporting to Ministries of Health. In this study, we evaluated the relationship between facility ownership type and performance on HIV indicator data reporting, using the case of Kenya. We conducted Mann-Whitney U tests using HIV indicator data extracted from years 2011 to 2018 for all the counties in Kenya, from the District Health Information Software 2 (DHIS2). Results from the study reveal that public facilities have statistically significant better performance compared to private facilities, with an exception of year 2017 in reporting of counselling and testing, and prevention of mother-to-child transmission indicator categories.
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http://dx.doi.org/10.3233/SHTI200412DOI Listing
June 2020

Performance of an open source facial recognition system for unique patient matching in a resource-limited setting.

Int J Med Inform 2020 09 4;141:104180. Epub 2020 Jun 4.

Institute of Biomedical Informatics, Moi University, Eldoret, Kenya; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address:

Background: The lack of unique patient identifiers is a challenge to patient care in developing countries. Probabilistic and deterministic matching approaches remain sub-optimal. However, affordable and scalable biometric solutions have not been rigorously evaluated in these settings.

Methods: We implemented and evaluated performance of an open-source facial recognition system, OpenFace, integrated within a nationally-endorsed electronic health record system in Western Kenya. Patients were first enrolled via facial images, and later matched via the system. Accuracy of facial recognition was evaluated using Sensitivity; False Acceptance Rate (FAR); False Rejection Rate (FRR); Failure to Capture Rate (FTC) and Failure to Enroll Rate (FTE). 103 patients (mean age 37.8, 49.5% female) were enrolled.

Results: The system had a sensitivity of 99.0%, FAR <1%, FRR 0.00, FTC 0.00 and FTE 0.00. Wearing spectacles did not affect performance.

Conclusion: An open source facial recognition system correctly and accurately identified almost all patients during the first match.
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http://dx.doi.org/10.1016/j.ijmedinf.2020.104180DOI Listing
September 2020

Timely completion of vaccination and its determinants among children in northwest, Ethiopia: a multilevel analysis.

BMC Public Health 2020 Jun 11;20(1):908. Epub 2020 Jun 11.

Department of Health Informatics, Institute of Public Health, University of Gondar, Gondar, Ethiopia.

Background: Timely vaccination is key to prevent unnecessary childhood mortality from vaccine-preventable diseases. Despite the substantial efforts to improve vaccination completeness, the effort towards timeliness of vaccination is limited with non-attendance and delays to vaccination appointments remaining a big challenge in developing countries. There is also a limited evidence on timeliness of vaccination. Therefore, this study aimed to determine the magnitude and associated factors for timely completion of vaccination among children in Gondar city administration, north-west, Ethiopia.

Method: This study employed a community-based cross sectional study design. A sample size of 821 children aged 12 to 23 months were considered. Two stages random sampling technique was used to select study subjects. To account the effect of clustering, bivariable and multivariable multilevel logistic regression analysis were applied. The measures of association estimates were expressed as adjusted odds ratio (AOR) with their 95% confidence intervals (CIs).

Results: Of the 774 children included for analysis, 498 (64.3%) were fully vaccinated while 247 (31.9%) were fully vaccinated on-time. Caregivers who had secondary education and above (AOR = 2.391; 95% CI: 1.317-4.343), from richest households (AOR = 2.381; 95% CI: 1.502-3.773), children whose mother attended four or more ante natal care visits (AOR = 2.844; 95% CI: 1.310-6.174) and whose mother had two or more post natal care visits (AOR = 2.054; 95%CI:1.377-3.063) were positively associated with on-time full vaccination. In contrary, caregivers aged above 35 years (AOR = 0.469; 95 % CI: 0.253-0.869], being vaccinated at health post (AOR = 0.144; 95%CI: 0.048-0.428) and travelling more than 30 min to the vaccination site (AOR = 0.158; 95%CI: 0.033-0.739) were negatively associated with on-time full vaccination. The random effects indicated that 26% of the variability in on-time full vaccination was attributable to differences between communities.

