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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).
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