Botswana's health sector comprises numerous digital health systems that operate in isolation, thereby constraining interoperability, limiting data exchange, and hindering coordinated patient care. Although national strategies such as the Botswana eHealth Strategy (2020-24) articulate overarching digital health objectives, they offer limited technical direction for harmonizing digital investments and achieving system-wide interoperability. This article presents a national digital health case study detailing the development of the Botswana eHealth Enterprise Architecture, a strategic blueprint intended to guide the integration and governance of digital health systems nationwide. The architecture was formulated through a participatory process involving stakeholders from the Ministry of Health, healthcare facilities, academic institutions, and international partners. The initiative was informed by internationally recognized frameworks, including The Open Group Architecture Framework and the Open Health Information Exchange interoperability model. Through an iterative development process undertaken between 2023 and 2024, the architecture delineated four core layers-business, data, application, and technology-and established a national interoperability framework grounded in open standards, including HL7 Fast Healthcare Interoperability Resources and HL7 v2. The resulting architecture further introduced a suite of shared national digital health services, such as a Master Patient Index, a Shared Health Record, and national facility and provider registries. Key lessons from Botswana's experience underscore the importance of robust governance structures, inclusive stakeholder engagement, the adoption of open standards, and phased implementation approaches in the development of national digital health architectures. This case study offers practical insights for other low- and middle-income countries seeking to mitigate fragmentation in their health information systems and to implement interoperable digital health ecosystems.
The rapid growth of digital health initiatives has heightened reliance on frontline health workers (FLHWs) to deliver, document, and manage services through digital tools, particularly in low- and middleincome countries (LMICs). In India, the widespread rollout of platforms under the Ayushman Bharat Digital Mission (ABDM) is not yet matched by a standardized digital health competency framework (DHCF) for FLHWs, hindering systematic skill development, assessment, and integration. This study designed, developed, and evaluated a theory-driven, evidence-based, and scalable DHCF for India's health workforce. Framed as a feasibility and proof-ofconcept study, it was piloted among FLHWs in Uttar Pradesh using a three-stage approach comprising design, implementation, and evaluation. The framework development drew on a systematic literature review and the Government of India's Framework for Roles, Activities, and Competencies (FRAC). A cadre-agnostic competency dictionary was created, spanning functional, behavioral, domainspecific, and intervention-specific skills across graded proficiency levels. Competencies were mapped to FLHW roles, and aligned training materials and assessments were developed. The framework was piloted through in-person, instructor-led sessions for Auxiliary Nurse Midwives (ANMs) in two districts (n = 70), alongside baseline assessments for Accredited Social Health Activists (ASHAs; n = 32). The resulting DHCF comprises a three-component package: (i) a cadre-agnostic competency dictionary with progressive proficiency levels; (ii) systematic role-tocompetency mapping using the FRAC methodology; and (iii) integrated training content and assessment scaffolding designed for institutional embedding. The framework defined 10 core competencies, enabling role-specific mapping across cadres. Feasibility testing demonstrated significant gains in ANMs' knowledge and digital skills: Wilcoxon signed-rank tests showed significant improvements in two of four competency levels (C1L1 and C2L1; both P < .001), with the largest effect for data collection basics (r = 0.84). ASHA baseline assessments revealed substantial foundational literacy gaps (mean total score 11.97/30 [39.9%]; data collection was the weakest competency at 32.5%, with no ASHA scoring above 60% on C2L1). Stakeholders affirmed the framework's relevance, feasibility, and adaptability, while identifying the need for hybrid training models and stronger institutional embedding.The DHCF offers a structured, scalable approach to standardizing digital health training for FLHWs and strengthening workforce preparedness in resource-limited settings during India's digital health transition. This feasibility study establishes the framework's relevance and applicability; future work is needed to evaluate effectiveness at scale, long-term competency retention, and linkage to service delivery outcomes. Parallel attention to digital tool design and usability will be essential to complement competency-building efforts.
