Mobile health in Sierra Leone: Evidence and implications for health systems

mHealth in Sierra Leone

Sierra Leone has taken important steps over the last decade towards improving the health status of its people; the launch of the Free Healthcare Initiative (FHCI) in 2010 was a major milestone that made healthcare services available free of charge for pregnant and lactating women and children under five years. But the current maternal and newborn health statistics illustrate that the health system still faces challenges.

There is a need to increase demand, improve healthcare provision, and facilitate the connection between communities and healthcare providers.

These challenges and the need for stronger involvement of communities and better communication between these and health workers came even more to the forefront during the current Ebola crisis.

Mobile communication technologies are rapidly spreading globally and Africa is no exception.

It is an opportune time to use this technology development as a platform for public health interventions. But the evidence for how best to use mobile communication technology for health (called mobile health, abbreviated as mHealth) is still sparse.

This technical brief summarises a mobile health intervention research in Bombali district, in north-west Sierra Leone. It describes how health providers were connected to clients through mobile telephones (the interventions), and the assessment of these interventions (the findings regarding results and impact). This technical brief provides recommendations for healthcare providers and policy-makers interested in adopting mobile health interventions to advance maternal and newborn health.

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA:


A new reference guide addresses the challenges and strengths of large-scale CHW programs

Over the next few months, CHW Central will be providing a series of features highlighting sections of a new Reference Guide: Developing and Strengthening Community Health Worker Programs at Scale.  Dr. Henry Perry and a team of writers with global experience and knowledge on CHW programming developed the guide to help decision-makers and program implementers strengthen existing large-scale programs and design and scale up new programs. The authors foresee the effective functioning of large-scale CHW programs as one of the most important opportunities for improving the health of impoverished populations in low-income countries.  Case studies from Asia, South America and Africa illustrate how some national CHW programs have made a difference in reducing maternal and child mortality and expanding coverage of family planning services.

A New Resource for Developing and Strengthening Large-Scale Community Health Worker Programs – See more 


IntraHealth International Acquires Switchboard

IntraHealth announced yesterday their acquisition of Switchboard. You can read a copy of the press release at at IntraHealth’s website by clicking the link below. Switchboard’s promising mobile phone-based model for low- and middle-income countries joins ministries of health, private mobile phone companies and health workers to improve real-time access to critical information and peer-to-peer communication.

“The Switchboard model of developing innovative public-private partnerships and leveraging existing technologies to connect health workers and health officials throughout the country makes Switchboard a natural and exciting addition to the tools we can offer to countries to improve health services,” says Pape Gaye, president and CEO of  IntraHealth.

Eric Woods, Switchboard’s cofounder and former chief executive officer, was named one of the Top 11 Innovators in mHealth in 2011 by the mHealth Alliance and Rockefeller Foundation and a Rainer Arnhold Fellow in 2012. The company launched start-up projects in Ghana, Liberia and Tanzania with support from individuals and foundations, including the Rockefeller Foundation, and Mulago Foundation.

“With more than 35 years in health service delivery and software supporting records for over one million practitioners, IntraHealth is the global leader in health worker information management, the critical backbone of Switchboard’s model,” Woods says. “We’re thrilled to offer IntraHealth an innovative extension into mobile and health service delivery, made possible by an acquisition that was our most effective path to remarkable scale.”

We here at IntraHealth look forward to sharing our vision for Switchboard under our leadership and how we will leverage this great opportunity to increase our impact as a partner of choice to the donors, health workers, countries and communities that we serve. If you have any questions please feel free to contact me at


Michael Drane

Open Source Community Manager

IntraHealth International

Chapel Hill, NC

+1 919 433 5714

Free X-ray learning

Some of you, particularly those with an interest in radiology, may already be familiar with ( and, on Facebook, ).

In a recent article about them, it was interesting to see the following quote from its founder, Dr Gaillard, who said: ‘his site was an example of how opening access to information was beginning to revolutionise the way medicine was taught and practiced around the world.’.

