Promoting access equity and improving health care for women, children and people living with HIV/AIDS in Burkina Faso through mHealth

Background In Burkina Faso, access to health services for women, children and people living with HIV/AIDS (PLWHAs) remains limited. Mobile telephony offers an alternative solution for reaching these individuals. The objective of the study was to improve equity of access to health care and information among women and PLWHAs by reinforcing community participation. Methods Using a quasi-experimental approach, a mobile telephone system was set up at five health centres to provide an automated reminder service for health care consultation appointments. Performance evaluations based on key performance indicators were subsequently conducted. Results A total of 1501 pregnant women and 301 PLWHAs were registered and received appointment reminders. A 7.34% increase in prenatal coverage, an 84% decrease in loss to follow-up for HIV (P < 0.001) and a 31% increase in assisted deliveries in 2016 (P < 0.0001) were observed in intervention areas. However, there was no statistically significant difference between intervention site and control site (P= 0.451 > 0.05) at post-intervention. Efforts to involve community members in decision-making processes contributed to improved health system governance. Conclusion Mhealth may improve maternal and child health and the health of PLWHAs. However, establishment of a mHealth system requires taking into account community dynamics and potential technological challenges. Keywords access to care, Burkina Faso, equity, health system governance, mobile telephony, Nouna. The study was conducted in Nouna Health District (NHD) in Burkina Faso. Nouna has hada Health and Demographic Surveillance system (HDSS) data gathering since 1984.21 Longitudinal data collection is being done in 25 primary health centres (HCs). The HDSS served as a framework for selection of the HCs. Figure ​Figure11 illustrates the study area. Nouna mHealth project area within the HDSS. HDSS, Health and Demographic Surveillance System. The intervention involved equipping 52 godmothers and 10 HIV/AIDS facilitators—with free mobile telephones. Godmothers are former traditional birth attendants used now in HCs to conduct community-based activities to support health care provision (sensitization, home visits, counselling of pregnant women, etc.). HIV/AIDS facilitators are members of registered associations working with health services to support HIV/AIDS patients care. Their activities focusses on PLWHAs to increase their adherence to service, compliance with treatment and retrieval of patients lost to follow-up. The project mHealth description covers only some relevant criteria of the mHealth evidence reporting and assessment checklist (mERA).22 The MOS@N project was developed using the open-source Java programming language relying on J2EE JSP/Servlet technology and standard web services technologies. MOS@N features an interactive voice response (IVR) and SMS transmission system functioning in five local languages (French, Dioula, Moore, Dafing and Bwamu). The mHealth system was programmed to send automated reminders to Godmother and HIV/AIDS facilitator’s phone via SMS at regular intervals once every day. Five IVR modules for patients management were developed, namely: (i) IVR module to deliver awareness and sensitization messages to patients; (ii) IVR module for patient’s data management and follow-up; (iii) IVR module for appointment or return visit reminders; (iv) IVR module for transferring calls to the caller’s referral HC; and (v) IVR module for calls transfer to referral HCs. The system architecture is based on five components: a mobile Internet connection, a Web server to host the database and application, a main database, a communication server with voice mail and email functionality that interacts with the server and peripheral system (mobile telephones and the computers based at HCs).23 Figure ​Figure22 depicts the conceptual model of the platform. mHealth platform structure. Within the HDSS, the mobile phone possession rate increased from 3.8% in 2006 to 63.80% in 2013. This growth is consistent with that reported at national level: ~66%.24 In addition, HCs capacity assessment was conducted prior to the intervention, and deficiency in power supply was addressed by solar panel deployment at health facility level coupled with provision of mobile energy kits to community health workers involved in the project for mobile phone charging in addition to regular communication credit allowance (10 $/month). This was a cross-sectional study of a community-based mHealth project using quasi-experimental design. Five intervention and five control sites out of 17 HDSS HCs, were selected to participate in the study. Firstly, convenience sampling was used to selected HCs that met some criteria (two health staff, a maternity ward, a dispensary, functioning solar panel system, and accessibility to health district). The 17 HCs out of 25 met that criteria. Secondly, a simple random sampling was used to select five HCs for intervention and five for control out of the 17 HDSS sites. For HIV/AIDS intervention, the sampling base was the whole district with regard to the centralized HIV/AIDS database at district level. For qualitative study, convenience sampling was used to enrol participants until the required sample size is reached. A structured questionnaire was used to record information on key statistics at HCs and district level in 2013 and 2016. In addition, the degree of acceptance of mobile telephony was explored among 52 godmothers, 10 HIV/AIDS facilitators and 15 health workers, using the standard technology assessment model (TAM).26 Qualitative approach was use to collect data among key respondents. Individual in-depth interview and focus group discussions (FGDs) were favoured: 10 FGDs with 91 women, while 35 semi-structured individual interview were conducted with (10 health workers (HWs), 10 community health workers (CHWs), 5 godmother and 2 HIV/AIDS facilitators). Quantitative data analysis was performed by STATA.11. A t-test for two independents samples means was used to estimate the difference at pre- and post-intervention for key indicators prenatal care (PNC1), prenatal care 4(PNC4), tetanus toxoid (TV2+), intermittent treatment of malaria (IPT2), high pregnancy referred (HRP), prevention of mother to child HIV (PMTCT), assisted deliveries (AD,) postpartum care (PPC) and polio and BCG, lost to follow-up of HIV/AIDS patients. The results were significant if P-value <0.05. For qualitative data analysis, recorded interviews were transcribed in French and imported into the application ATLAS.ti4.2. The content analysis method was used, with a focus on the manifest content and treating all statements in the verbatim transcriptions as complete units.25 The study was approved by Burkina Ethical Committee for Health Research (CERS/2013-12-115). Prior to interview, all participants’ voluntary consent was sought either written or verbal.