TY - JOUR
AU1 - Mishra, Shiva, Raj
AU2 - Lygidakis,, Charilaos
AU3 - Neupane,, Dinesh
AU4 - Gyawali,, Bishal
AU5 - Uwizihiwe, Jean, Paul
AU6 - Virani, Salim, S
AU7 - Kallestrup,, Per
AU8 - Miranda, J, Jaime
AB - Abstract The use of community health workers (CHWs) has been explored as a viable option to provide home health education, counselling and basic health care, notwithstanding their challenges in training and retention. In this manuscript, we review the evidence and discuss how the digitalization affects the CHWs programmes for tackling non-communicable diseases (NCDs) in low- and middle-income countries (LMICs). We conducted a review of literature covering two databases: PubMED and Embase. A total of 97 articles were abstracted for full text review of which 26 are included in the analysis. Existing theories were used to construct a conceptual framework for understanding how digitalization affects the prospects of CHW programmes for NCDs. The results are divided into two themes: (1) the benefits of digitalization and (2) the challenges to the prospects of digitalization. We also conducted supplemental search in non-peer reviewed literature to identify and map the digital platforms currently in use in CHW programmes. We identified three benefits and three challenges of digitalization. Firstly, it will help improve the access and quality of services, notwithstanding its higher establishment and maintenance costs. Secondly, it will add efficiency in training and personnel management. Thirdly, it will leverage the use of data generated across grass-roots platforms to further research and evaluation. The challenges posed are related to funding, health literacy of CHWs and systemic challenges related to motivating CHWs. Several dozens of digital platforms were mapped, including mobile-based networking devices (used for behavioural change communication), Web-applications (used for contact tracking, reminder system, adherence tracing, data collection and decision support), videoconference (used for decision support) and mobile applications (used for reminder system, supervision, patients’ management, hearing screening and tele-consultation). The digitalization efforts of CHW programmes are afflicted by many challenges, yet the rapid technological penetration and acceptability coupled with the gradual fall in costs constitute encouraging signals for the LMICs. Both CHWs interventions and digital technologies are not inexpensive, but they may provide better value for the money when applied at the right place and time. Community health workers, non-communicable diseases, low-income countries, community health programmes Key Messages The technological boom in low- and middle-income countries has opened up plethora of avenues where digital technologies can become part of community health worker (CHW) programmes. There are some benefits, of the digitalization process whereby CHW programme would help expanding access to services and their quality, catalyses training and supervision of CHWs for personnel management, as well as benefiting evaluation and research processes. The challenges related to the prospects of digitalization are related to funding of CHW programmes in general as well as funding for uptake of digitalization process, digital literacy of CHWs and other systematic challenges that are present in the programme even before the digitalization process could began. Background Community Health Workers (CHWs) constitute the backbone of health delivery systems globally (Mishra et al., 2015). Recently, it has been proposed to train an additional million CHWs to speed up the strides towards universal health coverage in rural sub-Saharan Africa (One Million Community Health Workers Campaign). The World Health Organization (WHO) defines CHWs as men and women, young or old, literate or illiterate, who are members of the community, and pertinently trained to deal with the health problems of individuals and the community (Rifkin, 2008). The term CHW is broad with more than 30 different titles named worldwide (Bhattacharyya et al., 2001); CHWs have been classified as health associate professionals (Beard and Redmond, 1979; International Labour Office, 2012). The activities and roles of CHWs are tailored to meet the unique health needs of their communities, and depend on factors such as, whether they work in the health care or social service sectors (Rural Health Information Hub), the type and duration of training and previous education, and the size and geographical spread of the covered population. CHWs have been largely used in programmes that target infectious diseases (e.g. HIV/AIDS and tuberculosis), as well as in those related to maternal and child health (Tsolekile et al., 2014). This focus has been driven by the Millennium Development Goals, resulting in less attention to other conditions such as non-communicable diseases (NCDs) (Lewin et al., 2010; Perry and Zulliger, 2012). According to the 2015 Global Burden of Disease Study, NCDs accounted for more than 70% of global deaths (Reddy, 2016). Responding to this challenge, the United Nations’ Member States included a target in the sustainable development goals for all countries to reduce premature mortality from NCDs by one-third by 2030 (United Nations, 2015). Recent evidence has demonstrated that CHWs may be effective in tackling the burden of cardiovascular diseases (CVDs) and other NCDs in low- and middle-income countries (LMICs) (Khetan et al., 2016), where there is a perennial shortage of health professionals. Digital technologies have changed the way consumers (the patients) and providers (health professionals) interact with each other, especially in LMICs, such as India and China. Internet connectivity currently covers 85% of habitable areas in the world, far greater than the average coverage of electrical grid (Kay et al., 2011; International Telecommunication Union, 2017). A 2009 study found 83% of the 114 investigated countries offered at least 1 mobile Health (mHealth) service, with high-income countries showing higher usage than low-income ones. The increasing use of mobile phones and expansion in internet connectivity are expected to be the driving forces for the electronic Health (eHealth) expansion in LMICs. It is inevitable that the CHW programmes will be affected in this process. It is unclear, however, how technology will benefit the existing CHW interventions for NCDs. Previous reviews discussed the benefits of digitalization with focus on mHealth (Källander et al., 2013), particularly covering regions such as Africa (Opoku et al., 2017). A review by Källandar et al. identified six main areas in which mobile technologies can be used: education and awareness, data access, monitoring and compliance, disease and emergency tracking, health information systems, and diagnosis and consultation (Källander et al., 2013). The aim of this review is to explore the digital opportunities and challenges for CHW programmes in LMICs, particularly focusing on NCDs. Two themes have been used to support this discussion: (1) how digitalization will support CHWs interventions for NCDs and (2) what are the challenges for the CHW programmes with digitalization in the future. Methods A review of literature was conducted in PubMed/Medline using the MeSH terms ‘Telemedicine’ and ‘Community Health Workers’ from 1 January 2000 to 31 December 2016. The MeSH term in PubMed for telemedicine entails the following entry terms: ‘Mobile Health’, ‘Health, Mobile’, ‘mHealth’, ‘Telehealth’ and ‘eHealth’. Articles and abstracts in English were only taken into consideration. A total of 33 articles were identified