The article quotes him as follows:

“A typical text book, for a sub-speciality especially, will be a couple of hundred dollars to buy – and that’s in one space, in one shelf, locked in one office,” he said.

“Digital versions of those text books are just as expensive, and very carefully controlled because the whole infrastructure is built around monetising the restriction to access to information…

…”If you want be grandiose or paranoid about it, the medical information industry makes its money by stopping people accessing the information that they need to better treat and diagnose their patients.

“What we’re about is thinking that that’s not such a great thing, and thinking that you can make this information for free.”

What do others think?

After Ebola: What next for West Africa’s health systems?

Below are extracts from a news item on the IRIN, the UN humanitarian news service. The full text is available here:

NAIROBI, 26 January 2015 (IRIN) – As rates of Ebola infection fall in Guinea, Liberia and Sierra Leone planning has begun on how to rebuild public health systems and learn lessons from the outbreak….

Lessons learnt: “Community, community, community. Engagement, engagement, engagement”

Among the lessons learned across the region has been the importance of consulting, engaging and empowering local communities: their lack of trust in central government was a major handicap in tackling the epidemic… “We need to listen more. We need to do a lot of work with sociologists and anthropologists.” [said Margaret Harris, spokesperson of the World Health Organization (WHO)]

Best wishes, Neil

Mobile phone text messaging interventions for HIV and other chronic diseases: an overview of systematic reviews and framework for evidence transfer

Below is the citation and abstract of a new paper in the open-access journal BMC Health Services Research (with thanks to Irina Ibraghimova and LRC Network).

CITATION: Mobile phone text messaging interventions for HIV and other chronic diseases: an overview of systematic reviews and framework for evidence transfer

Lawrence Mbuagbaw, Sara Mursleen, Lyubov Lytvyn, Marek Smieja, Lisa Dolovich and Lehana Thabane.

Corresponding author: Lawrence Mbuagbaw

BMC Health Services Research 2015, 15:33  doi:10.1186/s12913-014-0654-6

Published: 22 January 2015

ABSTRACT (provisional)

Background: Strong international commitment and the widespread use of antiretroviral therapy have led to higher longevity for people living with human immune deficiency virus (HIV). Text messaging interventions have been shown to improve health outcomes in people living with HIV. The objectives of this overview were to: map the state of the evidence of text messaging interventions, identify knowledge gaps, and develop a framework for the transfer of evidence to other chronic diseases.

Methods: We conducted a systematic review of systematic reviews on text messaging interventions to improve health or health related outcomes. We conducted a comprehensive search of PubMed, EMBASE (Exerpta Medica Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, Web of Science (WoS) and the Cochrane Library on the 17th April 2014. Screening, data extraction and assessment of methodological quality were done in duplicate. Our findings were used to develop a conceptual framework for transfer.

Results: Our search identified 135 potential systematic reviews of which nine were included, reporting on 37 source studies, conducted in 19 different countries. Seven of nine (77.7%) of these reviews were high quality. There was some evidence for text messaging as a tool to improve adherence to antiretroviral therapy. Text messages also improved attendance at appointments and behaviour change outcomes. The findings were inconclusive for self-management of illness, treatment of tuberculosis and communicating results of medical investigations. The geographical distribution of text messaging research was limited to specific regions of the world. Prominent knowledge gaps included the absence of data on long term outcomes, patient satisfaction, and economic evaluations. The included reviews also identified methodological limitations in many of the primary studies.

Conclusions: Global evidence supports the use of text messaging as a tool to improve adherence to medication and attendance at scheduled appointments. Given the similarities between HIV and other chronic diseases (long-term medications, life-long care, strong link to behaviour and the need for home-based support) evidence from HIV may be transferred to these diseases using our proposed framework by integration of HIV and chronic disease services or direct transfer.