Conclusion: In this study, untimely vaccination was found to be high. Different individual and contextual factors were found to be associated with on-time full vaccination. Therefore, tailored strategies have to be designed and implemented to address people and the communities where they live. Moreover, timeliness of vaccination should be considered as important indicator of the immunization program performance in Ethiopia.
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http://dx.doi.org/10.1186/s12889-020-08935-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7291496PMC
June 2020

Therapeutic turnaround times for common laboratory tests in a tertiary hospital in Kenya.

PLoS One 2020 8;15(4):e0230858. Epub 2020 Apr 8.

Department of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America.

Methods: We evaluated therapeutic TAT for a tertiary hospital in Western Kenya, using a time-motion study focusing specifically on common hematology and biochemistry orders. The aim was to determine significant bottlenecks in diagnostic testing processes at the institution.

Results: A total of 356 (155 hematology and 201 biochemistry) laboratory tests were fully tracked from the time of ordering to availability of results to care providers. The total therapeutic TAT for all tests was 21.5 ± 0.249 hours (95% CI). The therapeutic TAT for hematology was 20.3 ± 0.331 hours (95% CI) while that for biochemistry tests was 22.2 ± 0.346 hours (95% CI). Printing, sorting and dispatch of the printed results emerged as the most significant bottlenecks, accounting for up to 8 hours of delay (Hematology-8.3 ± 1.29 hours (95% CI), Biochemistry-8.5 ± 1.18 hours (95% CI)). Time of test orders affected TAT, with orders made early in the morning and those in the afternoon experiencing the most delays in TAT.

Conclusion: Significant inefficiencies exist at multiple steps in the turnaround times for routine laboratory tests at a large referral hospital within an LMIC setting. Multiple opportunities exist to improve TAT and streamline processes around diagnostic testing in this and other similar settings.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230858PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141613PMC
July 2020

Effect of mobile phone text message reminders on improving completeness and timeliness of routine childhood vaccinations in North-West, Ethiopia: a study protocol for randomised controlled trial.

BMJ Open 2019 11 5;9(11):e031254. Epub 2019 Nov 5.

Institute of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Introduction: Non-attendance and delay in vaccination schedules remain a big challenge to healthcare workers. With the continuous growth of mobile network coverage and exponential penetration of mobile devices in the developing world, adoption of short message service has been shown to increase attendance for health services by targeting participant characteristics such as forgetfulness. Therefore, the aim of this trial is to determine the effect of mobile text message reminders on completeness and timeliness of childhood vaccination in North-West, Ethiopia.

Methods And Analysis: A two-arm, parallel, superiority, randomised controlled trial study will be employed. The study arms are the intervention group (text message reminders plus routine care) and the control group (routine care only). Mother-infant pairs will be randomised to one of the groups during enrolment. The trial will consider a sample size of 434 mother-infant pairs with 1:1 allocation ratio. Mothers assigned to the intervention group will receive text message reminder 1 day before the scheduled vaccination visit at 6 weeks, 10 weeks, 14 weeks and at 9 months. Initially, descriptive statistics will be computed. For the primary outcome log-binomial regression model will be used to identify associated factors, and relative risk with 95% CI will be reported. Primarily, iIntention-to-treat analysis principle will be applied. STATA V.14 software will be used for the analysis.

Ethics And Dissemination: This study obtained ethical approval from the University of Gondar Institutional Ethical Review Board. The trial findings on the effectiveness of mobile text message reminders in improving vaccination uptake will help to inform decision makers on the use of mobile health interventions in developing countries like Ethiopia. The scientific findings of the trial will also be published in reputable journals.

Trial Registration Number: PACTR201901533237287.
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http://dx.doi.org/10.1136/bmjopen-2019-031254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858152PMC
November 2019

Mobile Phone Access and Willingness Among Mothers to Receive a Text-Based mHealth Intervention to Improve Prenatal Care in Northwest Ethiopia: Cross-Sectional Study.

JMIR Pediatr Parent 2018 Oct 17;1(2):e9. Epub 2018 Oct 17.

eHealthLab Ethiopia, Department of Health Informatics, University of Gondar, Gondar, Ethiopia.

Background: Maternal mortality remains high in many low- and middle-income countries where limited access to health services is linked to low antenatal care utilization. Effective communication and engagement with care providers are vital for the delivery and receipt of sufficient health care services. There is strong evidence that simple text-based interventions can improve the prenatal care utilization, but most mobile health (mHealth) interventions are not implemented on a larger scale owing to the lack of context and preliminary evidence on how to make the transition.