and reviewed. Similarly, a search for studies was performed in Embase, replacing ‘community health workers in PubMed with ‘health auxiliary’ and using a combination of entry terms in Emtree (equivalent of MeSH in Embase) such as ‘telehealth’, ‘mobile health’, ‘mHealth’ and ‘telemedicine’, as done in PubMed. A total of 70 papers were obtained from 1 January 2000 to 31 December 2016. Further searches were conducted in Google Scholar for grey literature and 69 papers were identified. Individual papers (e.g. reviews, opinion pieces and commentaries) were considered for full text review. A total of 97 papers were accessed for full text (observational studies n = 20, interventional studies n = 27, review articles n = 15, comments/letters/opinion pieces n = 6, conference abstracts n = 29), and of them, 26 papers that laid down uses of at least 1 digital device and/or platform were abstracted for information (see Supplementary data S1) and included in the review. To facilitate the analysis, a framework centred on digitalization was developed based on earlier work (Labrique et al., 2013,; Opoku et al., 2017). There are only limited deliberations of the impact of digitalization on CHW programmes in NCDs context, and it is also relatively unclear whether digitalization is in itself a process or an outcome in this context. Therefore, we presented this paper as a structured narrative review, following some components of the preferred reporting of systematic review and meta-analysis guidelines (Figure 1). Figure 1 View largeDownload slide Flow diagram of the review process Figure 1 View largeDownload slide Flow diagram of the review process An adapted framework for NCDs According to Gartner, digitalization is: ‘the use of digital technologies to change a business model and provide new revenue and value-producing opportunities; simply said it is the process of moving to a digital business’ (Gartner). Building on this definition, our interpretation is of ‘an ongoing process by which information and communicating technologies (ICT) are adopted to improve the value of services’ both at the public and private sector. Contrary to ‘digitization’, ‘digitalization’ goes beyond the mere introduction of ICT, as it builds upon the experience of multiple sectors, and catalyses the convergence of processes to improve their efficiency. The current digital solutions for NCD services are presented in Supplementary Table S1, and cover such areas as: networking devices (used for behavioural change communication), Web-applications (used for contact tracking, reminder systems, adherence tracing, data collection and decision support), videoconferencing (used for decision support) and mobile applications (used as a reminder system and for supervision, patient management, hearing screening and tele-consultation). In an earlier review, Opoku described how patients and providers interact in a complex system involving mHealth, and laid down the factors that influence them (Opoku et al., 2017). Figure 2 of our ‘digital-temple model’ illustrates the impact of digitalization on health systems involving complex interactions among patients, providers and CHWs. This framework may be applicable to other health care areas beyond those related to NCDs. How such interactions take place is discussed in previous works (Agarwal et al., 2016,; Opoku et al., 2017). The outcomes of such interactions would have impact on: (1) expanding access and quality of services; (2) training and supervision of personnel, and (3) research and evaluation. Figure 2 View largeDownload slide ‘Digital-temple model’ for understanding the impact of digitalization and complex interaction among the patients, providers and CHWs in health system. The model shows digitalization as a catalyst in the system. The interactions between patients and providers, as well as CHWs and patients have been shown to be reciprocal, similar to previous studies (Opoku et al., 2017; Agarwal et al., 2016). This model is based on earlier work (Opoku et al., 2017). The 12 core functions presented are adaption of Labrique (2013) work on 12 key functions of mHealth platforms in reproductive, child and maternal health context (Labrique et al., 2013). The model presents three stepping stones as (1) research and evaluation, (2) training, supervision on personnel management and (3) access and quality of services. Figure 2 View largeDownload slide ‘Digital-temple model’ for understanding the impact of digitalization and complex interaction among the patients, providers and CHWs in health system. The model shows digitalization as a catalyst in the system. The interactions between patients and providers, as well as CHWs and patients have been shown to be reciprocal, similar to previous studies (Opoku et al., 2017; Agarwal et al., 2016). This model is based on earlier work (Opoku et al., 2017). The 12 core functions presented are adaption of Labrique (2013) work on 12 key functions of mHealth platforms in reproductive, child and maternal health context (Labrique et al., 2013). The model presents three stepping stones as (1) research and evaluation, (2) training, supervision on personnel management and (3) access and quality of services. Opportunities for CHW programmes in LMICS Increasing service access and quality The CHW programmes can become more efficient, expand their range of services and increase their quality. CHWs use mobile phones, tablets and other digital devices (Källander et al., 2013), which have become increasingly affordable, in a task-specific manner. For example, digital blood pressure monitoring devices, glucometers and spirometers have been adapted to fit the local context increasing service access (Agarwal et al., 2016). Risk assessment cards can be used in addition to glucometers to track and report progress on diabetes and to increase effectiveness in risk prediction (Ranslow et al., 2015). Such devices which readily provide interpretable visual results are highly useful for CHWs with low literacy (Ranslow et al., 2015). For maternal and child health, mobile applications have been in use for a long time (Little et al., 2013). In a study in India, a mobile application for scheduling (electronic registries, prompts and reminders for home visits) is used as a job aid to increase the frequency of CHW’s home visits (Modi et al., 2015). The inclusion of checklists and video clips can help with the behavioural change communication activities of CHWs. Additionally, algorithms recommend relevant examinations for diagnosis and treatment plan customization. Some applications are also linked with the primary care centres, so that the clinicians can supervise CHWs, monitor them for performance-based incentives, follow high-risk patients and their vital statistics, and track items across the supply chain (Modi et al., 2015). Other solutions can also enable central monitoring. For example, in Rajasthan State in India, the CHWs use digital devices to record vaccination data (Mishra et al., 2016), helping to identify children who drop out from the regular vaccination schedule. The data from CHWs are later transferred to a cloud-based dashboard and analysed centrally. Alerts, notifications, reminders, checklists and decision-support tools facilitate compliance to protocols, support evidence-based practice and ultimately, improve the quality of the care provided by the CHWs (Svoronos et al., 2010). For example, DeRenzi et al. (2012) reported improvement in the performance of CHWs by integrating text reminders into the regular practice and aiding supervisors to be aware of overdue visits. Florez-Arango et al. (2011) noticed an increase in