By 2015, the emergence and dissemination of multidrug-resistant Plasmodium falciparum in the Greater Mekong Subregion threatened regional and global malaria control efforts. In response, Greater Mekong Subregion countries committed to malaria elimination by 2030, with strengthened surveillance as a strategic pillar. In 2017, Cambodia introduced an elimination-oriented digital Malaria Information System (MIS). Its health center app enables real-time, geo-located, case-based malaria reporting across primary health centers, and is fully integrated with the MIS. This study aimed to evaluate the real-world national implementation of Cambodia's Android-based health center app, considering coverage, fidelity, timeliness, and data use, and their effects on malaria surveillance performance, case management, programmatic response, and public health outcomes. System performance and public health use were assessed using system-generated metadata, national surveillance data, and user surveys. Operational indicators included technical performance, data completeness, and reporting timeliness, alongside surveillance outcomes such as case notification, classification, reactive case detection, and foci investigation. Nationwide user experience was measured via a survey of 761 health centers across 21 provinces, with in-depth structured surveys at 9 health centers in 3 provinces. Descriptive analyses evaluated system functionality, contribution to malaria surveillance and response, and usability among frontline health workers. The health center app demonstrated strong technical performance, with rapid loading and resilient data transmission under low-bandwidth conditions, supporting reliable reporting in resource-constrained settings. Integrated real-time dashboards provided analytics for case management, surveillance monitoring, risk stratification, and targeted public health interventions. Data completeness remained high (99%, 89/90 fields in 2024), demonstrating consistent routine use even as case incidence declined. Between January 1, 2025, and July 31, 2025, 69 malaria cases were reported nationally (23 locally acquired, 7 domestically imported, and 39 internationally imported). Of these, 95.7% (66/69) were notified and classified within 1 day. Reactive case detection was completed within 3 days for all 21 eligible cases, and 16 of 19 eligible foci received a response within 7 days, indicating strong operational responsiveness. User surveys showed 96.3% (733/761) of health centers were satisfied or very satisfied, 90.1% (686/761) reported rare or no technical issues, and 91.7% (698/761) found the app easy to navigate. Operational challenges included limited internet connectivity, transport to remote areas, and electricity interruptions. In-depth surveys confirmed high uptake, confidence in reporting, and routine use of surveillance data, although gaps in local analytical capacity were identified. Developed and managed locally to enhance sustainability, the MIS drove significant reductions in malaria case incidence, with the health center app contributing timely, complete, structured reporting at the point of care. Public health responses were facilitated by real-time analysis, targeted interventions, and decentralized decision-making. User engagement was sustained as malaria cases declined, and further enhancements are planned to ensure seamless transition to postelimination surveillance, reducing the risk of malaria reestablishment in Cambodia.
The healthcare sector has undergone a transformation driven by the adoption of digital technology. Digital strategies have become the principal mechanism for delivering high-quality, cost-effective healthcare at scale. The Indian Government is also rapidly deploying the Ayushman Bharat Digital Mission (ABDM), launched in September 2021. ABDM is the flagship programme of the Indian Government, which has become the standard platform for healthcare delivery and allied services, including insurance management. The COVID-19 pandemic further accelerated digital adoption, making dependence on digital infrastructure both pervasive and unavoidable. Ensuring cybersecurity and resilience is therefore fundamental to uninterrupted healthcare delivery. This paper examines cyber resilience and cybersecurity within ABDM, with specific reference to its architecture and governing policies. A rigorous assessment of cyber resilience and cybersecurity, encompassing potential threats and attack vectors, is essential to the programme&#×2019;s long-term success. We conclude that ABDM&#×2019;s success is intrinsically linked to robust cybersecurity and resilience. Further work is required to develop a comprehensive framework for ABDM cyber resilience and security that is applicable across all ecosystem partners.
Digital health tools are increasingly used in mental health care to passively collect patient data and analyze health status outside of clinical settings. While technologies such as digital phenotyping, affective computing, and computational behavioral analysis offer new insights into symptom manifestation in daily life, they generate large volumes of potentially sensitive data that raise significant data privacy concerns, requiring high levels of patient awareness and consent. Empirical research is lacking on stakeholder understandings toward the sensitivity of these data and expectations for data stewardship, perspectives that are critical for developing robust informed consent and data protection policies for digital health data use. This study aimed to explore key stakeholder perspectives on the sensitivity of computer perception (CP) data, trust in existing data protections, willingness to share CP data externally, and desire for transparency of CP data transactions outside of the clinical space. As part of a larger, multisite study, we conducted qualitative interviews (n=40) via Zoom (Zoom Communications, Inc) with 20 adolescents (aged 12-17 years) familiar with CP tools and their caregivers (n=20). Interviews consisted of a series of open-ended questions regarding stakeholders' perspectives on privacy, data security, and the use and exchange of CP data. We developed a qualitative codebook to identify and label thematic patterns in responses to questions addressing the topics above, using thematic content analysis to identify themes inductively. Each interview was coded by merging work from at least two separate coders, and several team members contributed to qualitative analysis. Most adolescents and caregivers viewed CP data as highly sensitive and expressed a reluctance to share these data beyond their clinical teams. While many participants expressed trust in existing data protections to protect CP data, they often misunderstood or overestimated the extent of protections to safeguard CP data. Our findings underscore the critical need for clear and effective patient communication and education about the risks, benefits, and protections associated with CP data through informed consent protocols. To promote greater transparency, understanding, and trust, we recommend 5 strategies: educating patients about data protection; studying secondary data exchange and reidentification risks; strengthening transparency regulations; improving data traceability mechanisms, such as distributed ledger technologies, to enhance data traceability and auditability; and adopting dynamic consent models.