The complete article is available as a provisional PDF:

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: 

Is insulin the most effective injectable antihyperglycaemic therapy?. Diabetes Obes Metab. 2014 Oct 17

IMS: The recent type 2 diabetes American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) position statement suggested insulin is the most effective glucose-lowering therapy, especially when glycated haemoglobin (HbA1c) is very high. However, randomized studies comparing glucagon-like peptide-1 receptor agonists (GLP-1RAs) exenatide once-weekly [OW; DURATION-3 (Diabetes therapy Utilization: Researching changes in A1c, weight, and other factors Through Intervention with exenatide ONce-Weekly)] and liraglutide once-daily [OD; LEAD-5 (Liraglutide Effect and Action in Diabetes)] with insulin glargine documented greater HbA1c reduction with GLP-1RAs, from baseline HbA1c approximately 8.3% (67 mmol/mol). This post hoc analysis of DURATION-3 and LEAD-5 examined changes in HbA1c, fasting glucose and weight with exenatide OW or liraglutide and glargine, by baseline HbA1c quartile.
METHODS: Descriptive statistics were provided for change in HbA1c, fasting glucose, weight, and insulin dose, and subjects (%) achieving HbA1c <7.0%, by baseline HbA1c quartile. Inferential statistical analysis on the effect of baseline HbA1c quartile was performed for change in HbA1c. An analysis of covariance (ANCOVA) model was used to evaluate similarity in change in HbA1c across HbA1c quartiles.
RESULTS: At 26 weeks, in both studies, HbA1c reduction, and proportion of subjects reaching HbA1c <7.0%, were similar or numerically greater with the GLP-1RAs than glargine for all baseline HbA1c quartiles. Fasting glucose reduction was similar or numerically greater with glargine. Weight decreased with both GLP-1RAs across all quartiles; subjects taking glargine gained weight, more at higher baseline HbA1c. Adverse events were uncommon although gastrointestinal events occurred more frequently with GLP-1RAs.
CONCLUSIONS: HbA1c reduction with the GLP-1RAs appears at least equivalent to that with basal insulin, irrespective of baseline HbA1c. This suggests that liraglutide and exenatide OW may be appropriate alternatives to basal insulin in type 2 diabetes, including when baseline HbA1c is very high (>/=9.0%). ….more


Distance courses on evidence-based practice

The American International Health Alliance has provided free distance training courses on evidence-based practice for LMIC since 2004. Courses we have developed include ‘Introduction to evidence-based practice in healthcare,’ ‘Introduction to evidence-based practice in social work,’ and ‘Evidence-based patient information materials.’ Those courses are now provided in English for our partner organizations (hospitals, universities, nursing colleges) in Tanzania, Ethiopia, South Africa, Botswana and Zambia.

In addition to gaining knowledge and new skills, participants are NOW also interested in earning points towards their CE and acquiring a statement of accomplishment from globally reknowned programs.

As a part of our recent Knowledge Management strategy, we will investigate the following solutions:

– Certifying our courses with universities in the countries where AIHA is delivering its programs.

– Repackaging those courses for self-paced learning and posting them on reknown platforms geared towards distance training in health and related topics.

We would appreciate your ideas and recommendations for how to persue those possibilities.

For more information on evidence-based practice courses and AIHA Knowledge Management strategy, visit:


Irina Ibraghimova, PhD

Library and Information Management Consultant

Thomas Achilles,

Administration & Communications Assistant

American International Health Alliance

1225 Eye Street, NW, Suite 250

Washington, DC 20005


Dilemmas faced by WHO in connection with the Ebola Emergency response

Below are extracts from an article in the BMJ (with thanks to our sister forum HIFA-EVIPNet-French). The full text is available here:

A linked article concludes: ‘[Member States] should support unequivocally the strengthening of WHO and its multilateral solutions and not favor solutions outside WHO’.

