The arduous path to make mHealth work at last

挽救生命的移动应用程序可能会延续到年龄。艾尔温追踪他们崇高的承诺和凌乱的现实。

2016年与与之合作的社区卫生工作者的几个月children在马拉维北部，有一只助手。

智能手机应用程序带领他们遵循了标准的考试协议，有助于提高诊断的准确性以及信心。他们告诉researchers他们之所以喜欢该应用程序，是因为它使他们放心他们的决定是扎实的[1]。

但是，八个月后，该项目结束了，由于担心，该应用程序被删除了 -funding消失了 - 它可能很快就会过时。

这几乎不是孤立的事件。MHealth提出了诱人的优惠：插入空白health使用廉价，可用的工具为贫困国家 /地区提供。但整个撒哈拉以南非洲，亚洲和南美为了希望改善医疗保健一两年后，进行了数以百计的MHealth实验中的数百个MHealth实验。

2016年reviewcast a harsh light on mHealth [2]. Led by Alain Labrique, a public health professor who heads the Global mHealth Initiative at Johns Hopkins University in the United States, it concluded that — with some exceptions — “the strength of the findings to support the use of mobile interventions over alternate strategies is still limited”.

The review found that many interventions go undocumented; many are designed without academic rigour, making it hard to gauge their success; and often the chosen outcome measures mean they cannot be compared with other studies.

瑞士日内瓦大学的远程医疗博士学位Caroline Perrin说，研究倾向于衡量有多少卫生专业人员像他们的新应用程序这样的卫生专业人员，并且通常太小，并且具有很小的统计敏感性，无法检测到死亡率下降， 例如。

她说，这增加了很难证明编织成复杂的卫生系统的单个数字元素实际上有所作为。

Perrin’s professor, Antoine Geissbühler, adds that rigorous evidence is important not just to prove effectiveness, but to avoid harm. Even at pilot stage, he says, training sessions that focus on one health activity can eat up time and distort priorities. And governments need to make hard decisions between deploying eHealth and other activities, such as running vaccination campaigns. “Some countries cannot do [it] all.”

拉布里克（Labrique）的评论说，很少有研究能够扩大研究，因为他们无法向捐助者证明他们有效。由于设计阶段的选择不良，因此许多项目根本无法实现。

Choice of software, for example, is crucial, says Garrett Mehl, a specialist in digital health at the World Health Organisation (WHO). A bespoke bit of standalone software might be fine for a few villages. But could it withstand the demands of 100,000 health workers — the help desks, the training and re-training, the ‘community of knowledge’ that’s in the background, keeping it ticking over?

他说：“现实是，除非他们使用'全球善良'的软件，否则不可能扩展。”但是即使那样，其他因素也可能发挥作用。

采用证明在诊断马拉维北部儿童有用的应用程序 -Supporting LIFEAPP（疾病控制的低成本干预）。“Even though the software was open source, the ministry of health just doesn't have any internal capacity to roll out the software or even maintain it,” says project’s coordinator John O’Donoghue, now an eHealth specialist at University College Cork, in Ireland.

“实际上，如果要修改和维护和实施该项目，我们可能每年都在谈论数百万欧元的努力。”

数字和卫生社区正试图找到更好的方法来利用MHealth的承诺。

例如，佩林（Perrin）在建立飞行员时帮助研究人员选择有用的结果指标。尽管一项研究可能太小，无法发现孕产妇或新生儿死亡率下降，但它可能能够检测出显示降低死亡率的另一个参数的改进。

她已经确定了70个这样的变量，所有这些变量都可能受数字干预措施的影响 - 例如，怀孕期间进行了四次检查，或者确定预测新生儿疾病的危险迹象。

唐格说,这样的代理是必不可少的pporting LIFE. “Thankfully,” he says, “no child passed away during our study”, so they measured hospital referral rates for evidence that the digital system improved the accuracy of health workers’ referrals.