End user co-design in the personal digital health technology space is underdeveloped. Clinical uptake of personal digital health technologies has been poor, highlighting a need to cocreate solutions with end users. The study aimed to describe an "end user" co-design framework in the development of 5 prototype personal health apps for patients with different rare or complex diseases. A patient-led, user-centered, collaborative personal health app plus wearable plug-in co-design methodology was developed. Five prototype apps were developed for end users with long COVID-19, pancreatitis, primary ciliary dyskinesia, sarcoidosis, and valosin-containing protein disease by a multidisciplinary partnership including patients, app design and development experts, user experience experts, clinicians, and patient-driven organizations. Phase 1 involved a 6-month co-design process with 5 modules involving patient-driven organizations that included the codevelopment of specifications through group workshops and independent exercises that defined the goals, content, features, and user experience of each app. Phase 2 involved app build-out, internal alpha testing, and beta study preparations. Phase 3 involved a usability beta testing study in which end users used the app and associated wearable/smart devices (Oura ring, Lumia ear device, Empatica EmbracePlus, and MIR Spirobank Spirometer) for up to 5 months. Participant feedback was documented continuously and systematically, centering on the following themes: functionality, usability, harms, benefits, self-explorations, and beta testing study details related to retention and adherence. While unique app goals were codeveloped by each disease group, a central goal across groups was to develop a personal health app enabling users to track subjective, self-reported symptoms, objective measures of health, and unique modifiers of symptoms. A total of 239 end user participants participated in the beta testing pilot study. Enrollment and retention rates were high, ranging from 94% to 100% and 92.2% to 100%, respectively. All active participants gave some form of feedback: there were 257 unique participant suggestions of how to specifically modify or improve the study app experience. Participant feedback themes commonly centered around customization to reduce daily burden and improve personal tailoring of the app. Participants' desires surrounding symptom displays were heterogeneous. Personal health app co-design is rooted in a complex digital landscape that requires a significant amount of up-front effort and time. However, the up-front investment of time can result in rich and diverse end user feedback that could save time in the app development trajectory to implementation. This paper provides a co-design framework and the building blocks of 5 prototype personal health apps with publicly available open-source code on GitHub. These prototypes could be leveraged for improving understanding of, communicating symptoms of, and providing n-of-1 suggestions for rare or complex diseases, providing benefit to patient communities and individual patients.
To describe the quality of nurse-patient interactions when nurses use Electronic Health Record systems in four acute hospital wards. An explanatory sequential mixed methods study. Sixteen researcher observations were conducted using a published Quality of Interactions Schedule tool to evaluate the duration and quality of nurse-patient interactions. Observations were followed by 16 nurse and 16 patient interviews. Data were analysed by descriptive statistics and thematic analysis and integrated to inform overall study meta-themes. Three study meta-themes emerged: (1) Limited social, open, reciprocal and face-to-face nurse-patient communication; (2) Cumbersome computer systems monopolised nurses' time and attention and impeded face-to-face communication; and (3) Nurses' use of Electronic Health Record scripts fostered a task-orientated agenda. Nurses, healthcare employers and system developers need to consider the unintended impact of nurses' use of Electronic Health Records on the quality of nurse-patient interactions. Nurses need to evaluate practices that promote, and not hinder, quality nurse-patient interactions when nurses use Electronic Health Record systems in acute care settings. Researchers developing Electronic Health Record systems need to involve nurses and patients. Balancing the complex tripartite relationship between the nurse, patient and digital interface has implications for nursing practice, education and research. The challenges encountered when nurses use Electronic Health Records need to be addressed to promote quality nurse-patient interactions. Less obtrusive Electronic Health Record technology is required that is developed with nurses who are the principal users. Nurse educators need to promote techniques that facilitate person-centred communication when nurses use Electronic Health Record systems and researchers need to evaluate practices that promote quality nurse-patient interactions. Digital transformation will continue to dominate nursing in the future and the significant findings from this study will help inform further exploration and developments in this area. Patients consented to the collection of data and for the data to be used in future potential publications. Patient participants were all discharged from the acute care hospital soon after data collection.
The Mental health care: Adverse Sequelae of COVID-19 study aimed to (1) compare the consequences of the COVID-19 pandemic for mental health services and people with pre-existing mental health conditions (MHCs) in six low- and middle-income countries and (2) identify good practice to mitigate these impacts. An observational study, using a mixed-methods convergent design triangulating data from (1) semistructured interviews or focus groups and/or a self-completed survey, (2) routine service utilisation data, (3) local grey literature and (4) expert consultation. The study was conducted in Chile, Ethiopia, Georgia, Nigeria, South Africa and Sri Lanka. 121 key informants. We found clear evidence in all sites that the pandemic exacerbated pre-existing disadvantages experienced by people with MHCs and led to a deterioration in the availability and quality of care, especially psychosocial care. Alongside increased vulnerability to COVID-19, people with MHCs faced additional barriers to accessing prevention and treatment interventions compared with the general population. To varying extents, sites showed accelerated implementation of digital technologies, but with evidence of worsening inequities in access. In sites where primary care-based mental healthcare was more developed or prioritised, systems seemed more resilient and adaptive. Our findings have the following implications. First, these mental health service reductions are clear examples of 'structural stigma', namely policy level decisions in healthcare which place a low priority upon services for people with MHCs. Second, integration of mental healthcare into all general healthcare settings is key to ensuring accessibility and parity of physical and mental healthcare. Third, digital innovations should be designed to strengthen and not fragment health systems. We discuss these findings in terms of anticipating such challenges for future pandemics and preparing layers of resilience.
