Operationalizing mHealth to improve patient care: A qualitative implementation science evaluation of the WelTel texting intervention in Canada and Kenya

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Study Justification:
– The study aimed to explore the implementation, effectiveness, and potential for scale-up of the WelTel texting intervention, an mHealth application designed to improve patient adherence to medication and engagement in care.
– The study sought to understand how contextual factors influenced the implementation of WelTel in Canada and Kenya.
– The study aimed to provide insights into the challenges and enabling factors associated with scaling up mHealth interventions.
Highlights:
– WelTel had positive influences on the “culture of care” at local clinics and hospitals in Canada and Kenya, extending beyond the patient-client relationship to influence wider organizational systems.
– The success of WelTel was mediated by clinician norms and practices, the availability of local champion staff, the capacity of local management, and the characteristics of the technology platform.
– Scale-up of WelTel was influenced by different forms of data and evidence, which played important roles in legitimization and partnership building.
– Moving from mHealth pilots to scale was found to be a difficult and context-specific process, requiring new organizational partnerships and ways of learning.
Recommendations:
– Foster new organizational partnerships to support the scale-up of mHealth interventions.
– Develop strategies to engage with the structural barriers that affect people’s health and access to services.
– Ensure the availability of local champion staff to support the implementation and scale-up of mHealth interventions.
– Incorporate data and evidence into the scaling-up process to build legitimacy and partnerships.
– Avoid relying solely on technology as a solution and consider the wider political and financing aspects of health systems.
Key Role Players:
– Researchers involved in mHealth projects
– Health administrators and managers
– Clinicians and clinic staff
– Local champion staff
– Government officials
– WelTel staff
Cost Items for Planning Recommendations:
– Research and evaluation costs
– Training and capacity building for local champion staff
– Partnership development and collaboration costs
– Technology platform development and maintenance costs
– Communication and dissemination costs
– Policy development and implementation costs

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a comparative qualitative case study design and draws on 32 key informant interviews. The study methodology is guided by the Consolidated Framework for Implementation Research (CFIR), which adds to the rigor of the research. The findings highlight the positive influences of the WelTel texting intervention on the ‘culture of care’ in Canada and Kenya, as well as the challenges and complexities of scaling up mHealth interventions. To improve the evidence, the abstract could provide more specific details about the key findings and their implications for future research and practice.

Background: Mobile health (mHealth) applications have proliferated across the globe with much enthusiasm, although few have reached scale and shown public health impact. In this study, we explored how different contextual factors influenced the implementation, effectiveness and potential for scale-up of WelTel, an easy-to-use and evidence-based mHealth intervention. WelTel uses two-way SMS communication to improve patient adherence to medication and engagement in care, and has been developed and tested in Canada and Kenya. Methods: We used a comparative qualitative case study design, which drew on 32 key informant interviews, conducted in 2016, with stakeholders involved in six WelTel projects. Our research was guided by the Consolidated Framework for Implementation Research (CFIR), a meta-theoretical framework, and our analysis relied on a modified approach to grounded theory, which allowed us to compare findings across these projects. Results: We found that WelTel had positive influences on the “culture of care” at local clinics and hospitals in Canada and Kenya, many of which stretched beyond the immediate patient-client relationship to influence wider organizational systems. However, these were mediated by clinician norms and practices, the availability of local champion staff, the receptivity and capacity of local management, and the particular characteristics of the technology platform, including the ability for adaptation and co-design. We also found that scale-up was influenced by different forms of data and evidence, which played important roles in legitimization and partnership building. Even with robust research evidence, scale-up was viewed as a precarious and uncertain process, embedded within the wider politics and financing of Canadian and Kenyan health systems. Challenges included juggling different interests, determining appropriate financing pathways, maintaining network growth, and “packaging” the intervention for impact and relevance. Conclusions: Our comparative case study, of a unique transnational mobile health research network, revealed that moving from mHealth pilots to scale is a difficult, context-specific process that couples social and technological innovation. Fostering new organizational partnerships and ways of learning are paramount, as mHealth platforms straddle the world of research, industry and public health. Partnerships need to avoid the perils of the technological fix, and engage the structural barriers that mediate people’s health and access to services.

