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TitleThe Effect of Text Message Reminders to Health Workers on Quality of Care for Malaria, Pneumonia, and Diarrhea in Malawi: A Cluster-Randomized, Controlled Trial.
AuthorsSteinhardt, LC; Mathanga, DP; Mwandama, D; Nsona, H; Moyo, D; Gumbo, A; Kobayashi, M; Namuyinga, R; Shah, MP; Bauleni, A; Troell, P; Zurovac, D; Rowe, AK
JournalThe American journal of tropical medicine and hygiene
Publication Date1 Feb 2019
Date Added to PubMed11 Jan 2019
AbstractThe use of mobile technologies in medicine, or mHealth, holds promise to improve health worker (HW) performance, but evidence is mixed. We conducted a cluster-randomized controlled trial to evaluate the effect of text message reminders to HWs in outpatient health facilities (HFs) on quality of care for malaria, pneumonia, and diarrhea in Malawi. After a baseline HF survey (2,360 patients) in January 2015, 105 HFs were randomized to three arms: 1) text messages to HWs on malaria case management; 2) text messages to HWs on malaria, pneumonia, and diarrhea case management (latter two for children < 5 years); and 3) control arm (no messages). Messages were sent beginning April 2015 twice daily for 6 months, followed by an endline HF survey (2,536 patients) in November 2015. An intention-to-treat analysis with difference-in-differences binomial regression modeling was performed. The proportion of patients with uncomplicated malaria managed correctly increased from 42.8% to 59.6% in the control arm, from 43.7% to 55.8% in arm 1 (effect size -4.7%-points, 95% confidence interval (CI): -18.2, 8.9, P = 0.50) and from 30.2% to 50.9% in arm 2 (effect size 3.9%-points, 95% CI: -14.1, 22.0, P = 0.67). Prescription of first-line antibiotics to children < 5 years with clinically defined pneumonia increased in all arms, but decreased in arm 2 (effect size -4.1%-points, 95% CI: -42.0, 33.8, P = 0.83). Prescription of oral rehydration solution to children with diarrhea declined slightly in all arms. We found no significant improvements in malaria, pneumonia, or diarrhea treatment after HW reminders, illustrating the importance of rigorously testing new interventions before adoption.
Linkhttp://doi.org/10.4269/ajtmh.18-0529
TitleAnalytical mapping of information and communication technology in emerging infectious diseases using CiteSpace.
AuthorsSood, SK; Rawat, KS; Kumar, D
JournalTelematics and informatics
Publication Date1 Apr 2022
Date Added to PubMed15 Mar 2022
AbstractThe prevalence of severe infectious diseases has become a major global health concern. Currently, the COVID-19 outbreak has spread across the world and has created an unprecedented humanitarian crisis. The proliferation of novel viruses has put traditional health systems under immense pressure and posed several serious issues. Henceforth, early detection, identification, rapid testing, and advanced surveillance systems are required to address public health emergencies. However, Information and Communication Technology (ICT) tackles several issues raised by this pandemic and significantly improves the quality of services in the health care sector. This paper presents an ICT-assisted scientometric analysis of infectious diseases, namely, airborne, food & waterborne, fomite-borne, sexually transmitted illnesses, and vector-borne illnesses. It assesses the international research status of this field in terms of citation structure, prolific journals, and country contributions. It has used the CiteSpace tool to address the visualization needs and in-depth insights of scientific literature to pinpoint core hotspots, research frontiers, emerging research areas, and ICT trends. The research finding reveals that mobile apps, telemedicine, and artificial intelligence technologies have greater scope to reduce the threats of infectious diseases. COVID-19, influenza, HIV, and malaria viruses have been identified as research hotspots whereas COVID-19, contact tracing applications, security and privacy concerns about users' data are the recent challenges in this field that need to address. The United States has produced higher research output in all domains of infectious diseases. Furthermore, it explores the co-occurrence network analysis and intellectual landscape of each domain of infectious diseases. It provides potential research directions and insightful clues to researchers and the academic fraternity for further research.
Linkhttp://doi.org/10.1016/j.tele.2022.101796
TitleThe effect of mobile phone text message reminders on health workers' adherence to case management guidelines for malaria and other diseases in Malawi: lessons from qualitative data from a cluster-randomized trial.