protocol compliance and a reduction of errors when conducting an mHealth intervention with CHWs using point-of-care guidelines in an experimental setting. Furthermore, sophisticated platforms can be used for peer-to-peer communication, electronic decision support and imparting positive education and behaviour in the community (Table 1). Additionally, the use of such platforms can be on supply chain management to provide records of their stocks (Labrique et al., 2013; Agarwal et al., 2016). Table 1 provides the summary of various platforms in use today and where they fit in a complex system involving patients, providers and CHWs, and the interaction thereof. Table 1 Functions, characteristics and examples of digital platforms in relation to their interaction with patients, providers and health system Interaction Theme Functions (Labrique et al., 2013) Characteristics Patients CHWs Providers Health system Examples (Funes et al., 2012; Braun et al., 2013; Labrique et al., 2013; Agarwal et al., 2016; Basavarajappa and Chand, 2017) Health system goals Opportunities for NCDs Challenges Increasing service access and quality Patient’s education and communication One-way or two-way communication gateway for BCC + + + Kunji (BBC world trust), Dimagi, FreeSwitch, FrontlineSMS, RapidPro, txtAlert, Verboice, Voto, Vumi, SMS, SAMHSA, PRIORI -Impart knowledge, attitude and behaviour -Increase health literacy of the population Bulk or individual SMS, audio, video schemes for health promotion, a continuous communication may lead to establishing and enhancing the therapeutic alliance between HWs and patients Illiteracy, low mobile network coverage, power shortages, fragmentation of solutions, increased costs for adaptation of educational material and contextualization of the solutions, user experience and usability concerns Point-of-care decision support system Provides point by point support to diagnosis and management of illness, based on a guideline for diagnosis and treatment + + e-IMCI, GuideView, MDconsults, Mezzanine, Mobenzi-outreach, OpenSRP -Support decision-making -Evidenced-based care -Appropriate use of resources -Preventing adverse reactions and errors Management of HTN, diabetes (e.g. foot ulcers) following simple algorithms, management of multimorbidity and multiple drug regimes, prioritization of health needs No treatment and management guidelines in LMICs for most NCDs, decision-support systems are regulated as medical devices is some nations requiring more time and resources, user experience and usability concerns Systems, sensors at point of care diagnostics Extends the delivery points, uses sensors that records and transmits patients’ health records/information, on real time or for later during counselling + + AliveCor, Ubiquitous health care −Patient-based data collection at real time off the facility Tracking blood pressure, glucose, physical activity Integration of data deriving from sensors into eHealth records to facilitate case management Increase health literacy of the population and by extent, encourage health behaviour change Digital literacy is low, costs associated with devices and connectivity, limited mobile coverage, durability of the devices, privacy and security concerns, regulatory and legislative frameworks are needed Supply chain and logistics management Checks, tracks the stock of supplies or medicines, to ensure supply of commodities are maintained year around + + + Life mHealth, Sproxil, Dimagi(commcare supply), mSupply, OpenLMIS -Improve stock management and availability, and decrease waste - Ensure appropriate medicine conservation and patient safety Tracking stocks of HTN, antidiabetic medications at community level when CHWs and HWs fills out their stocks Digital literacy of CHWs, user experience and usability concerns, high burden on the providers, initial costs of the implementation, durability of the devices Research and evaluation Repositories and databases, and built in system for vital events tracking Tracks unique identifiers or indicators for later use, for monitoring, evaluation and research + + + Mother and Child tracking System (MCTS) in India, Rapid SMS Uganda, OpenSRP, mTika, Cell PREVEN -Tacking indicators, storage for future use - data aggregation Storing blood pressure, glucose, medication use data for compliance reporting Costs of registries, and maintenance Data collection, harmonization, harvesting and reporting Reduces the lag between data collection and reporting to go to authorities, improves the completeness and accuracy of data. + + Open Data Kit (ODK),FrontlineSMS,Magpi,Fromhub,DHIS2,Dimagi(commcare),Data Winners,iFormBuilderEnketo,Mango platform,MedicMobile,Mobenzi-research,ONA,OpenXData,PoimapperKhusibaby(necklace & app),GSM,PDA PREVEN  -Improve accuracy, completeness and timeliness of data collection, harvest more data points on real time  - Data aggregation  - Better intelligence for targeted interventions Collection of WHO core modifiable NCD risk factors in existing LMICs surveys Network coverage for reporting or sinking collected data Health care data platform From one office to community set up, routinely collected data can be added to the data pool longitudinally + OpenMRS, Childcount+, OpenEMR −Systematize data reporting and storage process with ability to tack patients longitudinally Blood pressure, glucose, lipids, GFR, creatinine levels from local PHC, or blood pressure, glucose from CHWs Identification of at-risk patients Costs, and maintenance of platform, fragmentation of solutions, digital literacy Training, supervision on personnel management CHW to CHW or CHW to patients/providers interaction Exchange of voice, images, or texts for instant communication at/for remote consultation and decision support + + Switchboard (Closed User Group), Case.io -Improve CHW to CHW, CHW to provide communication for decision support -Access to otherwise unavailable resources and expertise -Interprofessional collaboration leading to better quality of care -Enhance work satisfaction of HWs Decision support for HTN, diabetes management Digital literacy, mobile coverage costs CHW’s work planning, organization and scheduling Reminder-based system, to increase compliance and accountability + txtAlert,MoTech −Improve productivity at work Reminders to make regular home visitation Increase treatment adherence Digital literacy CHW’s training and education Provides continued opportunity for enhancing skills via quizzes and case-based learning to inforce in-person training + eMOCHA, Moodle, OppiaMobile; Leap, Tele-ECHO, Mobile Kunji, mTrack, MOTECH, IQCare, Pesinet Mali, Nompilo, Uganda HIN, Mozambique HIN -Continued education and skills enhancement -Enhance work satisfaction of HWs Simple point-point algorithm for HTN, diabetes, diagnosis, management, counselling Recruit and retain through training Digital literacy, Existing burden on CHWs for other duties, need for updated material, demand for contextualized material, blended learning seems more effective but may be more expensive Human resource and personnel management Monitoring of field activities, and that helps to set up performance-based incentive scheme + mUbuzima, Rapid SMS, iHRIS, MOTECH −Performance tracking GPS tracking of CHWs to be tied with monthly follow ups Network coverage Financial transaction, incentive management and disbursement Mobile transaction scheme as payment or transfer or cash voucher + MTN, m-Pesa −Easing performance-based incentives (CHWs, HWs), payment at point of care (patients) Patients can pay for services or medicines upfront, and CHWs getting performance-based incentives Mobile network partner limited in