Digital transformation is fundamentally changing the diagnosis, monitoring and treatment of multiple sclerosis. The integration of multimodal data from imaging, laboratory tests, clinical assessments, patient-reported outcomes and continuous measurements via wearables is creating high-resolution, longitudinal profiles of disease progression. Based on this data, modern analysis methods and artificial intelligence enable predictive models for disease activity, progression and therapeutic response, supporting personalised decision-making. Digital patient pathways and patient portals open up new options for participatory, standardised care, while telemedicine, telerehabilitation and digital health applications complement care regardless of location and time. In research, real-world data, federated learning and virtual, decentralised studies are accelerating patient-centred evidence generation. Concepts such as the digital twin outline the next stage of development in simulation-based precision medicine. Key challenges relate to data protection and data security, data quality, interoperability, bias, transparency and the traceability of algorithmic decisions. Overall, digitalisation offers substantial opportunities to detect disease activity earlier, optimise treatment goals and improve quality of life and care - provided that technical, regulatory and ethical requirements are consistently addressed and translated into scalable care models. Die digitale Transformation verändert Diagnostik, Monitoring und Therapie der Multiplen Sklerose grundlegend. Durch die Integration multimodaler Daten aus Bildgebung, Labor, klinischen Assessments, patientenberichteten Ergebnissen sowie kontinuierlichen Messungen via Wearables entstehen hochauflösende, longitudinale Profile des Krankheitsverlaufs. Auf dieser Datengrundlage ermöglichen moderne Analyseverfahren und Künstliche Intelligenz prädiktive Modelle zur Krankheitsaktivität, Progression und Therapieantwort und unterstützen personalisierte Entscheidungswege. Digitale Patientenpfade und Patientenportale eröffnen neue Optionen für partizipative, standardisierte Versorgung, während Telemedizin, Telerehabilitation und digitale Gesundheitsanwendungen die Betreuung orts- und zeitunabhängig ergänzen. In der Forschung beschleunigen Real-World-Daten, föderiertes Lernen und virtuelle, dezentralisierte Studien patientenzentrierte Evidenzgenerierung. Konzepte wie der digitale Zwilling skizzieren die nächste Entwicklungsstufe einer simulationsgestützten Präzisionsmedizin. Zentrale Herausforderungen betreffen Datenschutz und Datensicherheit, Datenqualität, Interoperabilität sowie Bias, Transparenz und Nachvollziehbarkeit algorithmischer Entscheidungen. Insgesamt bietet die Digitalisierung substanzielle Chancen, Krankheitsaktivität früher zu erkennen, Therapieziele zu optimieren und die Lebens- und Versorgungsqualität zu verbessen – vorausgesetzt, dass technische, regulatorische und ethische Voraussetzungen konsequent adressiert und in skalierbare Versorgungsmodelle überführt werden.
Myanmar migrant workers in Thailand's seafood processing industry develop work-related musculoskeletal disorders from tasks such as repetitive shrimp peeling and standing for extended periods. These workers remain largely unreached by standard health interventions due to language barriers and cultural isolation. Developing effective study for this vulnerable population requires meaningful involvement of workers in the study design process, recognizing their experiential expertise while acknowledging the distinct roles of researchers and community members. This paper documents how involvement with stakeholders such as migrant workers themselves shaped the co-design of a study testing a culturally appropriate digital health intervention for managing existing symptoms and preventing progression of musculoskeletal disorders. This was a mixed-methods co-design study combining qualitative community engagement with quantitative expert validation. We conducted engagement sessions with 29 Myanmar migrant workers, organized into three groups by length of work experience (less than 2 years, 2-5 years, more than 5 years). We engaged 5 workplace stakeholders (human resource managers and production line supervisors) and consulted 4 international physical therapy experts for validation. Sessions were structured as conversations. Workers provided substantial input on intervention content, delivery methods, and practical requirements for the planned study. We accommodated their 12-hour work schedules, communicated in Myanmar language, and valued their experiential knowledge as essential for culturally appropriate study design. Thematic analysis identified key themes from worker input. Expert validators assessed the co-designed intervention using Content Validity Index (CVI) methodology. All participating workers reported hand symptoms including numbness, tingling, and pain. Workers expressed preferences for health information through platforms they used daily, with Facebook emerging as the clear preference over text-based materials or in-person workshops on their only day off. These insights shaped the study intervention: a 4-week intervention with 12 progressive exercises addressing observed strain patterns: forward-leaning postures and repetitive hand movements. Workers specified practical requirements such as exercises must function in small dormitory spaces, outside work hours, without equipment. The peer challenge format emerged from their suggestions about sustained engagement. The co-designed study intervention achieved strong content validity scores from expert validators (I-CVI: 0.95-1.00; S-CVI/Ave: 0.94). The engagement process also highlighted ethical considerations when working with vulnerable migrant populations, including managing power differentials and protecting workers from potential workplace repercussions. Workers possess essential knowledge about their needs and what works in their circumstances. We found that when research incorporates the input of the intended beneficiaries in study design, the result is a study intervention that is both clinically appropriate and practically usable. The co-designed intervention is now used for evaluation in the implementation research. This paper contributes a documented methodological approach to community involvement with a vulnerable migrant population, demonstrating that structured engagement can produce interventions meeting both worker feasibility requirements and clinical validity standards, while generating an honest account of the ethical tensions such work entails. WHAT IS THE PROBLEM?: Myanmar migrant workers in Thailand’s seafood industry perform repetitive tasks like shrimp peeling while standing for long hours. This leads to pain in their hands, necks, backs, and other body parts. Language barriers, limited healthcare access, and demanding work schedules make it difficult for these workers to get help or learn how to prevent these problems. WHAT DID WE DO?: We worked directly with 29 Myanmar workers, workplace managers, and physical therapy experts to design a study that would test a health program on addressing pain in their hands, necks, backs, and other body parts specifically for this community. We sought input from workers to help shape the study based on what would actually work in their daily lives. We asked about their pain, their access to healthcare, and how they prefer to receive health information. WHAT DID WE FIND?: Every worker we spoke with experienced hand symptoms, and many also had neck, back, or leg pain. Workers told us they prefer getting health information through Facebook videos they can watch during their limited free time, rather than attending workshops on their only day off. They wanted short, practical exercises they could do in their dormitories without special equipment. We also encountered some ethical issues, including ensuring workers felt safe to speak honestly without fear of workplace consequences and addressing the power imbalance between researchers and workers in the co-design process. WHAT DOES THIS MEAN?: By involving stakeholders including migrant workers themselves in designing this study, we created a Facebook-based program with simple exercises and health tips tailored to their needs that is now ready to be tested in a future study. We describe how migrant workers can be effective contributors in developing study that address their unique challenges, and digital platforms offer a practical way to reach people with demanding work schedules.