AuthorsKaunda-Khangamwa, BN; Steinhardt, LC; Rowe, AK; Gumbo, A; Moyo, D; Nsona, H; Troell, P; Zurovac, D; Mathanga, D
JournalMalaria journal
Publication Date19 Dec 2018
Date Added to PubMed21 Dec 2018
AbstractMobile health (mHealth), which uses technology such as mobile phones to improve patient health and health care delivery, is increasingly being tested as an intervention to promote health worker (HW) performance. This study assessed the effect of short messaging services (SMS) reminders in a study setting. Following a trial of text-message reminders to HWs to improve case management of malaria and other childhood diseases in southern Malawi that showed little effect, qualitative data was collected to explore the reasons why the intervention was ineffective and describe lessons learned. Qualitative data collection was undertaken to lend insight into quantitative results from a trial in which 105 health facilities were randomized to three arms: (1) twice-daily text-message reminders to HWs, including clinicians and drug dispensers, on case management of malaria; (2) twice-daily text-message reminders to HWs on case management of malaria, pneumonia and diarrhoea; and, (3) a control arm. In-depth interviews were conducted with 50 HWs in the intervention arms across seven districts. HWs were asked about acceptability and feasibility of the text-messaging intervention and its perceived impact on recommended case management. The interviews were recorded, transcribed and translated into English for a thematic and framework analysis. Nvivo 11 software was used for data management and analysis. A total of 50 HWs were interviewed at 22 facilities. HWs expressed high acceptance of text-message reminders and appreciated messages as job aids and practical reference material for their day-to-day work. However, HWs said that health systems barriers, including very high outpatient workload, commodity stock-outs, and lack of supportive supervision and financial incentives demotivated them, limited their ability to act on messages and therefore adherence to case management guidelines. Drug dispensers were more likely than clinicians to report usage of text-message reminders. Despite these challenges, nearly all HWs expressed a desire for a longer duration of the SMS intervention. Text-message reminders to HWs can provide a platform to improve understanding of treatment guidelines and case management decision-making skills, but might not improve actual adherence to guidelines. More interaction, for example through targeted supervision or two-way technology communication, might be an essential intervention component to help address structural barriers and facilitate improved clinical practice.
Linkhttp://doi.org/10.1186/s12936-018-2629-2
TitleA digital mobile health platform increasing efficiency and transparency towards universal health coverage in low- and middle-income countries.
AuthorsHuisman, L; van Duijn, SM; Silva, N; van Doeveren, R; Michuki, J; Kuria, M; Otieno Okeyo, D; Okoth, I; Houben, N; Rinke de Wit, TF; Rogo, K
JournalDigital health
Publication Date1 Dec 2022
Date Added to PubMed19 Apr 2022
AbstractIn low-and middle-income countries, achieving universal health coverage remains challenging due to insufficient, temporary and fragmented funding as well as limited accessibility to quality healthcare. Leveraging a mobile health platform can be a powerful tool to address these problems. This paper demonstrates how analysing data collected from a mobile health platform helps optimize healthcare provider networks, monitor patient flows and assess the quality and equitability of access to care. The COVID-19 pandemic reinforces the importance of real-time data on health-seeking behaviour. Between 2018 and 2019, as a Kenyan universal health coverage pilot was being planned, Kisumu County, with support from PharmAccess Foundation, implemented household-level digital registration for healthcare and collected socio-economic and healthcare claims data using the M-TIBA platform. In total, 273,350 Kisumu households enrolled. The claims data showed many patients visit higher-level facilities for ailments, that can be treated at primary care levels, unnecessarily. High-level estimate of the disease burden at participating facilities revealed rampant overprescription of pertinent medicines for highly prevalent malaria and respiratory tract infections, exemplifying clinical management deficiencies. M-TIBA data allowed tracking of individual patient trajectories. Analyses of data are shown at the aggregate level. The paper shows how mobile health platforms can be used to generate valuable insights into access to and quality of care. Funding for healthcare can be united through mobile health platforms, limiting the fragmentation in funding. They can be useful for funders, health managers and policymakers to improve the implementation of universal health coverage programs in low-and middle-income countries.