most LMICs, business model not clear Interaction Theme Functions (Labrique et al., 2013) Characteristics Patients CHWs Providers Health system Examples (Funes et al., 2012; Braun et al., 2013; Labrique et al., 2013; Agarwal et al., 2016; Basavarajappa and Chand, 2017) Health system goals Opportunities for NCDs Challenges Increasing service access and quality Patient’s education and communication One-way or two-way communication gateway for BCC + + + Kunji (BBC world trust), Dimagi, FreeSwitch, FrontlineSMS, RapidPro, txtAlert, Verboice, Voto, Vumi, SMS, SAMHSA, PRIORI -Impart knowledge, attitude and behaviour -Increase health literacy of the population Bulk or individual SMS, audio, video schemes for health promotion, a continuous communication may lead to establishing and enhancing the therapeutic alliance between HWs and patients Illiteracy, low mobile network coverage, power shortages, fragmentation of solutions, increased costs for adaptation of educational material and contextualization of the solutions, user experience and usability concerns Point-of-care decision support system Provides point by point support to diagnosis and management of illness, based on a guideline for diagnosis and treatment + + e-IMCI, GuideView, MDconsults, Mezzanine, Mobenzi-outreach, OpenSRP -Support decision-making -Evidenced-based care -Appropriate use of resources -Preventing adverse reactions and errors Management of HTN, diabetes (e.g. foot ulcers) following simple algorithms, management of multimorbidity and multiple drug regimes, prioritization of health needs No treatment and management guidelines in LMICs for most NCDs, decision-support systems are regulated as medical devices is some nations requiring more time and resources, user experience and usability concerns Systems, sensors at point of care diagnostics Extends the delivery points, uses sensors that records and transmits patients’ health records/information, on real time or for later during counselling + + AliveCor, Ubiquitous health care −Patient-based data collection at real time off the facility Tracking blood pressure, glucose, physical activity Integration of data deriving from sensors into eHealth records to facilitate case management Increase health literacy of the population and by extent, encourage health behaviour change Digital literacy is low, costs associated with devices and connectivity, limited mobile coverage, durability of the devices, privacy and security concerns, regulatory and legislative frameworks are needed Supply chain and logistics management Checks, tracks the stock of supplies or medicines, to ensure supply of commodities are maintained year around + + + Life mHealth, Sproxil, Dimagi(commcare supply), mSupply, OpenLMIS -Improve stock management and availability, and decrease waste - Ensure appropriate medicine conservation and patient safety Tracking stocks of HTN, antidiabetic medications at community level when CHWs and HWs fills out their stocks Digital literacy of CHWs, user experience and usability concerns, high burden on the providers, initial costs of the implementation, durability of the devices Research and evaluation Repositories and databases, and built in system for vital events tracking Tracks unique identifiers or indicators for later use, for monitoring, evaluation and research + + + Mother and Child tracking System (MCTS) in India, Rapid SMS Uganda, OpenSRP, mTika, Cell PREVEN -Tacking indicators, storage for future use - data aggregation Storing blood pressure, glucose, medication use data for compliance reporting Costs of registries, and maintenance Data collection, harmonization, harvesting and reporting Reduces the lag between data collection and reporting to go to authorities, improves the completeness and accuracy of data. + + Open Data Kit (ODK),FrontlineSMS,Magpi,Fromhub,DHIS2,Dimagi(commcare),Data Winners,iFormBuilderEnketo,Mango platform,MedicMobile,Mobenzi-research,ONA,OpenXData,PoimapperKhusibaby(necklace & app),GSM,PDA PREVEN  -Improve accuracy, completeness and timeliness of data collection, harvest more data points on real time  - Data aggregation  - Better intelligence for targeted interventions Collection of WHO core modifiable NCD risk factors in existing LMICs surveys Network coverage for reporting or sinking collected data Health care data platform From one office to community set up, routinely collected data can be added to the data pool longitudinally + OpenMRS, Childcount+, OpenEMR −Systematize data reporting and storage process with ability to tack patients longitudinally Blood pressure, glucose, lipids, GFR, creatinine levels from local PHC, or blood pressure, glucose from CHWs Identification of at-risk patients Costs, and maintenance of platform, fragmentation of solutions, digital literacy Training, supervision on personnel management CHW to CHW or CHW to patients/providers interaction Exchange of voice, images, or texts for instant communication at/for remote consultation and decision support + + Switchboard (Closed User Group), Case.io -Improve CHW to CHW, CHW to provide communication for decision support -Access to otherwise unavailable resources and expertise -Interprofessional collaboration leading to better quality of care -Enhance work satisfaction of HWs Decision support for HTN, diabetes management Digital literacy, mobile coverage costs CHW’s work planning, organization and scheduling Reminder-based system, to increase compliance and accountability + txtAlert,MoTech −Improve productivity at work Reminders to make regular home visitation Increase treatment adherence Digital literacy CHW’s training and education Provides continued opportunity for enhancing skills via quizzes and case-based learning to inforce in-person training + eMOCHA, Moodle, OppiaMobile; Leap, Tele-ECHO, Mobile Kunji, mTrack, MOTECH, IQCare, Pesinet Mali, Nompilo, Uganda HIN, Mozambique HIN -Continued education and skills enhancement -Enhance work satisfaction of HWs Simple point-point algorithm for HTN, diabetes, diagnosis, management, counselling Recruit and retain through training Digital literacy, Existing burden on CHWs for other duties, need for updated material, demand for contextualized material, blended learning seems more effective but may be more expensive Human resource and personnel management Monitoring of field activities, and that helps to set up performance-based incentive scheme + mUbuzima, Rapid SMS, iHRIS, MOTECH −Performance tracking GPS tracking of CHWs to be tied with monthly follow ups Network coverage Financial transaction, incentive management and disbursement Mobile transaction scheme as payment or transfer or cash voucher + MTN, m-Pesa −Easing performance-based incentives (CHWs, HWs), payment at point of care (patients) Patients can pay for services or medicines upfront, and CHWs getting performance-based incentives Mobile network partner limited in most LMICs, business model not clear The 12 functions presented are adaption of the Labrique et al. (2013) work on 12 key functions of mHealth platforms (Labrique et al., 2013). The list of platforms are adaption of Agarwal et al. (2016) work on lists of mHealth platforms for CHWs (Agarwal et al., 2016) which is then divided into 12 core-functions and 3 themes, with additional searches online (Funes et al., 2012; Braun et al., 2013; Labrique et al., 2013; Basavarajappa and Chand 2017). CHWs, community health workers; HIN, health information network; HTN, hypertension; HWs, health workers; LMICs, low- and middle-income countries; NCDs, non-communicable diseases; BCC, behaviour change communication. View Large Table 1 Functions, characteristics and examples of digital