Dilemmas faced by the World Health Organization in connection with the Ebola Emergency response

‘On January 25th a Special Session of the World Health Organization’s (WHO) Executive Board will be convened to discuss the Ebola emergency and the WHO response to the epidemic that has affected several countries in West Africa It is the third time in the history of WHO that the Executive Board organizes a Special Session. This is motivated by the multiple difficulties faced by the international response to the problem, resulting in ineffective and untimely action in countries lacking the adequate health infrastructure and sufficient health workforce…

‘The fight against Ebola has been full of mistakes and has lacked coordination…

‘In the weeks before the release of these two documents many worrisome ideas and opinions on the issues at stake floated in different media:

1) the idea of creating a new international agency for facing health emergency situations, relegating WHO to a role of producing technical norms and standards without any armed branches for orchestrating operational responses at country, regional or global level;

2) creating an international health emergency response fund outside WHO; and

3) creating an international corps of emergency health workers managed outside WHO and not linked neither to the structures established by the International Health Regulations approved in 2005 nor to the Health Cluster that is part of the International Humanitarian Response.

‘Evidently these absurd ideas have been triggered by the frustration resulting from the lack of an effective and timely response. However they point in the wrong direction fostering proposals that would only weaken the global health architecture and its current coordination mechanisms… It is time to halt this trend and make the necessary steps for rationalizing the huge dispersion of channels and mechanisms associated to the global health partnerships created during the last 20 years at a high cost for the effective coordination of international public health.’

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA:  

The Effectiveness of Health Animations in Audiences With Different Health Literacy Levels: An Experimental Study

Below is the citation and abstract of a new paper in the Journal of Medical Internet research. The full text is freely available here:

The authors conclude that ‘spoken animation is the best way to communicate complex health information to people with low health literacy’. It should be noted, however, that the authors compared animations with static pictures and text, and did not look at other types of film/audiovisual material. It would be interesting to compare the impact of animated versus ‘real’ film in different contexts.

CITATION: Meppelink CS, van Weert JC, Haven CJ, Smit EG. The Effectiveness of Health Animations in Audiences With Different Health Literacy Levels: An Experimental Study. J Med Internet Res 2015;17(1):e11

DOI: 10.2196/jmir.3979


Background: Processing Web-based health information can be difficult, especially for people with low health literacy. Presenting health information in an audiovisual format, such as animation, is expected to improve understanding among low health literate audiences.

Objective: The aim of this paper is to investigate what features of spoken health animations improve information recall and attitudes and whether there are differences between health literacy groups.

Methods: We conducted an online experiment among 231 participants aged 55 years or older with either low or high health literacy. A 2 (spoken vs written text) x 2 (illustration vs animation) design was used. Participants were randomly exposed to one of the four experimental messages, all providing the same information on colorectal cancer screening.

Results: The results showed that, among people with low health literacy, spoken messages about colorectal cancer screening improved recall (P=.03) and attitudes (P=.02) compared to written messages. Animations alone did not improve recall, but when combined with spoken text, they significantly improved recall in this group (P=.02). When exposed to spoken animations, people with low health literacy recalled the same amount of information as their high health literate counterparts (P=.12), whereas in all other conditions people with high health literacy recalled more information compared to low health literate individuals. For people with low health literacy, positive attitudes mediated the relationship between spoken text and the intention to have a colorectal cancer screening (b=.12; 95% CI 0.02-0.25).

Conclusions: We conclude that spoken animation is the best way to communicate complex health information to people with low health literacy. This format can even bridge the information processing gap between audiences with low and high health literacy as the recall differences between the two groups are eliminated. As animations do not negatively influence high health literate audiences, it is concluded that information adapted to audiences with low health literacy suits people with high health literacy as well.