Objective: The objective of this study was to determine access to mobile phones by pregnant women attending antenatal care as well as willingness to receive a text message (short message service, SMS)-based mHealth intervention for antenatal care services and identify its associated factors among pregnant women attending an antenatal care clinic in Gondar Town Administration, Northwest Ethiopia, Africa.

Methods: A cross-sectional quantitative study was conducted among 422 pregnant women attending antenatal care from March 27 to April 28, 2017. Data were collected using structured questionnaires. Data entry and analysis were performed using Epi-Info version 7 and SPSS version 20, respectively. In addition, descriptive statistics and bivariable and multivariable logistic regression analyses were performed. Furthermore, odds ratio with 95% CI was used to identify factors associated with the willingness to receive a text message-based mHealth intervention.

Results: A total of 416 respondents (response rate 98.6%, 416/422) were included in the analysis. About 76.7% (319/416) of respondents owned a mobile phone and 71.2% (296/416) were willing to receive an SMS text message. Among the mobile phone owners, only 37.6% (120/319) were having smartphones. Of all women with mobile phones, 89.7% (286/319) described that they are the primary holders of these phones and among them, 85.0% (271/319) reported having had the same phone number for more than a year. Among the phone owners, 90.0% (287/319) described that they could read and 86.8% (277/416) could send SMS text messages using their mobile phones in their day-to-day activities. Among pregnant women who were willing to receive SMS text messages, about 96.3% (285/296) were willing to receive information regarding activities or things to avoid during pregnancy. Factors associated with willingness were youth age group (adjusted odds ratio [AOR] 2.869, 95% CI 1.451-5.651), having attained secondary and higher educational level (AOR 4.995, 95% CI 1.489-14.773), and the frequency of mobile phone use (AOR 0.319, 95% CI 0.141-0.718).

Conclusions: A high proportion of pregnant women in an antenatal care clinic in this remote setting have a mobile phone and are willing to receive an SMS text message-based mHealth intervention. Age, educational status, and the frequency of mobile phone use are significantly associated with the willingness to receive SMS text message-based mHealth interventions.
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http://dx.doi.org/10.2196/pediatrics.9618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715064PMC
October 2018

Community Health Workers Improve Linkage to Hypertension Care in Western Kenya.

J Am Coll Cardiol 2019 10 2;74(15):1897-1906. Epub 2019 Sep 2.

Icahn School of Medicine at Mount Sinai, New York, New York.

Background: Elevated blood pressure (BP) is the leading global risk factor for mortality. Delay in seeking hypertension care is associated with increased mortality.

Objectives: This study investigated whether community health workers, equipped with behavioral communication strategies and smartphone technology, can increase linkage of individuals with elevated BP to a hypertension care program in western Kenya and significantly reduce BP.

Methods: The study was a cluster randomized trial with 3 arms: 1) usual care (standard training); 2) "paper-based" (tailored behavioral communication, using paper-based tools); and 3) "smartphone" (tailored behavioral communication, using smartphone technology). The co-primary outcomes were: 1) linkage to care; and 2) change in systolic BP (SBP). A covariate-adjusted mixed-effects model was used, adjusting for differential time to follow-up. Bootstrap and multiple imputation were used to handle missing data.

Results: A total of 1,460 individuals (58% women) were enrolled (491 usual care, 500 paper-based, 469 smartphone). Average baseline SBP was 159.4 mm Hg. Follow-up measures of linkage were available for 1,128 (77%) and BP for 1,106 (76%). Linkage to care was 49% overall, with significantly greater linkage in the usual care and smartphone arms of the trial. Average overall follow-up SBP was 149.9 mm Hg. Participants in the smartphone arm experienced a modestly greater reduction in SBP versus usual care (-13.1 mm Hg vs. -9.7 mm Hg), but this difference was not statistically significant. Mediation analysis revealed that linkage to care contributed to SBP change.

Conclusions: A strategy combining tailored behavioral communication and mobile health (mHealth) for community health workers led to improved linkage to care, but not statistically significant improvement in SBP reduction. Further innovations to improve hypertension control are needed. (Optimizing Linkage and Retention to Hypertension Care in Rural Kenya [LARK]; NCT01844596).
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http://dx.doi.org/10.1016/j.jacc.2019.08.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788970PMC
October 2019

A Model Driven Approach to the Design of a Gamified e-Learning System for Clinical Guidelines.