Linkhttp://doi.org/10.1177/20552076221092213
TitleMobile health (mHealth) approaches and lessons for increased performance and retention of community health workers in low- and middle-income countries: a review.
AuthorsKällander, K; Tibenderana, JK; Akpogheneta, OJ; Strachan, DL; Hill, Z; ten Asbroek, AH; Conteh, L; Kirkwood, BR; Meek, SR
JournalJournal of medical Internet research
Publication Date25 Jan 2013
Date Added to PubMed29 Jan 2013
AbstractMobile health (mHealth) describes the use of portable electronic devices with software applications to provide health services and manage patient information. With approximately 5 billion mobile phone users globally, opportunities for mobile technologies to play a formal role in health services, particularly in low- and middle-income countries, are increasingly being recognized. mHealth can also support the performance of health care workers by the dissemination of clinical updates, learning materials, and reminders, particularly in underserved rural locations in low- and middle-income countries where community health workers deliver integrated community case management to children sick with diarrhea, pneumonia, and malaria. Our aim was to conduct a thematic review of how mHealth projects have approached the intersection of cellular technology and public health in low- and middle-income countries and identify the promising practices and experiences learned, as well as novel and innovative approaches of how mHealth can support community health workers. In this review, 6 themes of mHealth initiatives were examined using information from peer-reviewed journals, websites, and key reports. Primary mHealth technologies reviewed included mobile phones, personal digital assistants (PDAs) and smartphones, patient monitoring devices, and mobile telemedicine devices. We examined how these tools could be used for education and awareness, data access, and for strengthening health information systems. We also considered how mHealth may support patient monitoring, clinical decision making, and tracking of drugs and supplies. Lessons from mHealth trials and studies were summarized, focusing on low- and middle-income countries and community health workers. The review revealed that there are very few formal outcome evaluations of mHealth in low-income countries. Although there is vast documentation of project process evaluations, there are few studies demonstrating an impact on clinical outcomes. There is also a lack of mHealth applications and services operating at scale in low- and middle-income countries. The most commonly documented use of mHealth was 1-way text-message and phone reminders to encourage follow-up appointments, healthy behaviors, and data gathering. Innovative mHealth applications for community health workers include the use of mobile phones as job aides, clinical decision support tools, and for data submission and instant feedback on performance. With partnerships forming between governments, technologists, non-governmental organizations, academia, and industry, there is great potential to improve health services delivery by using mHealth in low- and middle-income countries. As with many other health improvement projects, a key challenge is moving mHealth approaches from pilot projects to national scalable programs while properly engaging health workers and communities in the process. By harnessing the increasing presence of mobile phones among diverse populations, there is promising evidence to suggest that mHealth can be used to deliver increased and enhanced health care services to individuals and communities, while helping to strengthen health systems.
Linkhttp://doi.org/10.2196/jmir.2130
TitleMalaria diagnosis and mapping with m-Health and geographic information systems (GIS): evidence from Uganda.
AuthorsLarocca, A; Moro Visconti, R; Marconi, M
JournalMalaria journal
Publication Date24 Oct 2016
Date Added to PubMed26 Oct 2016
AbstractRural populations experience several barriers to accessing clinical facilities for malaria diagnosis. Increasing penetration of ICT and mobile-phones and subsequent m-Health applications can contribute overcoming such obstacles. GIS is used to evaluate the feasibility of m-Health technologies as part of anti-malaria strategies. This study investigates where in Uganda: (1) malaria affects the largest number of people; (2) the application of m-Health protocol based on the mobile network has the highest potential impact. About 75% of the population affected by Plasmodium falciparum malaria have scarce access to healthcare facilities. The introduction of m-Health technologies should be based on the 2G protocol, as 3G mobile network coverage is still limited. The western border and the central-Southeast are the regions where m-Health could reach the largest percentage of the remote population. Six districts (Arua, Apac, Lira, Kamuli, Iganga, and Mubende) could have the largest benefit because they account for about 28% of the remote population affected by falciparum malaria with access to the 2G mobile network. The application of m-Health technologies could improve access to medical services for distant populations. Affordable remote malaria diagnosis could help to decongest health facilities, reducing costs and contagion. The combination of m-Health and GIS could provide real-time and geo-localized data transmission, improving anti-malarial strategies in Uganda. Scalability to other countries and diseases looks promising.