platforms in relation to their interaction with patients, providers and health system Interaction Theme Functions (Labrique et al., 2013) Characteristics Patients CHWs Providers Health system Examples (Funes et al., 2012; Braun et al., 2013; Labrique et al., 2013; Agarwal et al., 2016; Basavarajappa and Chand, 2017) Health system goals Opportunities for NCDs Challenges Increasing service access and quality Patient’s education and communication One-way or two-way communication gateway for BCC + + + Kunji (BBC world trust), Dimagi, FreeSwitch, FrontlineSMS, RapidPro, txtAlert, Verboice, Voto, Vumi, SMS, SAMHSA, PRIORI -Impart knowledge, attitude and behaviour -Increase health literacy of the population Bulk or individual SMS, audio, video schemes for health promotion, a continuous communication may lead to establishing and enhancing the therapeutic alliance between HWs and patients Illiteracy, low mobile network coverage, power shortages, fragmentation of solutions, increased costs for adaptation of educational material and contextualization of the solutions, user experience and usability concerns Point-of-care decision support system Provides point by point support to diagnosis and management of illness, based on a guideline for diagnosis and treatment + + e-IMCI, GuideView, MDconsults, Mezzanine, Mobenzi-outreach, OpenSRP -Support decision-making -Evidenced-based care -Appropriate use of resources -Preventing adverse reactions and errors Management of HTN, diabetes (e.g. foot ulcers) following simple algorithms, management of multimorbidity and multiple drug regimes, prioritization of health needs No treatment and management guidelines in LMICs for most NCDs, decision-support systems are regulated as medical devices is some nations requiring more time and resources, user experience and usability concerns Systems, sensors at point of care diagnostics Extends the delivery points, uses sensors that records and transmits patients’ health records/information, on real time or for later during counselling + + AliveCor, Ubiquitous health care −Patient-based data collection at real time off the facility Tracking blood pressure, glucose, physical activity Integration of data deriving from sensors into eHealth records to facilitate case management Increase health literacy of the population and by extent, encourage health behaviour change Digital literacy is low, costs associated with devices and connectivity, limited mobile coverage, durability of the devices, privacy and security concerns, regulatory and legislative frameworks are needed Supply chain and logistics management Checks, tracks the stock of supplies or medicines, to ensure supply of commodities are maintained year around + + + Life mHealth, Sproxil, Dimagi(commcare supply), mSupply, OpenLMIS -Improve stock management and availability, and decrease waste - Ensure appropriate medicine conservation and patient safety Tracking stocks of HTN, antidiabetic medications at community level when CHWs and HWs fills out their stocks Digital literacy of CHWs, user experience and usability concerns, high burden on the providers, initial costs of the implementation, durability of the devices Research and evaluation Repositories and databases, and built in system for vital events tracking Tracks unique identifiers or indicators for later use, for monitoring, evaluation and research + + + Mother and Child tracking System (MCTS) in India, Rapid SMS Uganda, OpenSRP, mTika, Cell PREVEN -Tacking indicators, storage for future use - data aggregation Storing blood pressure, glucose, medication use data for compliance reporting Costs of registries, and maintenance Data collection, harmonization, harvesting and reporting Reduces the lag between data collection and reporting to go to authorities, improves the completeness and accuracy of data. + + Open Data Kit (ODK),FrontlineSMS,Magpi,Fromhub,DHIS2,Dimagi(commcare),Data Winners,iFormBuilderEnketo,Mango platform,MedicMobile,Mobenzi-research,ONA,OpenXData,PoimapperKhusibaby(necklace & app),GSM,PDA PREVEN  -Improve accuracy, completeness and timeliness of data collection, harvest more data points on real time  - Data aggregation  - Better intelligence for targeted interventions Collection of WHO core modifiable NCD risk factors in existing LMICs surveys Network coverage for reporting or sinking collected data Health care data platform From one office to community set up, routinely collected data can be added to the data pool longitudinally + OpenMRS, Childcount+, OpenEMR −Systematize data reporting and storage process with ability to tack patients longitudinally Blood pressure, glucose, lipids, GFR, creatinine levels from local PHC, or blood pressure, glucose from CHWs Identification of at-risk patients Costs, and maintenance of platform, fragmentation of solutions, digital literacy Training, supervision on personnel management CHW to CHW or CHW to patients/providers interaction Exchange of voice, images, or texts for instant communication at/for remote consultation and decision support + + Switchboard (Closed User Group), Case.io -Improve CHW to CHW, CHW to provide communication for decision support -Access to otherwise unavailable resources and expertise -Interprofessional collaboration leading to better quality of care -Enhance work satisfaction of HWs Decision support for HTN, diabetes management Digital literacy, mobile coverage costs CHW’s work planning, organization and scheduling Reminder-based system, to increase compliance and accountability + txtAlert,MoTech −Improve productivity at work Reminders to make regular home visitation Increase treatment adherence Digital literacy CHW’s training and education Provides continued opportunity for enhancing skills via quizzes and case-based learning to inforce in-person training + eMOCHA, Moodle, OppiaMobile; Leap, Tele-ECHO, Mobile Kunji, mTrack, MOTECH, IQCare, Pesinet Mali, Nompilo, Uganda HIN, Mozambique HIN -Continued education and skills enhancement -Enhance work satisfaction of HWs Simple point-point algorithm for HTN, diabetes, diagnosis, management, counselling Recruit and retain through training Digital literacy, Existing burden on CHWs for other duties, need for updated material, demand for contextualized material, blended learning seems more effective but may be more expensive Human resource and personnel management Monitoring of field activities, and that helps to set up performance-based incentive scheme + mUbuzima, Rapid SMS, iHRIS, MOTECH −Performance tracking GPS tracking of CHWs to be tied with monthly follow ups Network coverage Financial transaction, incentive management and disbursement Mobile transaction scheme as payment or transfer or cash voucher + MTN, m-Pesa −Easing performance-based incentives (CHWs, HWs), payment at point of care (patients) Patients can pay for services or medicines upfront, and CHWs getting performance-based incentives Mobile network partner limited in most LMICs, business model not clear Interaction Theme Functions (Labrique et al., 2013) Characteristics Patients CHWs Providers Health system Examples (Funes et al., 2012; Braun et al., 2013; Labrique et al., 2013; Agarwal et al., 2016; Basavarajappa and Chand, 2017) Health system goals Opportunities for NCDs Challenges Increasing service access and quality Patient’s education and communication One-way or two-way communication gateway for BCC + + + Kunji (BBC world trust), Dimagi, FreeSwitch, FrontlineSMS, RapidPro, txtAlert, Verboice, Voto, Vumi, SMS, SAMHSA, PRIORI -Impart knowledge, attitude and behaviour -Increase health literacy of the population Bulk or individual SMS, audio, video schemes for health promotion, a