Stud Health Technol Inform 2019 Aug;264:734-738

Department of Computing, Mathematics, and Physics, Western Norway University of Applied Sciences, Bergen Norway.

Clinical practice guidelines (CPGs) are indispensable in the practice of evidence-based medicine. However, the cost of effective CPG dissemination strategies is prohibitive and not cost-effective. Therefore, scalable strategies using available technology are needed. We describe a formal model-driven approach to design a gamified e-learning system for clinical guidelines. We employ gamification to increase user motivation and engagement in the training of guideline content. Our approach involves the use of models for different aspects of the system, an entity model for the clinical domain, a workflow model for the clinical processes and a game model to manage the training sessions. A game engine instantiates a training session by coupling the workflow and entity models to automatically generate questions based on the data in the model instances. Our approach is flexible and adaptive as it allows for easy updates of the guidelines, integration with different device interfaces and representation of any guideline.
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http://dx.doi.org/10.3233/SHTI190320DOI Listing
August 2019

Development and Usability of Mobile-based Healthcare Protocols in Kenya.

Stud Health Technol Inform 2019 Jul;262:248-251

Institute of Biomedical Informatics, Moi University, Eldoret, Kenya.

Healthcare protocols have been shown to improve the quality of health service delivery by offering explicit guidelines and recommendations for clinicians who are uncertain about how to proceed in a given clinical situation. While various modalities are used to implement protocols, few rigorous evaluations of protocol use exist in low-resource clinical settings. This study aimed to develop mobile-based protocols (MBPs) and test their usability against currently used paper-based protocol (PBPs). Satisfaction, efficiency and effectiveness of the protocols were evaluated through a think-aloud usability exercise, in-depth interviews, and through a questionnaire. Compared to PBPs, satisfaction scores were higher with MBPs (83.8 versus 66.8, p=0.0498), number of errors lower with MBPs (2/25 versus 5/25, p=0.1089), with average time for task completion higher with MBPs (23.3s versus21.6s, p=0.7394). MBPs offer more satisfaction and trend towards being more effective as a dissemination modality for healthcare protocols in low-resource settings.
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http://dx.doi.org/10.3233/SHTI190065DOI Listing
July 2019

Implementation of USSD Technology to Improve Quality of Routinely Reported Health Data in a Resource-Limited Setting.

Stud Health Technol Inform 2019 Jul;262:162-165

Institute of Biomedical Informatics, Moi University, Eldoret, Kenya.

Health decision-making is heavily premised on routinely reported data from lower levels of healthcare delivery to the national level. The reported data are of best use if their quality is high. Unfortunately, in many resource-limited settings in sub-Saharan Africa, the quality of reported data is often poor. Among the reasons attributed for poor data quality is use of sub-optimal modalities for collecting and transmitting data, such as paper-based and Short Message Service (SMS). Through a user-centered approach, we developed and implemented an Unstructured Supplementary Service Data (USSD)-based health data reporting intervention in a district in Uganda. The impact of the developed system on report accuracy, timeliness and completeness was evaluated against the expected 100% rates by the Ministry of Health (MoH). A total of 224 reports were submitted over the two-month study period. Of the submitted reports, 171 (76.3%) were complete (p<0.0001) compared to MoH's required 100%). 161 (71.9%) were accurate (P<0.0001), and 158 (70.5%) of the reports were submitted on time (p<0.0001). The deficiencies were largely attributed to a few facilities, as only 17.9% of facilities had data discrepancies with a mean of - 2.11 (P=0.38), 96.4% (0.130) of the facilities had complete reports and 87.4% (0.100) of the facilities reported on time. Poor network coverage was an outstanding challenge to reporting.
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http://dx.doi.org/10.3233/SHTI190042DOI Listing
July 2019

Effect of mobile text message reminders on routine childhood vaccination: a systematic review and meta-analysis.

Syst Rev 2019 06 28;8(1):154. Epub 2019 Jun 28.

Department of Health Informatics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.