Linkhttp://doi.org/10.1186/s12936-016-1546-5
TitleCOVID-19 and inequities in the Americas: lessons learned and implications for essential health services.
AuthorsHennis, AJM; Coates, A; Del Pino, S; Ghidinelli, M; Gomez Ponce de Leon, R; Bolastig, E; Castellanos, L; Oliveira E Souza, R; Luciani, S
JournalRevista panamericana de salud publica = Pan American journal of public health
Publication Date1 Dec 2021
Date Added to PubMed7 Jan 2022
AbstractThe COVID-19 pandemic has exacerbated social, economic, and health-related disparities, which disproportionately affect persons living in conditions of vulnerability. Such populations include ethnic groups who face discrimination and experience barriers to accessing comprehensive health care. The COVID-19 pandemic has exposed these health disparities, and disruptions of essential health services have further widened the gaps in access to health care. Noncommunicable diseases are more prevalent among groups most impacted by poor social determinants of health and have been associated with an increased likelihood of severe COVID-19 disease and higher mortality. Disruptions in the provision of essential health services for noncommunicable diseases, mental health, communicable diseases such as HIV, tuberculosis, and malaria, and maternal and child health services (including sexual and reproductive health), are projected to also increase poor health outcomes. Other challenges have been an increased frequency of interpersonal violence and food insecurity. Countries in the Americas have responded to the disruptions caused by the pandemic by means of health service delivery through telemedicine and other digital solutions and stepping up social service support interventions. As vaccinations for COVID-19 create the opportunity to overcome the pandemic, countries must strengthen primary health care and essential health services with a view to ensuring equity, if the region is to achieve universal health coverage in fulfillment of the Sustainable Development Goals. HennisAnselm J MAJMPan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America.CoatesAnnaAPan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America.Del PinoSandraSPan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America.GhidinelliMassimoMPan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America.Gomez Ponce de LeonRodolfoRPan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America.BolastigEdwinEPan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America.CastellanosLuisLPan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America.Oliveira E SouzaRenatoRPan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America.LucianiSilvanaSPan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America.engJournal Article20211228United StatesRev Panam Salud Publica97054001020-4989La pandemia de COVID-19 ha acentuado las desigualdades sociales, económicas y relacionadas con la salud, que afectan desproporcionadamente a las personas en situación de vulnerabilidad. Esta población incluye grupos étnicos que se enfrentan a la discriminación y obstáculos para el acceso a la atención integral de salud. La pandemia de COVID-19 ha expuesto estas desigualdades de salud, y las interrupciones de los servicios esenciales de salud han ampliado aún más las brechas en el acceso a la atención de salud. Las enfermedades no transmisibles son más prevalentes en los grupos que han sufrido un mayor impacto de los determinantes sociales de la salud deficientes y se han asociado con una mayor probabilidad de presentar un cuadro grave de COVID-19 y una mayor mortalidad. Asimismo, se proyecta que las interrupciones en la prestación de servicios esenciales de salud para las enfermedades no transmisibles, la salud mental, las enfermedades transmisibles como la infección por el VIH, la tuberculosis y la malaria, y los servicios de salud maternoinfantil (como la salud sexual y reproductiva) incrementen los resultados deficientes en materia de salud. Otros retos son una mayor frecuencia de la violencia interpersonal y la inseguridad alimentaria. Los países de la Región de las Américas han respondido a las interrupciones causadas por la pandemia con la prestación de servicios de salud mediante