continuous communication may lead to establishing and enhancing the therapeutic alliance between HWs and patients Illiteracy, low mobile network coverage, power shortages, fragmentation of solutions, increased costs for adaptation of educational material and contextualization of the solutions, user experience and usability concerns Point-of-care decision support system Provides point by point support to diagnosis and management of illness, based on a guideline for diagnosis and treatment + + e-IMCI, GuideView, MDconsults, Mezzanine, Mobenzi-outreach, OpenSRP -Support decision-making -Evidenced-based care -Appropriate use of resources -Preventing adverse reactions and errors Management of HTN, diabetes (e.g. foot ulcers) following simple algorithms, management of multimorbidity and multiple drug regimes, prioritization of health needs No treatment and management guidelines in LMICs for most NCDs, decision-support systems are regulated as medical devices is some nations requiring more time and resources, user experience and usability concerns Systems, sensors at point of care diagnostics Extends the delivery points, uses sensors that records and transmits patients’ health records/information, on real time or for later during counselling + + AliveCor, Ubiquitous health care −Patient-based data collection at real time off the facility Tracking blood pressure, glucose, physical activity Integration of data deriving from sensors into eHealth records to facilitate case management Increase health literacy of the population and by extent, encourage health behaviour change Digital literacy is low, costs associated with devices and connectivity, limited mobile coverage, durability of the devices, privacy and security concerns, regulatory and legislative frameworks are needed Supply chain and logistics management Checks, tracks the stock of supplies or medicines, to ensure supply of commodities are maintained year around + + + Life mHealth, Sproxil, Dimagi(commcare supply), mSupply, OpenLMIS -Improve stock management and availability, and decrease waste - Ensure appropriate medicine conservation and patient safety Tracking stocks of HTN, antidiabetic medications at community level when CHWs and HWs fills out their stocks Digital literacy of CHWs, user experience and usability concerns, high burden on the providers, initial costs of the implementation, durability of the devices Research and evaluation Repositories and databases, and built in system for vital events tracking Tracks unique identifiers or indicators for later use, for monitoring, evaluation and research + + + Mother and Child tracking System (MCTS) in India, Rapid SMS Uganda, OpenSRP, mTika, Cell PREVEN -Tacking indicators, storage for future use - data aggregation Storing blood pressure, glucose, medication use data for compliance reporting Costs of registries, and maintenance Data collection, harmonization, harvesting and reporting Reduces the lag between data collection and reporting to go to authorities, improves the completeness and accuracy of data. + + Open Data Kit (ODK),FrontlineSMS,Magpi,Fromhub,DHIS2,Dimagi(commcare),Data Winners,iFormBuilderEnketo,Mango platform,MedicMobile,Mobenzi-research,ONA,OpenXData,PoimapperKhusibaby(necklace & app),GSM,PDA PREVEN  -Improve accuracy, completeness and timeliness of data collection, harvest more data points on real time  - Data aggregation  - Better intelligence for targeted interventions Collection of WHO core modifiable NCD risk factors in existing LMICs surveys Network coverage for reporting or sinking collected data Health care data platform From one office to community set up, routinely collected data can be added to the data pool longitudinally + OpenMRS, Childcount+, OpenEMR −Systematize data reporting and storage process with ability to tack patients longitudinally Blood pressure, glucose, lipids, GFR, creatinine levels from local PHC, or blood pressure, glucose from CHWs Identification of at-risk patients Costs, and maintenance of platform, fragmentation of solutions, digital literacy Training, supervision on personnel management CHW to CHW or CHW to patients/providers interaction Exchange of voice, images, or texts for instant communication at/for remote consultation and decision support + + Switchboard (Closed User Group), Case.io -Improve CHW to CHW, CHW to provide communication for decision support -Access to otherwise unavailable resources and expertise -Interprofessional collaboration leading to better quality of care -Enhance work satisfaction of HWs Decision support for HTN, diabetes management Digital literacy, mobile coverage costs CHW’s work planning, organization and scheduling Reminder-based system, to increase compliance and accountability + txtAlert,MoTech −Improve productivity at work Reminders to make regular home visitation Increase treatment adherence Digital literacy CHW’s training and education Provides continued opportunity for enhancing skills via quizzes and case-based learning to inforce in-person training + eMOCHA, Moodle, OppiaMobile; Leap, Tele-ECHO, Mobile Kunji, mTrack, MOTECH, IQCare, Pesinet Mali, Nompilo, Uganda HIN, Mozambique HIN -Continued education and skills enhancement -Enhance work satisfaction of HWs Simple point-point algorithm for HTN, diabetes, diagnosis, management, counselling Recruit and retain through training Digital literacy, Existing burden on CHWs for other duties, need for updated material, demand for contextualized material, blended learning seems more effective but may be more expensive Human resource and personnel management Monitoring of field activities, and that helps to set up performance-based incentive scheme + mUbuzima, Rapid SMS, iHRIS, MOTECH −Performance tracking GPS tracking of CHWs to be tied with monthly follow ups Network coverage Financial transaction, incentive management and disbursement Mobile transaction scheme as payment or transfer or cash voucher + MTN, m-Pesa −Easing performance-based incentives (CHWs, HWs), payment at point of care (patients) Patients can pay for services or medicines upfront, and CHWs getting performance-based incentives Mobile network partner limited in most LMICs, business model not clear The 12 functions presented are adaption of the Labrique et al. (2013) work on 12 key functions of mHealth platforms (Labrique et al., 2013). The list of platforms are adaption of Agarwal et al. (2016) work on lists of mHealth platforms for CHWs (Agarwal et al., 2016) which is then divided into 12 core-functions and 3 themes, with additional searches online (Funes et al., 2012; Braun et al., 2013; Labrique et al., 2013; Basavarajappa and Chand 2017). CHWs, community health workers; HIN, health information network; HTN, hypertension; HWs, health workers; LMICs, low- and middle-income countries; NCDs, non-communicable diseases; BCC, behaviour change communication. View Large Training and supervision on personnel management Digital devices can be used for training, personalized supervision of CHWs, and communication between CHWs and their supervisors at a higher institution (Mishra et al., 2015; White et al., 2016). In Table 1, we present various platforms, which can be used for CHW’s work planning and scheduling, CHW’s training and education, overall human resource management, financial transaction and incentive scheme, all aiming to improve the management and performance of CHWs (Labrique et al., 2013; Agarwal et al., 2016). Digital applications can provide a supportive channel between CHWs and their supervisors. Blended learning can combine digital delivery of the content and remote interaction with in-person training (Diedhiou et al., 