This study sought to comparatively explore enabling factors and challenges associated with implementation across a number of related but different projects. In total, we conducted interviews with stakeholders involved in six ongoing WelTel projects in Canada and Kenya: WelTel eAsthma, WelTel Kenya-2 Grand Challenges Canada (GCC), Cedar Project, WelTel Oak Tree, WelTel Retain and WelTel LTB1 (see Fig. 2 ). WelTel intervention projects The primary focus was on the most developed projects: WelTel in Kenya’s Northern Arid Lands (WelTel Kenya2 GCC) for HIV and Maternal, Neonatal and Child Health (MNCH), and to a lesser degree, on two HIV projects in British Columbia, Canada (Oak Tree and Cedar). The Kenyan project was primarily aimed at scaling-up and finding ways to integrate the service within the local health system, while Oak Tree and Cedar were still very much focused on generating evidence and proof-of-concept. We also explored the relationships between the Kenyan and Canadian projects. Projects are described throughout the text; here we provide a short summary: Research was informed by the Consolidated Framework for Implementation Research (CFIR), a meta-theoretical framework particularly well-suited to a comparative, cross-project evaluation. The CFIR includes five domains (intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation), which are divided into over 30 different constructs, or “sub-domains” (see [14]). Based on the CFIR, our study methodology involved a comparative case study design. To guide this, we developed three key informant interview guides, for health administers/managers, researchers and clinicians to be used across the various projects. These were divided into five sections: impressions before implementation, impressions during the early stages of implementation, the intervention-health system interface, the functionality of the technology platform and scaling-up. We conducted 32 key informant interviews in British Columbia, Canada (11), and in Isiolo and Nairobi, Kenya (21), between February and April 2016 (see Table 1 ). We purposively selected our informants to cover a range of perspectives. Interviews lasted between 45 min to one-and-a-half hours. All interviews were conducted in private, and data collection included manual notes. Consent forms were signed for formal interviews, although we supplemented these with a more ethnographic approach, generating data through casual conversations at Isiolo District Hospital (IDH), with other stakeholders and with the WelTel team in Canada. Qualitative Interviewees by Category and Country Semi-structured interviews were done with nine researchers involved in current projects. In Canada, interviews also included two clinic staff responsible for managing the platform. A total of eight WelTel staff in Kenya were interviewed. Research at Isiolo District Hospital (IDH) included 10 different staff members at the Antenatal clinic (ANC) and HIV clinic. We also interviewed health managers and government officials. The focus on researchers in Canada and WelTel staff and clinic staff in Kenya (Table 1 ) reflected different levels of knowledge engagement. In Canada, most of the researchers we interviewed were intimately involved in the implementation of the pilot projects, whereas in Kenya this was the responsibility of WelTel staff working with the local clinics. We used a modified approach to grounded theory for data analysis. This involved open coding, preformed manually on data collection notes by a trained qualitative researcher (KB), in order to generate a key list of codes. A field-note diary was also kept, for brainstorming and reflection. This included case-based and analytical memos. This process facilitated the exploration of relationships and connections between different themes and subthemes, generating our analytical interpretations. Importantly, analysis was validated through a follow-up workshop in Kenya with IDH and WelTel project staff in July 2016, and through providing drafts of this article to a sub-group of key informants in Canada, as a form of member checking. The study was approved by the University of British Columbia’s Clinical Research Ethics Board (H16–00189), and Amref’s Ethics and Scientific Review Committee (AMREF-ESRC P161/2015).