la telemedicina y otras soluciones digitales, y la aceleración de las intervenciones de apoyo de los servicios sociales. A medida que la vacunación contra la COVID-19 crea la oportunidad de superar la pandemia, los países deben fortalecer su atención primaria de salud y sus servicios de salud esenciales a fin de garantizar la equidad, para que la Región logre la cobertura universal de salud en cumplimiento de los Objetivos de Desarrollo Sostenible. A pandemia de COVID-19 exacerbou as disparidades sociais, econômicas e as relacionadas à saúde, que afetam de maneira desproporcional as pessoas que vivem em situação de vulnerabilidade. Essas populações incluem grupos étnicos que enfrentam discriminação e barreiras para o acesso à atenção integral à saúde. A pandemia de COVID-19 expôs essas disparidades, e as interrupções nos serviços essenciais de saúde ampliaram ainda mais as lacunas no acesso aos cuidados de saúde. As doenças não transmissíveis são mais prevalentes entre os grupos mais afetados por determinantes sociais da saúde deficientes e estão associadas a um aumento na probabilidade de doença grave pela COVID-19 e mortalidade mais elevada. Prevê-se que as interrupções na prestação de serviços essenciais de saúde para doenças não transmissíveis, saúde mental, doenças transmissíveis como HIV, tuberculose e malária, bem como dos serviços de saúde materno-infantil (incluindo saúde sexual e reprodutiva) também aumentem os desfechos adversos de saúde. Outros desafios são o aumento da frequência da violência interpessoal e insegurança alimentar. Os países das Américas responderam às interrupções causadas pela pandemia com a prestação de serviços de saúde por meio da telemedicina e outras soluções digitais, e a aceleração de intervenções de apoio dos serviços sociais. À medida em que a vacinação contra a COVID-19 oferece a oportunidade de superar a pandemia, os países devem fortalecer a atenção primária à saúde e os serviços essenciais de saúde com o objetivo de garantir a equidade, para que a região atinja a cobertura universal de saúde em cumprimento aos Objetivos de Desenvolvimento Sustentável.
Linkhttp://doi.org/10.26633/RPSP.2021.130
TitleDigital health for the End TB Strategy: developing priority products and making them work.
AuthorsFalzon, D; Timimi, H; Kurosinski, P; Migliori, GB; Van Gemert, W; Denkinger, C; Isaacs, C; Story, A; Garfein, RS; do Valle Bastos, LG; Yassin, MA; Rusovich, V; Skrahina, A; Van Hoi, L; Broger, T; Abubakar, I; Hayward, A; Thomas, BV; Temesgen, Z; Quraishi, S; von Delft, D; Jaramillo, E; Weyer, K; Raviglione, MC
JournalThe European respiratory journal
Publication Date1 Jul 2016
Date Added to PubMed28 May 2016
AbstractIn 2014, the World Health Organization (WHO) developed the End TB Strategy in response to a World Health Assembly Resolution requesting Member States to end the worldwide epidemic of tuberculosis (TB) by 2035. For the strategy's objectives to be realised, the next 20 years will need novel solutions to address the challenges posed by TB to health professionals, and to affected people and communities. Information and communication technology presents opportunities for innovative approaches to support TB efforts in patient care, surveillance, programme management and electronic learning. The effective application of digital health products at a large scale and their continued development need the engagement of TB patients and their caregivers, innovators, funders, policy-makers, advocacy groups, and affected communities.In April 2015, WHO established its Global Task Force on Digital Health for TB to advocate and support the development of digital health innovations in global efforts to improve TB care and prevention. We outline the group's approach to stewarding this process in alignment with the three pillars of the End TB Strategy. The supplementary material of this article includes target product profiles, as developed by early 2016, defining nine priority digital health concepts and products that are strategically positioned to enhance TB action at the country level.
Linkhttp://doi.org/10.1183/13993003.00424-2016
TitleImproving the Quality of Antenatal Care Using Mobile Health in Madagascar: Five-Year Cross-Sectional Study.