Hypertension is a global health challenge accounting for 8.5 million deaths worldwide despite the availability of low-cost pharmaceutical treatment. About 14.9% of people (9.9 million) registered with primary care practices in England and Wales are prescribed medication for hypertension. However, many patients with hypertension and associated conditions do not take their medications as prescribed. Non-adherence to antihypertensive medication is associated with increased risk of suboptimal blood pressure (BP) control, complications and all-cause mortality, and increased healthcare costs. The Programme on Adherence to Medication (PAM) trial will estimate the effectiveness and cost-effectiveness of a medication adherence intervention in patients prescribed medication for hypertension with poorly controlled blood pressure in primary care. A two-arm multicentre individually randomised controlled parallel group superiority trial recruiting patients prescribed medication for hypertension with poorly controlled BP in primary care practices in England and Wales. The target sample size is 542. Participants in the Intervention group will receive a very brief intervention delivered remotely (by telephone or video call) by a practice nurse or healthcare assistant followed by a digital intervention (text messaging or smartphone app) in addition to usual care; control group participants will receive usual care alone. The primary outcome is systolic BP measured at 12 months. Medication adherence will be measured by chemical adherence testing of urine samples and self-report. An economic evaluation and a process evaluation will be undertaken. The Cambridge East Independent Research Ethics Committee (REC reference 19/EE/0354), the Health Research Authority (HRA) and Health and Care Research Wales (HCRW) approved the trial. The findings will be disseminated to the scientific community, participating practitioners and patients, relevant patient groups and the public using a range of methods, including journal articles, conference presentations, newsletters and the Programme website. The UK's Clinical Trial Registry ISRCTN82013652. About 15% of people (10 million) registered with primary care practices in England and Wales are prescribed treatment for hypertension (high blood pressure). However, many do not take their medications as prescribed, which may harm their health and increases health service costs. To address this problem, we need low-cost interventions that can reach all the people who need them. Based on findings from our previous studies using a range of different research methods, we have developed a new intervention (the PAM intervention – Programme on Adherence to Medication) to support people with poorly controlled blood pressure to take their antihypertensive medication as prescribed. The intervention has two parts: a very brief intervention delivered by a practice nurse or healthcare assistant by telephone or video call, followed by a digital intervention (individually-tailored text messages for up to 14 months or a smartphone app). We have already shown that the PAM intervention is feasible and acceptable. The next stage is to assess how well it works and how much it costs compared with usual care in a randomised controlled trial. In this trial, blood pressure and medication adherence will be measured in a large sample of participants recruited from primary care practices in England and Wales. This protocol describes the methods that will be used in the trial. If the intervention is shown to increase medication adherence and reduce blood pressure and is found to be good value for money, it could be introduced in primary care practices throughout the UK.
The prevalence of Major Depressive Disorder (MDD) is increasing at an alarming rate globally. There is a need for a digital tool that enables continuous and real-time data collection, helps overcome stigma, and improves mental health awareness. Here, we describe mHealth, an open-source, scalable mobile health application (iPhone operating systems, iOS, and Android) and present the details about the pilot phase of the application. We built the mHealth application using Xamarin, an open-source framework. Active data included four questions on mood administered twice daily and were collected as numerical data and mapped onto respective outcomes. Passive data included pedometer, location, device usage (calls, text, application usage), and location networks. Data were updated on the web-based portal and mobile application hourly. Of the 199 Texas Resilience Against Depression (T-RAD, observational, longitudinal study) study participants who consented to participate in the mHealth substudy, 113 (110 iOS testers and 3 Android testers) participated in the pilot. During the iOS pilot phase, application usage rates were high for the first three months with 90% engagement. We present detailed descriptive data from a participant to illustrate the types of data that can be extracted from the mobile application and how the data can be integrated into an observational study. Our pilot observations highlight opportunities to integrate mHealth into clinical studies. While this work demonstrates technical feasibility and user acceptability, the pilot phase was not powered to evaluate predictive utility. Further research will focus on testing and validating the application in independent cohorts to establish its clinical utility.