Background: The World Health Organization estimates that 29% of under-five mortality could be prevented with existing vaccines. However, non-consistent attendance for immunization appointments remains a global challenge to healthcare providers. Thus, innovative strategies are required to reach the last mile where technology could be effectively utilized to achieve better compliance with children immunization schedules. Therefore, the aim of the review was to systematically collect and summarize the available evidence on the effectiveness of text message reminders on childhood vaccination.

Methods: This review was conducted according to a priori published protocol on PROSPERO. A systematic literature search of databases (PubMed/MEDLINE, EMBASE, Cochrane/Wiley library, and Science direct) was conducted. Eligibility and risk of bias assessments were performed independently by two reviewers. PRISMA flow diagrams were used to summarize the study selection process. Taking into account the level of heterogeneity, a random effects model was used and risk ratios with their 95% CI were used to present the pooled estimates. To investigate the sources of heterogeneity, subgroup analysis and meta-regression analysis were also considered. In this review, publication bias was assessed statistically using Harbord test.

Results: A total of 1771 articles were searched. Out of those 1771 articles, 558 duplicated articles were removed. About 1213 articles were further screened, and finally, ten articles met the inclusion criteria. The meta-analysis showed that there is a significant effect of text message reminders on childhood vaccination coverage (RR = 1.11; 95% CI 1.05-1.17) with a moderate level of heterogeneity (I = 64.3%, P = 0.003). The results from the Harbord test suggested that there is no evidence for publication bias (P = 0.340).

Conclusion: This review highlights the potential benefits of incorporating mobile text message reminders into the standard management of childhood immunizations, especially in low- and middle-income countries. The frequency and timing of the text message reminders are also crucial in determining the effectiveness of text message reminders. Hence, mHealth interventions deserve more attention as a potential innovation to improve healthcare programs.

Systematic Review Registration: PROSPERO CRD42017074230.
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http://dx.doi.org/10.1186/s13643-019-1054-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6598255PMC
June 2019

A systematic approach to equity assessment for digital health interventions: case example of mobile personal health records.

J Am Med Inform Assoc 2019 08;26(8-9):884-890

School of Public Health, University of California, Berkeley, Berkeley, California.

Despite the increasing number of digital health interventions in low- and middle-income countries and other low-resource settings, little attention has been paid to systematically evaluating impacts of these interventions on health equity. In this article, we present a systematic approach for assessing equity impacts of digital health interventions modeled after the Health Equity Impact Assessment of the Ontario Ministry of Health and Long-Term Care. The assessment approach has 4 steps that address (1) scope, (2) potential equity impacts, (3) mitigation, (4) monitoring, and (5) dissemination strategies. The approach examines impacts on vulnerable and marginalized populations and considers various social determinants of health. Equity principles outlined by Whitehead and Dahlgren are used to ensure systematic considerations of all potential equity impacts. The digital health evaluation approach that is presented is applied to a case example of mobile personal health record application in Kenya.
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http://dx.doi.org/10.1093/jamia/ocz071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647229PMC
August 2019

Smartphone usage and preferences among postpartum HIV-positive women in South Africa.

AIDS Care 2019 06 31;31(6):723-729. Epub 2018 Dec 31.

c Vanderbilt Institute for Global Health , Vanderbilt University , Nashville , TN , USA.

In South Africa, HIV-positive women receiving antiretroviral therapy often are lost to care postpartum; strategies to support long-term engagement are needed. Mobile health (mHealth) interventions are emerging as a possible solution for supporting long-term engagement in the prevention of mother-to-child transmission (PMTCT) of HIV care continuum. In order to explore acceptability and feasibility of mobile health (mHealth) interventions in this context, we conducted focus group discussions (FGDs) to assess trends in smartphone usage in postpartum women. In six FGDs, we interviewed 27 HIV-positive, postpartum women who attended regular care at the Gugulethu Community Health Centre in Cape Town, South Africa, and who use a smartphone. Questions assessed the respondent's general trends in smartphone use, as well as their exposure to and perceptions of mHealth interventions. We found little turnover in phones and phone numbers, and about half the participants shared their devices with family and friends. Respondents reported high familiarity with smartphone applications, including WhatsApp, Facebook, YouTube, and Twitter, with WhatsApp as their preferred method of smartphone communication. Data bundles were most often used to connect to the internet, motivated by the perception that data bundles last longer and are cheaper than airtime, but respondents were adept at locating Wi-Fi sources at work or other public spaces. Nearly all participants were familiar with MomConnect, a national mHealth text support service in South Africa, and most described it positively. Respondents expressed interest in future HIV mHealth applications including complementary health information on physical activity, nutrition, mental health and basic social services. Participants were active and engaged smartphone users with reliable internet connections and a positive attitude towards mHealth platforms. Future mHealth interventions show promise in this population.
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http://dx.doi.org/10.1080/09540121.2018.1563283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6443468PMC
June 2019