Adding to efforts to impart rigour to mHealth pilots, a few years ago the WHO, with the International Telecommunications Union,已发表的建议关于如何扩展MHealth非传染性疾病项目。该机构还开发了lexiconfor both health and digital specialists, whose first version was released earlier this year.

同时，数字发展原则由一群捐助者和实施者撰写，在2015年得到许多国际组织的认可，并得到支持论坛launched last year.

谁生产了MHealth评估和规模计划（地图）工具包在2015年，新的Malawi eHealth Research Centre奥多诺格（O’Donoghue）帮助发现的Mzuzu大学。

这意味着任何提议MHealth干预措施的人都必须进入中心，并花几天时间对地图工具包进行评估。如果未能证明它可以满足人力资源，金融和技术能力等领域的需求，并且找不到解决方案，则该提案被放弃了。

工具包和更好的研究设计可以改善飞行员，也许可以扩大规模。但是，如果MHealth要在发展中国家中产生真正的影响，则需要扩大到国家一级。

Many people fail to grasp how formidable that challenge is, says Mehl. “It requires the enabling environment of policies, the infrastructure, the tools — and knowing which work and which don’t — and the training.”

作为成功的罕见例子，他强调了印度政府的消息传递服务Kilkari, designed by BBC Media Action, which delivers free audio messages about pregnancy, childbirth and childcare to women from the second trimester of pregnancy and continues until the child is one year old. Developed and tested in the state of Bihar in 2013, it went on to reach two million subscribers within 12 months of its launch. The government went on to adopt it in 2016, footing the bill for call costs and rolling it out in 13 states.

BBC Media Action India Digital Ection India Digital总监Sarah Chamberlain突出了其成功的三个因素。首先，政府已经投资了登记怀孕和分娩，它将基尔卡里视为激励妇女提供这些数据的一种方式。第二，捐助者的长期和“耐心”投资；第三，花费数年的时间与卫生部建立关系。她说：“您无法想象与国家政府建立关系需要多少精力。”“你不能只是飞进去。”

Mehl还认为，从地方规模转移到国家规模需要文化变革和信任的飞跃：部长必须说服抛弃纸进入数字机器的价值。这与培训，帮助桌，硬件和软件茶点的长期资金有关。

他说，坦桑尼亚的卫生部在经历了这样的旅程方面是“非凡的”。与国际卫生组织路径合作更好的免疫数据（BID）计划，它正在使用MHealth以与其他数字健康干预措施兼容的方式来改善免疫接种的跟踪。

该系统已扩展到坦桑尼亚的四个地区，并计划尽快到达十个地区。非洲和数字健康区域总监Henry Mwanyika将其成功归因于健康等级的咨询，并“打破语言障碍”，以便工程师，政客和卫生工作者可以相互交流。

梅尔印象最深刻的是该部的早期认可，该项目将至少需要五年的“燃烧”，这意味着“理解，吸收，调整和优化”。

这可能表明国家正在唤醒MHealth的复杂性。这反映在解决that was adopted by member states at the World Health Assembly this May, and is widely seen as a milestone for catalysing progress in the field, says Mehl.

该决议寻求一项全球战略，扩大规模的技术援助以及有关数字健康最佳实践和发展的信息。

mHealth may be emerging from its Wild West phase. Indeed, the term itself is being abandoned in favour of ‘digital health’, to convey the joined-up thinking required for success.

但we might need to subdue our hopes. “The expectation that it’s going to have massive impacts early in the phase of adoption is unrealistic,” Mehl says. “It’s largely helping people to do what they are already doing but a little bit better, faster and more effectively.

“It’s going to be a slow transformation.”

*该文章于2018年9月3日修改。该文章的较早版本指出，一组70个变量可能会受到数字干预措施的影响，该变量将被Who作为即将到来的数字孕产妇健康干预措施的指导的一部分。该声明是不正确的，已被删除。