2015,; Agarwal et al., 2016; Lygidakis et al., 2016). Digital solutions have also been able to support peer communication in the form of virtual informal groups and learning networks that are able to create educational opportunities from the daily practice (Braun et al., 2013,; Lygidakis et al., 2016). The virtual communities of practice can be employed to foster team-building and collaborative training, as they enable CHWs to share interests, ask questions, raise concerns and exchange rich content, such as photos, with each other (Barnett et al., 2014). CHW programmes can capitalize on tools with an already broad user base, like WhatsApp (Henry et al., 2016). The 6-month review of WhatsApp chat logs from 41 CHWs showed that the multi-modal communication and information systems were used by CHWs for one-to-one, group and peer-to-peer forms of coaching, counselling and supervision, with minimal training (Henry et al., 2016). Finally, technology enables a participatory approach in the design and implementation of contextualized solutions. Svoronos et al. (2010) described how employing a participatory approach for the development of their mHealth module validated its appropriateness and fostered a shared ownership of the solution. Evaluation and research Digitalization increases the opportunities for data collection, analysis and research. Examples of use of mobile devices in maternal and child health provide early indications of the platforms that can be built for in-country and intercountry data-sharing and research collaboration (Agarwal et al., 2016). For example, user-friendly and personally tailored devices, connected to a cloud-based dashboard and a central database, will further boost research capacity in LMICs (Mishra et al., 2016). Three kinds of platforms are in use today: data collection and reporting; tracking vital events; building or maintaining eHealth records (Table 1) (Labrique et al., 2013; Agarwal et al., 2016). Evidence supports that the employment of digital tools is cost-effective, improves record completeness and decreases the time for the transmission of data from the source to the coordination centres (Manda and Herstad, 2009; Ngabo et al., 2012,; Agarwal et al., 2015). For instance, RapidSMS-MCH is a text-message-based system in Rwanda that assists CHWs reporting real-time information on pregnant women and following them up till the post-partum period in their communities (Ngabo et al., 2012). The system has also helped pregnant women seeking urgent care, as CHWs can alert the health facilities promptly. Further, in a study on diabetes medication decision tools among Latino and African American Adults, CHWs used an interactive and web-based tablet-/computer-delivered tool (iDecide) for reporting (Heisler et al., 2014). Challenges to prospect of digitalization Funding for CHW programmes The increased use of digital means in CHW programmes is in stark contrast with the countries’ capacity to scale up their use. Deployment and initial operational costs are considerable. With significant financial constraints and funding cuts (Atun et al., 2017), supporting digitalization in LMICs is challenged. To sustainably pool funds from diverse sectors for CHW programmes, partnership with the private sector may be needed, though it should be taken cautiously. The private sector can help mainly by technological expertise and know-how, and human and financial resources. The critical question is how we can leverage benefit from such collaboration. A new model for corporate social responsibility needs to be introduced. Mobile connectivity is spreading rapidly and there are IT companies in every country, which may contribute (Kay et al., 2011). However, balance between corporate motives and the health needs of the population have to be guarded. Digital health literacy of the CHWs CHWs may be either illiterate or semi-literate, as there are no formal literacy requirements for CHWs in many countries (Rubinstein et al., 2016; Mishra et al., 2016). Training CHWs to different health programmes especially with NCD components can be difficult and increase the costs. Due to diverse literacy, socio-economic backgrounds and country health needs, there is no doubt that CHW interventions need to be country- and context-specific, and modulated according to the digital inputs the intervention requires. Our previous study from Nepal has shown that CHWs possess a positive attitude towards taking on future tasks to help tackling NCDs despite their lack of required technical competences and digital health literacy (Neupane et al., 2015). Future CHW programmes, however, need to introduce appropriate training to help CHWs acquire new skills, as this is one of the most important non-financial incentives that can prevent isolation, burn out and attrition (Bhattacharyya et al., 2001). Systemic challenges of CHW programmes Some perennial challenges to CHW programmes will also affect the prospect of digitalization, as they affect structure, performance and motivation of the workforce. Most of the CHW programmes run under a loose and informal structure, where there are inadequate formal recruitment processes, no job description and no provision for retirement (Singh et al., 2015). CHWs should be regularly supervised and routinely monitored (Mishra et al., 2015). Due to lack of health workers at the primary health care level and their high work load, adequate supervision for CHWs in future NCD programmes seems challenging during their early years of implementation when the supervisory need is the most. There is increasing expectation of financial incentives (salaried position, daily allowance, transportation support and logistics) among CHWs. This will even go further, if they are to use digital devices, which demand higher skills and literacy. However, other non-monetary incentives, such as a desire to better their family health, change from routine work, gain of health knowledge, social recognition and religious merits, are also important determinants (Singh et al., 2015). A study from Nepal showed that despite being minimally trained and having low literacy in hypertension (HTN), CHWs were intrinsically motivated to take part in future HTN management programmes at the community level (Neupane et al., 2015). A precautionary step should be taken not to overburden CHWs in future NCD programmes, as previous studies have shown burnout and stress reduces motivation in CHWs as with other health cadres (Tien et al., 2000). Discussion This review is an expansion of earlier reviews by Labrique et al. (2013) and Agrawal et al. (2016) in NCD context. Labrique et al. (2013) pointed out the 12 core functions of mHealth and proposed a visual framework for understanding their relationship in health system—specific to reproductive, maternal and child health. Our review discussed the three benefits of digitalization, including: (1) expanding coverage and quality; (2) training and supervision of personnel and (3) research and evaluation. We also mapped digital platforms currently in use, building on the work of Agrawal et al. (2016) and Labrique et al. (2013), and deliberated over the NCD context for CHWs (Labrique et al., 2013; Agarwal et al., 2016). Finally, we have identified relevant challenges, namely funding for the sustainability of CHW programmes, digital health literacy, and those existing and systematic related to motivation and myths around CHWs. The growing prevalence of NCDs will increase the burden on health care workers at primary care level. CHWs will be required to spend a significant amount of their time in counselling, conducting home visits and referring patients