Facilitators and Barriers of Electronic Medical Records Systems Implementation in Low Resource Settings: A Holistic View.

Stud Health Technol Inform 2018 ;251:187-190

Department of Information Science and Media Studies, University of Bergen, Norway.

Electronic Medical Records (EMR) systems show promise for facilitating health care improvement in quality patient care, patient safety and cost reduction. Nevertheless, their adoption requires careful planning and execution for successful implementation and optimal benefits. The main objective of this review was to identify, analyse and categorize facilitators and barriers to the implementation of EMRs in resource constrained settings in order to gain insight for successful EMR implementation. A literature review on papers from 2007 to 2017 concerning facilitators and barriers to EMRs implementation was conducted. The study included 18 articles that met selection criteria. Four categories of facilitators and barriers including a total of 28 sub-categories were identified from content analysis. These are technical, human, processes and organizational. EMR implementers should pay attention to these issues and adopt a change management strategy for sustainable EMR use in resource-constrained settings.
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November 2018

Setting the Agenda for Personal Health Records in Low- and Middle-Income Countries.

Stud Health Technol Inform 2017 ;245:1234

Institute of Biomedical Informatics, Moi University, Eldoret, Kenya.

In the developed world, Personal Health Records (PHRs) have been demonstrated to improve patient adherence, reduce medical errors, improve patient-provider communication, improve chronic disease management, and promote behavior change. PHRs have not been widely adopted in low- and middle-income countries. There is rising use of smartphones, adoption of national-level electronic health systems, and change in historical perceptions on acceptance of technology. It is thus an opportune time to critically examine the potential role and approaches to PHRs in LMICs.
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June 2018

Comparative Performance Analysis of Different Fingerprint Biometric Scanners for Patient Matching.

Stud Health Technol Inform 2017 ;245:1053-1057

Institute of Biomedical Informatics, Moi University, Eldoret, Kenya.

Unique patient identification within health services is an operational challenge in healthcare settings. Use of key identifiers, such as patient names, hospital identification numbers, national ID, and birth date are often inadequate for ensuring unique patient identification. In addition approximate string comparator algorithms, such as distance-based algorithms, have proven suboptimal for improving patient matching, especially in low-resource settings. Biometric approaches may improve unique patient identification. However, before implementing the technology in a given setting, such as health care, the right scanners should be rigorously tested to identify an optimal package for the implementation. This study aimed to investigate the effects of factors such as resolution, template size, and scan capture area on the matching performance of different fingerprint scanners for use within health care settings. Performance analysis of eight different scanners was tested using the demo application distributed as part of the Neurotech Verifinger SDK 6.0.
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June 2018

Ethical Issues in Implementing National-Level Health Data Warehouses in Developing Countries.

Stud Health Technol Inform 2017 ;245:718-722

Institute of Biomedical Informatics, Moi University, Eldoret, Kenya.

National Health Data Warehouses (NHDWHs) promise to improve individual and population health. These systems are now increasingly being deployed in low- and middle-income countries (LMICs), given increased recognition of the value of data analytics in informing decision-making. However, ethical issues relevant to implementation of NHDWHs in LMICs remain largely ignored or, at best, inadequately addressed. In this paper, we highlight and critically analyze several of the key ethical issues, including privacy, informed consent and trust, confidentiality and security, secondary data use, sustainability and implementation validity, risk-benefit ratio, governance and conflict of interest, justice, equity, access, and collaborative partnerships. We then provide a set of guiding principles and points to consider for countries and implementers to guide further decision-making around ethics of implementing NHDWHs within LMICs.
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June 2018
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