Chagas disease is a neglected tropical disease caused by the parasite Trypanosoma cruzi. It causes a significant health burden in the Americas, especially in Bolivia and Paraguay, where the disease is most endemic in the transnational Chaco region. Issues with data quality and availability prevent a true understanding of the current burden of disease, with missed opportunities for surveillance, resource allocation, and evaluation of interventions. This study aimed to explore routine Chagas disease data systems in Bolivia and Paraguay, focusing on data flow, barriers to data quality and reporting, and data sharing across health system levels, and to identify opportunities to strengthen surveillance and decision-making. A qualitative study was conducted between July-September 2024 in Bolivia and Paraguay. In-depth interviews were carried out with 43 key informants, with roles as healthcare workers, data managers, and technical advisors involved in Chagas Programs across different health system levels. A thematic analysis was conducted to develop a set of themes and recommendations related to data management practices. Four key themes emerged throughout interviews, with findings on data management practices, barriers to high quality routine data, data use, and cross-border data sharing. Key recommendations from participants to improve the overall Chagas disease data management systems in each country included strengthening digital infrastructure, promoting interoperability across systems, and fostering regional collaboration for cross-border data exchange. The study highlights critical gaps in routine data management for Chagas disease and underscores the importance of national-level solutions to support surveillance and control efforts. These findings offer concrete, actionable guidance for national health authorities and international stakeholders working to improve data systems for this neglected disease in endemic regions. This work was supported by the Fulbright U.S. Student Program; the Wellcome Trust [220211/Z/20/Z]; and ISGlobal (CEX2023-0001290-S, MCIN/AEI/10.13039/501100011033), with additional support from the Generalitat de Catalunya (CERCA Program). La enfermedad de Chagas es una enfermedad tropical desatendida causada por el parásito Trypanosoma cruzi. Representa una importante carga sanitaria en las Américas, especialmente en Bolivia y Paraguay, donde la enfermedad es más endémica en la región transnacional del Chaco. Los problemas relacionados con la calidad y disponibilidad de los datos impiden una comprensión real de la carga actual de la enfermedad, lo que limita las oportunidades para la vigilancia, la asignación de recursos y la evaluación de intervenciones. Se realizó un estudio cualitativo entre julio y septiembre de 2024 para comprender el flujo actual de los datos rutinarios de la enfermedad de Chagas desde el nivel local hasta el nivel nacional en Bolivia y Paraguay, e identificar las principales barreras para una gestión de datos de calidad en cada país. En total, se entrevistó a 43 participantes en ambos países, incluyendo personal sanitario, gestores de datos y asesores técnicos de los programas de Chagas. Los datos de las entrevistas se analizaron mediante un análisis temático para desarrollar un conjunto de temas y recomendaciones. Se identificaron cuatro temas clave a partir de las entrevistas, relacionados con las prácticas de gestión de datos, las barreras para obtener datos rutinarios de alta calidad, el uso de los datos y el intercambio transfronterizo de información. Las principales recomendaciones de los participantes para mejorar los sistemas de gestión de datos de la enfermedad de Chagas incluyeron el fortalecimiento de la infraestructura digital, la promoción de la interoperabilidad entre sistemas y el fomento de la colaboración regional para el intercambio de datos entre países. El estudio pone de manifiesto brechas críticas en la gestión de datos rutinarios sobre la enfermedad de Chagas y destaca la importancia de soluciones a nivel nacional para apoyar los esfuerzos de vigilancia y control. Estos hallazgos ofrecen orientaciones concretas y aplicables para las autoridades sanitarias nacionales y los actores internacionales que trabajan para mejorar los sistemas de datos de esta enfermedad desatendida en regiones endémicas. Este trabajo fue financiado por el programa Fulbright U.S. Student; el Wellcome Trust [220211/Z/20/Z]; e ISGlobal (CEX2023-0001290-S, MCIN/AEI/10.13039/501100011033), con apoyo adicional de la Generalitat de Catalunya (Programa CERCA). Con el propósito de acceso abierto, el autor ha aplicado una licencia pública CC BY a cualquier versión del manuscrito aceptado derivada de esta presentación. A doença de Chagas é uma doença tropical negligenciada causada pelo parasita Trypanosoma cruzi. Representa uma importante carga de doença nas Américas, especialmente na Bolívia e no Paraguai, onde a doença é mais endêmica na região transnacional do Chaco. Problemas relacionados à qualidade e disponibilidade dos dados dificultam uma estimativa precisa da carga atual da doença, limitando oportunidades para vigilância, alocação de recursos e avaliação de intervenções. Foi realizado um estudo qualitativo entre julho e setembro de 2024 para compreender o fluxo atual dos dados rotineiros da doença de Chagas desde o nível local até o nível nacional na Bolívia e no Paraguai, e identificar as principais barreiras para uma gestão de dados de qualidade em cada país. Foram entrevistados, 43 participantes nos dois países, incluindo profissionais de saúde, gestores de dados e assessores técnicos dos programas de Chagas. Os dados das entrevistas foram analisados por meio de análise temática para desenvolver um conjunto de temas e recomendações. Quatro temas principais emergiram das entrevistas, relacionados às práticas de gestão de dados, barreiras à obtenção de dados rotineiros de alta qualidade, uso dos dados e compartilhamento transfronteiriço de informações. As principais recomendações dos participantes para melhorar os sistemas de gestão de dados da doença de Chagas incluíram o fortalecimento da infraestrutura digital, a promoção da interoperabilidade entre sistemas e o incentivo à colaboração regional para o intercâmbio de dados entre países. O estudo destaca lacunas críticas na gestão de dados rotineiros sobre a doença de Chagas e ressalta a importância de soluções em nível nacional para apoiar esforços de vigilância e controle. Esses achados oferecem orientações concretas e aplicáveis para autoridades de saúde nacionais e atores internacionais que trabalham para melhorar os sistemas de dados dessa doença negligenciada em regiões endêmicas. Este trabalho foi financiado pelo programa Fulbright U.S. Student; pelo Wellcome Trust [220211/Z/20/Z]; e pelo ISGlobal (CEX2023-0001290-S, MCIN/AEI/10.13039/501100011033), com apoio adicional da Generalitat de Catalunya (Programa CERCA). Para fins de acesso aberto, o autor aplicou uma licença pública CC BY a qualquer versão do manuscrito aceito resultante desta submissão.