AuthorsBenski, AC; Schmidt, NC; Viviano, M; Stancanelli, G; Soaroby, A; Reich, MR
JournalJMIR mHealth and uHealth
Publication Date8 Jul 2020
Date Added to PubMed17 Jul 2020
AbstractDespite many efforts, maternal mortality remains a major burden in most developing countries. Mobile health (mHealth) has the potential to improve access to obstetric care through apps that help patients and providers. This study aimed to use mHealth to provide antenatal care (ANC) to 1446 pregnant women in a rural area in Madagascar and evaluate the quality of ANC provided by an mHealth system designed to change the behaviors of providers and patients. We included 1446 women who attended ANC visits in rural Madagascar from 2015 to 2019 using an mHealth system called Pregnancy and Newborn Diagnostic Assessment (PANDA). This cross-sectional study used data from different participants, with information collected over several years, to analyze the outputs related to the quality of ANC over time. Specifically, we examined the timing of the first ANC visit, the relationship between the visit duration and the risk factors among pregnant women, and the number of ANC visits per woman. Following the implementation of the mHealth system in 2015, we observed that women started to come earlier for their first ANC visit; more women attended their first ANC visit in the second trimester of pregnancy in 2019 than in the previous years (P<.001). In 2019, fewer women attended their first ANC visit in the third trimester (57/277, 20.6%) than in 2015 (147/343, 42.9%). There were statistically significant associations between the ANC visit durations and the risk factors, including age (>35 years; 25.0 min, 95% CI 24.0-25.9), educational level (longer visit for women with lower than primary education and for women who attended university and shorter for women with primary school-level education; 40.7 min, 95% CI 30.2-51.3 and 25.3 min, 95% CI 24.4-26.3 vs 23.3 min, 95% CI 22.9-23.8; P=.001), experience of domestic violence during pregnancy, gravidity, parity, infectious diseases (HIV, malaria, and syphilis), and level of anemia. Statistically significant associations were observed for all quality indicator variables. We observed a statistically significant increase in the number of ANC visits per woman over time from 2015 to 2017; the number of ANC visits per woman then became stable after the third year of implementing the PANDA mHealth system. This study shows the potential of an mHealth system to improve the quality of ANC, change provider behavior by standardizing ANC visits, and change patient behavior by increasing the willingness to return for subsequent visits and encouraging ANC attendance early in pregnancy. As this is an exploratory study, further studies are necessary to better understand how mHealth can change behavior and identify the conditions required for behavioral changes to persist over time.
Linkhttp://doi.org/10.2196/18543
TitleDevelopment and Validation of Manually Modified and Supervised Machine Learning Clinical Assessment Algorithms for Malaria in Nigerian Children.
AuthorsMcLaughlin, M; Pellé, KG; Scarpino, SV; Giwa, A; Mount-Finette, E; Haidar, N; Adamu, F; Ravi, N; Thompson, A; Heath, B; Dittrich, S; Finette, B
JournalFrontiers in artificial intelligence
Publication Date1 Dec 2021
Date Added to PubMed22 Feb 2022
AbstractIt is currently estimated that 67% of malaria deaths occur in children under-five years (WHO, 2020). To improve the identification of children at clinical risk for malaria, the WHO developed community (iCCM) and clinic-based (IMCI) protocols for frontline health workers using paper-based forms or digital mobile health (mHealth) platforms. To investigate improving the accuracy of these point-of-care clinical risk assessment protocols for malaria in febrile children, we embedded a malaria rapid diagnostic test (mRDT) workflow into THINKMD's (IMCI) mHealth clinical risk assessment platform. This allowed us to perform a comparative analysis of THINKMD-generated malaria risk assessments with mRDT truth data to guide modification of THINKMD algorithms, as well as develop new supervised machine learning (ML) malaria risk algorithms. We utilized paired clinical data and malaria risk assessments acquired from over 555 children presenting to five health clinics in Kano, Nigeria to train ML algorithms to identify malaria cases using symptom and location data, as well as confirmatory mRDT results. Supervised ML random forest algorithms were generated using 80% of our field-based data as the ML training set and 20% to test our new ML logic. New ML-based malaria algorithms showed an increased sensitivity and specificity of 60 and 79%, and PPV and NPV of 76 and 65%, respectively over THINKD initial IMCI-based algorithms. These results demonstrate that combining mRDT "truth" data with digital mHealth platform clinical assessments and clinical data can improve identification of children with malaria/non-malaria attributable febrile illnesses.
Linkhttp://doi.org/10.3389/frai.2021.554017
MNCHFPRHHIV/AIDSMalariaNoncommunicable diseaseCOVID-19Decision-makingEducation & trainingBehavior changeGovernancePrivacy & securityEquityCHWsYouth & adolescentsSystematic reviewsProtocols & research designMedical RecordsLaboratoryPharmacyHuman ResourcesmHealthSMSChatbotsAI