Based on the information provided, the study titled “Operationalizing mHealth to improve patient care: A qualitative implementation science evaluation of the WelTel texting intervention in Canada and Kenya” explores the implementation, effectiveness, and potential for scale-up of the WelTel mHealth intervention. The study examines different contextual factors that influence the intervention, including clinician norms and practices, local champion staff, local management capacity, and the characteristics of the technology platform. The study also highlights the importance of data and evidence in legitimization and partnership building for scale-up. Challenges identified in the study include juggling different interests, determining appropriate financing pathways, maintaining network growth, and packaging the intervention for impact and relevance. The study emphasizes the need for new organizational partnerships and ways of learning to navigate the complexities of scaling up mHealth interventions.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health is the use of mHealth applications, specifically the WelTel texting intervention. This recommendation is based on a qualitative implementation science evaluation of the WelTel texting intervention in Canada and Kenya.

The study found that WelTel, which uses two-way SMS communication to improve patient adherence to medication and engagement in care, had positive influences on the “culture of care” at local clinics and hospitals in both countries. These influences extended beyond the patient-client relationship and impacted wider organizational systems. However, the implementation and scale-up of WelTel were influenced by various contextual factors, including clinician norms and practices, the availability of local champion staff, the receptivity and capacity of local management, and the characteristics of the technology platform.

To develop this recommendation into an innovation, it is important to address the challenges identified in the study. These challenges include juggling different interests, determining appropriate financing pathways, maintaining network growth, and “packaging” the intervention for impact and relevance. Fostering new organizational partnerships and ways of learning are also crucial, as mHealth platforms like WelTel straddle the worlds of research, industry, and public health.

Innovation in this context could involve developing strategies to overcome the identified challenges, such as establishing sustainable financing models, strengthening partnerships between different stakeholders, and ensuring the adaptability and scalability of the technology platform. Additionally, continuous evaluation and improvement of the intervention based on feedback from users and stakeholders can help enhance its effectiveness and impact.

Overall, the recommendation to operationalize mHealth, specifically the WelTel texting intervention, can be developed into an innovation by addressing the challenges and leveraging the enabling factors identified in the study. This innovation has the potential to improve access to maternal health by enhancing patient adherence to medication and engagement in care, and by influencing the wider organizational systems involved in maternal health services.
AI Innovations Methodology
The study titled “Operationalizing mHealth to improve patient care: A qualitative implementation science evaluation of the WelTel texting intervention in Canada and Kenya” explores the implementation, effectiveness, and potential for scale-up of the WelTel mHealth intervention. The WelTel intervention uses two-way SMS communication to improve patient adherence to medication and engagement in care for maternal health in Canada and Kenya.

To simulate the impact of recommendations on improving access to maternal health, a methodology was employed. The research followed a comparative qualitative case study design, drawing on 32 key informant interviews conducted in 2016 with stakeholders involved in six WelTel projects. The research was guided by the Consolidated Framework for Implementation Research (CFIR), a meta-theoretical framework that includes five domains: intervention characteristics, outer setting, inner setting, characteristics of individuals involved, and the process of implementation.

The methodology involved the development of three key informant interview guides for health administrators/managers, researchers, and clinicians. These guides covered five sections: impressions before implementation, impressions during early stages of implementation, the intervention-health system interface, the functionality of the technology platform, and scaling-up. The interviews were conducted in Canada and Kenya, with purposively selected informants to cover a range of perspectives.

Data analysis was performed using a modified approach to grounded theory. Open coding was conducted on data collection notes to generate a key list of codes, and a field-note diary was kept for brainstorming and reflection. This process facilitated the exploration of relationships and connections between different themes and subthemes, leading to analytical interpretations.

The analysis was validated through a follow-up workshop in Kenya with project staff and by providing drafts of the article to a sub-group of key informants in Canada for member checking. The study was approved by the University of British Columbia’s Clinical Research Ethics Board and Amref’s Ethics and Scientific Review Committee.

Overall, this methodology allowed for a comprehensive exploration of the enabling factors and challenges associated with implementing the WelTel mHealth intervention for maternal health, providing insights into the potential for scale-up and improving access to maternal health services.

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