Global investments in digital health are accelerating progress toward universal health coverage, yet low- and middle-income countries face persistent challenges: fragmented data and limited interoperability inhibit systematic transformation. The World Health Organization's SMART (Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable) guidelines and Digital Adaptation Kits (DAKs) offer a standardized, evidence-based framework that enables countries to localize digital content and reinforce the uptake of standards at the point of care. Lessons from early adopters, including Cameroon, Ethiopia, Ghana, and Zambia, demonstrate that structured DAK localization strengthens alignment with national digital strategies and the potential to harmonize information systems. Effective adoption is driven by early user engagement, strong government leadership, and multisectorial collaboration. Mainstreaming the SMART Guidelines approach highlights the importance of robust governance and contextual adaptation in sustaining and scaling digital solutions that align with global standards.
Learning health systems (LHS) are an approach to translate patient data into actionable clinical insights, empower healthcare teams to drive quality improvement and reduce health inequalities. Here we present a protocol for a realist evaluation to explore what works to implement a learning health system approach in primary care settings in Thailand, for whom does it work, how, why and in what circumstances. A mixed-methods realist evaluation will run in parallel with an interventional trial [Reg No: NCT06873243] in Northern Thailand which aims to improve the management of hypertension (HTN), type 2 diabetes mellitus (T2DM) and chronic kidney diseases (CKDs) using a data-supported learning health systems approach. As part of the trial, 16 primary care units (PCUs) in Chiang Mai and Lamphun provinces will be randomly selected to receive a learning health system intervention to support quality improvement for care of HTN, T2DM and CKD. Performance will be compared between intervention PCUs and all other PCUs in the region. Participants of the realist evaluation will include clinical and other professional staff involved in the development and implementation of the LHS. This realist evaluation will use both quantitative and qualitative data, including semi-structured interviews, surveys and documents from participating sites. Quantitative and qualitative findings will be systematically integrated to test, refine and validate context-mechanism-outcomes to identify consistencies, contradictions and explanatory mechanisms as part of a final programme theory for the successful implementation of the LHS. Ethical approval has been granted by all collaborating university Research Ethics Committees (ref: 1090, 0321, 32540). Results will be disseminated to stakeholders, including patients and the public, health providers, the Thai government and WHO office. Our methods and dissemination will be guided by National Institute for Health Research and Guidelines International Network reporting standards for Patient and Public Involvement and Engagement.
As survival rates for children, adolescents, and young adults with cancer improve, managing treatment-related side effects is increasingly important. Enhancing physical activity levels has been shown to be effective in reducing some of these effects. Digital interventions, such as mobile apps, offer engaging tools to promote physical activity in young populations. This article introduces the "FORTEe Get Strong" app (Nurogames GmbH) and presents a formative evaluation of its acceptability among children, adolescents, and young adults with cancer. The "FORTEe Get Strong" app was developed within the multicenter FORTEe trial. Grounded in behavior change theories, the app uses gamification to deliver a child-friendly platform promoting physical activity and health-related knowledge. An embedded mixed methods design, with qualitative insights contextualizing quantitative findings, was applied. User experience was assessed using a self-developed questionnaire combining Likert scale items (1-5: "not at all satisfied" to "very satisfied," 1-3 for participants aged <8 y) and open-ended questions. Quantitative data were analyzed descriptively and inferentially, including chi-square tests for differences in app usage by age, sex, and diagnosis, and Kruskal-Wallis tests to compare app feature ratings between age groups. Free text responses underwent qualitative content analysis. The app was published in May 2023; it integrates gamified features to teach health knowledge. Exercise videos address endurance, strength, flexibility, coordination, and gait. Feedback on user experience was provided by 53 patients aged 5-19 years (mean 11.4, SD 3.8 years, 95% CI 10.4-12.5; 27/53, 51% male). App use did not differ significantly by age groups (χ²3=5.1; P=.16; Cramer V=0.135), sex (χ²1=3.4; P=.06; φ=0.110), or diagnosis (P=.54; Cramer V=0.168). The app was generally well-received, with a mean Likert scale score of 4.14 (SD 1.04, 95% CI 3.84-4.43). For individual components, mean scores ranged from 3.52 (SD 1.44, 95% CI 3.09-3.95) for exercise content to 4.37 (SD 0.82, 95% CI 4.14-4.60) for design. Kruskal-Wallis tests revealed no significant differences among age groups. Qualitative analysis identified key categories regarding overall app evaluation, specific features, target group perception, usability, and suggestions for improvement. While participants highlighted the app's design and gamification, concerns arose regarding age-appropriateness, lack of supervision, and adaptability of exercises. This study provides novel insights into user experience of children, adolescents, and young adults with cancer with a gamified exercise and health education app. Unlike previous studies focusing on survivorship, this evaluation offers a comprehensive understanding of how digital tools can support patients in maintaining physical activity during intensive treatment. Apps with interactive, gamified elements may complement clinical care by providing low-threshold access to exercise and health education. The findings advance the field by identifying key facilitators and barriers to engagement. Future research should assess adherence, behavioral outcomes, and effectiveness in larger samples to inform clinical implementation.