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA:  

BJOG: The prevention and treatment of postpartum haemorrhage

‘Postpartum haemorrhage (PPH) remains the most common cause of maternal mortality worldwide.[1] It is responsible for around 30% of maternal deaths, equivalent to 86 000 deaths per year annually or ten deaths every hour…’

Below is the citation and abstract of a review in the January 2015 issue of BJO – An International Journal of Obstetrics and Gynaecology. The full text is available here:

I was particularly struck by the following statement, in the full text:

‘How best to deliver emergency care

In 2005 Hussein called for the development of ‘obstetric first aid’ skills and for its training in the community to be given as much priority as cardiopulmonary resuscitation.[57] Sadly, a decade later, little has progressed in achieving this aim and there is no agreed, coherent first-aid strategy for PPH…’

This suggests a serious failure of global health research translation and I would like to invite comment from HIFA members. As previously discussed on HIFA, the World Health Organization, among others, have provided guidance on emergency care for PPH: WHO recommendations for the prevention and treatment of postpartum haemorrhage (2012).  

Is this guidance not agreed and/or coherent?

CITATION: Weeks, A. The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next? BJOG: An International Journal of Obstetrics & Gynaecology. 2015. 122; 2: 202-210.

ABSTRACT: Postpartum haemorrhage (PPH) remains a major cause of maternal deaths worldwide, and is estimated to cause the death of a woman every 10 minutes. This review presents the latest clinical advice, including new evidence on controlled cord traction, misoprostol, and oxytocin. The controversy around the diagnosis of PPH, the limitations of universal prophylaxis, and novel ways to provide obstetric first aid are also presented. It ends with a call to develop high-quality front-line obstetric services that can deal rapidly with unexpected haemorrhages as well as minimising blood loss at critical times: major abruption, placenta praevia, and caesarean for prolonged labour.

Best wishes, Neil

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA:  

The global met need for emergency obstetric care: a systematic review

Systematic Review: The global met need for emergency obstetric care: a systematic review

The January 2015 issue of BJOG – An International Journal of Obstetrics and Gynaecology – is a Special Issue on the theme of ‘Beyond 2015: The future of women’s health globally’. All the papers in this issue are freely available here:

Below is the citation and abstract of one of the papers.

CITATION: Systematic Review: The global met need for emergency obstetric care: a systematic review

H Holmer, K Oyerinde, JG Meara1, R Gillies, J Liljestrand, and L Hagander

Article first published online: 26 DEC 2014

DOI: 10.1111/1471-0528.13230


Background: Of the 287 000 maternal deaths every year, 99% happen in low- and middle-income countries. The vast majority could be averted with timely access to appropriate emergency obstetric care (EmOC). The proportion of women with complications of pregnancy or childbirth who actually receive treatment is reported as ‘Met need for EmOC’.

Objective: To estimate the global met need for EmOC and to examine the correlation between met need, maternal mortality ratio and other indicators.

Search strategy: A systematic review was performed according to the PRISMA guidelines. Searches were made in PubMed, EMBASE and Google Scholar.

Selection criteria: Studies containing data on met need in EmOC were selected.

Data collection and analysis: Analysis was performed with data extracted from 62 studies representing 51 countries. World Bank data were used for univariate and multiple linear regression.

Main results: Global met need for EmOC was 45% (IQR: 28–57%), with significant disparity between low- (21% [12–31%]), middle- (32% [15-56%]), and high-income countries (99% [99–99%]), (P = 0.041). This corresponds to 11.4 million (8.8–14.8) untreated complications yearly and 951 million (645–1174 million) women without access to EmOC. We found an inverse correlation between met need and maternal mortality ratio (r = -0.42, P < 0.001). Met need was significantly correlated with the proportion of births attended by skilled birth attendants (ß = 0.53 [95% CI 0.41–0.65], P < 0.001).

Authors’ conclusions: The results suggest a considerable inadequacy in global met need for EmOC, with vast disparities between countries of different income levels. Met need is a powerful indicator of the response to maternal mortality and strategies to improve EmOC act in synergy with the expansion of skilled birth attendance.

