Perspectives for low and middle-income countries
Lund S, PhD1,2,3, Sørensen B L,
PhD4, Nørrelund A, RNM5, Frøkjær
Barrie A M, MSc5, Frellsen A, MBA5,
Nejsum A6, Ugglas A, MSc7, Nielsen H
S, PhD2,5,8
Corresponding author: Stine Lund, Department of Neonatology, Hvidovre
Hospital, Denmark. Phone +4522440578. Email: stine.lund@regionh.dk
1Department of Neonatology, Hvidovre Hospital,
Kettegårds Alle 30, 2650 Hvidovre, Denmark
2Department of Clinical Medicine, University of
Copenhagen, Blegdamsvej 3B, 2200 Copenhagen
3Global Health Unit, Rigshospitalet, Blegdamsvej 9,
2100 Copenhagen, Denmark
4Department of Obstetrics and Gynecology, Sjaellands
University Hospital, Sygehusvej 10, 4000 Roskilde, Denmark
5 Maternity Foundation, Forbindelsesvej 3, 2100
Copenhagen, Denmark
6Visikon, Tangen 17, Århus N, Denmark
7Laerdal Global Health, Tanke Svilands gate 30, 4003
Stavanger, Norway
8Department of Obstetrics and Gynecology, Hvidovre
Hospital, Kettegårds Alle 30, 2650 Hvidovre, Denmark
Word count: 832
The COVID-19 pandemic is upon us and although currently the epicenters
are Europe and United States of America the prospects of consequences
for health systems, health workers and populations in low and
middle-income countries are daunting.
One of the major challenges in a pandemic is reaching health workers
with essential information on epidemiology, clinical guidelines,
personal protection measures and infection control. This is particularly
the case for resource constraint environments in low and middle-income
countries. Mobile health solutions have the last decade claimed ability
to reach large volumes of health workers in resource constraint
environments with up-to-date clinical guidelines and health information.
It is now time to raise up to expectations.
In-service training has long been used to improve health workers’
competences with varying degrees of success (1, 2). However traditional
in-service trainings are designed as a group-based workshop design
removes the health care providers from their facilities. Evidence also
show that the one-time training does not always improve providers
performance (1, 3) and it is suggested onsite repetitive, targeted
skill-based learning activities which are spaced overtime improves
learning outcome (3). With the current COVID-19 emergency where face to
face training and mentoring is a challenge, use of mobile technology
could help to fill the gap in training of front line health workers (4).
Most emergencies also in the COVID-19 era likely take place peripherally
where health workers have inadequate access to clinical guidelines and
reference materials to handle situations that are beyond their skills
(5). Promotion of health services via mobile electronic media (mHealth)
like mobile phones has been suggested as a means to bridge this outreach
gap (6). In 2019, 98% of adult people in low and middle income
countries had a cellular subscription, and approximately 72% of people
in Sub-Saharan Africa have a cellular subscription and more than half of
people in remote areas have a mobile phone (7). Mobile devices are in
increasing number being used to provide continued training support to
frontline health workers and remote providers, through access to
educational videos, information, interactive exercises, and can allow
for continued clinical and skills monitoring (8). Necessity is a driver
for technological innovation as previously seen in sub Saharan Africa
with development of the mobile banking systems and dual sim cards, and
we are now witnessing examples of health care innovation in the wake of
the COVID-19 pandemic.
We have, in a consortium of non-governmental organizations, academia and
the private sector, and in a collaboration with International
Confederation of Midwifes (ICM) and UNFPA, responded to the COVID-19
pandemic by rapid development of a COVID-19 module in an existing mobile
job and training aid called the Safe Delivery App (SDA) (9). The SDA, a
freely available tool, is an emergency obstetric and neonatal care
training aid for skilled birth attendants in low- and middle-income
countries. Launched in 2015 it uses animated videos for clinical
instructions and provides access to evidence-based and up-to-date
clinical guidelines. In addition to the animated videos four basic
features guide health workers in the App: action cards, drug lists,
practical procedures, and MyLearning an individualised e-learning
component. MyLearning, was developed in 2016 in response to requests
from partners to move beyond push messages and simulate self-learning
within the App through gamification principles. The app is free of
charge and follows WHO guidelines. Through continuous development it
currently exists in two global versions (English, French) and 14
language versions and has more than 120,000 downloads globally, with
greater use across Africa and South East Asia.
The COVID-19 module in the SDA contains an animated short movie on
infection prevention and personal protection equipment during COVID-19,
figure 1. It also contains latest evidence on COVID-19 consequences for
pregnant women and newborns and practical procedures for handling
deliveries and newborns during the pandemic. The language and
illustrations are simple with a focus on local adaptable measures such
as recipes and procedures for making your own alcohol rub. One challenge
is the rapid evolving evidence and ever-changing guidelines. To make
ongoing changes cost-effective the film speaks and visual is held in
general terms while written text in the film and action cards/practical
procedures is changeable in a content management system. User patterns
of the module in the app will be monitored continuously.
mHealth responses to the COVID-19 are emerging. The potential for
telemedicine is obvious as well as health information systems support
for outbreak monitoring and management (10, 11). Interestingly, there is
also a push towards open sharing of not only clinical and
epidemiological data but also social media data from technological
compagnies that can support community surveillance, contact tracing,
social mobilization and health promotion (12). The global community
claim that mHealth have the potential for rapid response, real time
data, up-to-date clinical guidelines in the hands of health workers. The
ultimate test is here in the COVID-19 pandemic. We are calling for the
mobile health community and global partners – it is time to raise up to
expectations of the potentials of mobile health.