to health centres. Not limited to primary prevention, there is some evidence to suggest CHWs can play a crucial role in secondary prevention (reducing the risk of recurrent events) of CVDs and many other chronic diseases. For example, in a study conducted in India (Xavier et al., 2016), CHWs were found effective in reducing the cardiovascular risk factors and improving adherence to evidence-based drugs among patients with CVD who were linked to their health centres in periphery. In the countries with workforce shortages, digitalization may reduce the workload of the health professionals, but cannot completely take over their role. The best way forward is to train the future health workforce in digital skills. Ability to use devices rationally is of paramount importance—more important rather than the coverage of devices itself, as authors in a report suggest: ‘it is not technology, it is the carefully planned home bred solutions, the key to success’ (Levy et al., 2012). The discussed core functions of digitalization are greatly dependent on having a reliable mobile network coverage and a source of electricity. Even though mobile subscriptions have already outnumbered people, the LMICs are yet to benefit from their greater expansion. Internet connectivity remains poor in most LMICs, especially in rural settings, where the majority of health care providers still do not have access to the internet at work. The cost of service can pose significant limitations too (Safaie et al., 2006; Wallis et al., 2017). Mobile devices used in some implementations do not require a stable mobile connection, allowing for offline use and database synchronization when internet is available; such are the cases of KhushiBaby (Mishra et al., 2016; Khusibaby) and the Nyitaho mobile app for diabetic patients in the D2Rwanda clinical trial (Lygidakis, 2017). With power shortages being a perennial problem in LMICs, solar powered devices and stations for connectivity, such as those provided by ‘Africa Renewable Energy Distributor (ARED)’ in Uganda and Rwanda, have the potential to help CHWs in some locations (Africa Renewable Energy Distributor). Furthermore, the high turnover on digital platforms is worrying. Many switches between platforms or abandon them within the first 6 months of use (Levy et al., 2012). This turnover raises questions of maintenance, cost-effectiveness and investments in retraining the workforce. Service integration of existing fragmented digital and non-digital CHW interventions is critical. Different programmes and components should be brought under a single umbrella, and either liaise or merge. Integrating CHWs programmes with mHealth potentially benefits hard-to-reach populations that are otherwise not covered by CHW programmes in LMICs (Källander et al., 2013). Similarly, many interventions can be combined. For example, interventions for diabetes and HTN can be brought together under a single umbrella, as they share common risk factors. Service integration will help create comprehensive digital platforms targeting many NCDs, even though there is still a paucity of evidence to what level the synergy works, and what components of the interventions should be brought together due to the diverse socio-economic, cultural and environmental conditions (Rubinstein et al., 2016; Mishra et al., 2016). Bridging the fragmented market of digital-device companies is also necessary. As many LMICs may lack resources and know-how, a systematic approach for database creation and maintenance is needed to enable data accessibility and tailoring for researchers, health professionals and other frontline workers (Mishra et al., 2016). The growth in digitalization has also spurred concerns over patient’s safety and privacy. Digitalization may lead to a fragmentation of health system by limiting patient–provider interaction and shifting decision-making on information deriving from applications [that can lead to the risk of wrong treatment given to the patients and the risk of an adverse drug reaction (ADE) in extreme cases] (Smart Conculting). Two million of such ADE happen every year in high-income countries such as Australia (Smart Conculting); therefore, an unregulated digital health industry and absence of coordination (between patients, providers and CHWs) is more likely to complicate the problem. Personal and sensitive information must always be collected after patient consent and protected accordingly. Greater use of multiple applications may create challenges in privacy of information shared across such platforms (Kay et al., 2011). To ensure patient safety and privacy, digital health applications must be regulated in LMICs in a similar way as in nations where strict legislation already exists, such as in the USA and the European Union. Countries need to collaborate to harmonize communication platforms, set up ethical standards for data sharing between research agencies and IT companies, and increase security and affordability of data exchange (Kay et al., 2011). To achieve this, engagement of the private sector, including tele-communication companies, is also necessary (Wallis et al., 2017). Finally, from the end-users’ perspective, a multidisciplinary approach is needed to improve the user experience, including usability and adaptability (Wallis et al., 2017). A digital health application which does not integrate with the everyday activities and the context and becomes a burden for the end user, whether he/she is a CHW or a patient, will most likely fail in its implementation. Some questions remain despite our deliberations. How can we monitor the digital platforms and guarantee data privacy and security? How can we balance the role of providers and the ‘digital inputs’ in decision making? How can we make CHW interventions more cost-effective and sustainable? Is it worth investing in unforeseen gains from digitalization? Can partnerships with IT companies bring good investments in LMICs and increase funding for future CHW interventions? Acknowledging the ethical dilemmas in balancing corporate motives, a line of equilibrium should be drawn with a clear demarcation where interests of both parties are met. Conclusions The prospects of digitization in CHW programmes are encouraging, but are equally coupled with challenges. The benefits range from an expansion in the coverage and quality of services, to adding efficiency to recording, reporting and personnel management, and finally catalysing research and evaluation processes. Digitally equipped CHWs may provide new services particularly around NCD prevention in the future. A substantial investment in capacity building, training, improving digital literacy, workforce management, supervision and logistics is however required. Sustainability issues of CHW programmes are critically important. Initial roll-out of the digital devices and maintenance incur significant costs, yet a surge in the availability of inexpensive digital devices and improved internet connectivity can accelerate the digitalization of CHW programmes and generate cascading benefits in the long run. Conflict of interest statement. None declared. 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For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Combating non-communicable diseases: potentials and challenges for community health workers in a digital age, a narrative review of the literature
JF - Health Policy and Planning
DO - 10.1093/heapol/czy099
DA - 2019-02-01
UR - https://www.deepdyve.com/lp/oxford-university-press/combating-non-communicable-diseases-potentials-and-challenges-for-zH0oTjiSfH
SP - 55
VL - 34
IS - 1
DP - DeepDyve
ER -