Best wishes,


Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA:  

Reviving rural towns would help drive to curb poverty

One of the most bewildering things when driving through the Eastern Cape’s many rural towns is the state of disrepair of the roads, the decaying infrastructure, the hopelessness in the eyes of the many poor residents. Poverty is endemic and it seems to me every year we plunge to new depths of despair. Local town administrators are doing their best it seems but these areas won’t get out of the starting blocks without massive infrastructure investment…..more

HealthPhone: Weekly news and social media on health and nutrition educational, instructional, tutorials and training videos

HealthPhone is a curated video library of some of the world’s best producers of health and nutrition educational, instructional, tutorials and training content for personal computers, mobile phones and tablets. The videos are freely available for immediate viewing and download at our web site ( ) which houses a fast growing library of over 2,500 videos across 77 languages.

HealthPhone’s main objective is to facilitate the flow of knowledge to rural low- middle-income families and health workers that serve them; delivering information to educate, motivate, empower and inspire communities around better health and nutrition practices.

The topics covered are primarily in the area of nutrition, water, timing births, safe motherhood, newborn health, child development, early learning, breastfeeding, nutrition, growth, immunization, diarrhoea, coughs, colds, serious illnesses, hygiene, malaria, HIV, child protection, injury prevention, emergencies preparedness and response.

Videos are promoted daily on our Twitter ( ) and Facebook ( ) pages and also through the weekly on-line issue of HealthPhone News ( ). Vist our web site, connect with us on social media and subscribe to our weekly news and YouTube channel ( ) for the latest in health and nutrition video content.

be well, nand

Nand Wadhwani

The Mother and Child Health and Education Trust  |

Now that we can, we must!

WHO publishes systematic review of eLearning in health professional education

WHO has just published eLearning for undergraduate health professional education – a systematic review informing a radical transformation of health workforce development.

You can download a copy of the report from:

The World Health Organization (WHO) Department of Health Workforce in collaboration with the Department of Knowledge, Ethics and Research commissioned the Global eHealth Unit (GeHU) at Imperial College London to conduct a systematic review of the scientific literature to evaluate the effectiveness of eLearning for undergraduate health professional education. The review is based on a rigorous search, analysis and presentation of data that provides decision-makers with an up-to-date picture of current knowledge on eLearning for undergraduate professional education. It responds to a need at the country level for evidence to inform and guide health professional education as an important vehicle in preparing health professionals to be ‘fit-for-purpose’.

At a global level, it will assist in the implementation of the WHO’s global human resources for health strategy by providing the best evidence of how and where eLearning can best be used in country settings. The report also provides a foundation for the development of future WHO guidelines for pre-service training and the direction for  future research.

Kind regards,


Rebecca Bailey | Health Workforce Development Team Lead

IntraHealth International | Because Health Workers Save Lives.

6340 Quadrangle Drive, Suite 200 | Chapel Hill, NC 27517

m. +1 (919) 360-3339

Webinar: Resources that support children who are hard of hearing

I would like to announce an upcoming webinar titled “Resources for service providers, family, and caretakers of children who are hard of hearing”.

Join Audiologist Larrain Bratt, staff and parents from the Center for Early Intervention on Deafness, and Hesperian’s Executive Director Sarah Shannon for a webinar and discussion about Hesperian materials and resources that support anyone who works with or cares for children who are hard of hearing.

Learn about Hesperian’s print and digital resources in many languages and hear examples and stories of putting these resources into action in a variety of scenarios- from the clinic to the home.

When: Tuesday, January 27th

1:00 pm PST; 4:00 pm EST

Click to sign up for the webinar:


Larrain Bratt, Audiologist with a focus on newborn hearing screening, infant diagnostics, and educational follow-up.

Helisa Katz, M.A. Teacher of the Deaf, Center for Early Intervention on Deafness

Melissa Lopez, Parent, Center for Early Intervention on Deafness

Sarah Shannon, Executive Director, Hesperian Health Guides

Special thanks to the California Communications Access Foundation for their support.

Warm Regards,

Libby Engles

Media and Communications Associate

510-845-1447 ext. 224