People living with inflammatory bowel disease (IBD) frequently experience abdominal pain, fatigue and faecal incontinence that persist despite optimal medical treatment. This study aimed to assess the cost-effectiveness of IBD-BOOST, a digital, interactive, facilitator-supported self-management intervention targeting these symptoms. A cost-effectiveness analysis was conducted alongside the IBD-BOOST trial, which randomised people with IBD experiencing fatigue, pain and/or faecal incontinence to the IBD-BOOST intervention (N=391) or care as usual (N=389) over 12 months. While the IBD-BOOST intervention did not significantly improve the primary trial outcome measures (UK Inflammatory Bowel Disease Questionnaire and global rating of symptom relief), trends towards benefit were observed across study outcomes. Therefore, this analysis focuses on secondary health economic outcome measures. The cost of the intervention, including its development, facilitation and delivery, was assessed. Participants reported their health service use, out-of-pocket expenses and time off work over the previous 3 months and their health-related quality of life at baseline, 6-month and 12-month follow-up. Participants' costs (2023 UK£) and quality-adjusted life years (QALYs) over the 12 months were compared between study arms using mixed effects models. The IBD-BOOST intervention resulted in additional per participant 0.016 QALYs (95% CI 0.002 to 0.030) over the 12 months in the study and cost savings of -£304.66 (-803.51 to 194.18) for healthcare and -£39.48 (-388.09 to 309.12) for out-of-pocket costs and time off work over months 4-6 and 10-12. This resulted in cost savings of -£28 633 (95% CI -51 555 to 18 764) and -£33 568 (-64 421 to 26 198) per QALY gained with IBD-BOOST from health services and societal perspectives, respectively, and high probability of cost-effectiveness. The IBD-BOOST intervention is highly likely to be cost-effective for the self-management of pain, fatigue and faecal incontinence in people living with IBD. ISRCTN71618461.
The transition from hospital to home is a vulnerable stage in the patient pathway. Patients and carers often report unmet information needs regarding diagnoses, medication changes, follow-up arrangements and escalation pathways during the post-hospital discharge period. Digital information interventions-such as electronic health records, patient portals or remote communication systems-have been proposed to improve discharge pathways. However, evidence on their impact is unproven. The aim of this review is to understand what works for whom, how, why and in what circumstances in relation to digital information interventions during the hospital-to-home journey. Pawson's realist review approach will be used. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards will also be followed. The review will follow five steps: (1) Development of the initial programme theory; (2) evidence search; (3) selection and appraisal of data; (4) extraction and organisation of data and (5) data synthesis and analysis. The search will be conducted in MEDLINE (Ovid); Embase; PsycINFO; Web of Science and Cochrane Library and supplemented with citation tracking, grey literature, relevant organisational websites, programme evaluation reports and through consultation with stakeholders. The realist review will be an iterative process, and the initial realist programme theory will be tested (confirmed, refuted or refined) in response to the data searches and stakeholder discussions. Patient and public involvement and engagement will be embedded throughout the review. Patients, carers and health and care stakeholders will contribute to refining the initial programme theory, interpreting emerging programme theory and co-developing dissemination outputs to ensure findings remain grounded in lived realities. Ethical approval is not required for this review as it involves secondary analysis of published literature. The review will be conducted in accordance with principles of research integrity, transparency and responsible stakeholder involvement. Findings will inform the co-design of future digital discharge interventions and contribute to national priorities around digital transformation, safety and equity in transitional care. Dissemination will include conference presentations, a peer-reviewed journal article and accessible summaries co-developed with stakeholders to support equitable implementation and impact.
Healthcare systems in low- and middle-income countries (LMICs) face persistent challenges in resource allocation due to fragmented health information systems and limited decision support capacity. In Botswana, despite significant investments in platforms such as District Health Information Software, Integrated Patient Management System, and Patient Information Management System, these systems remain siloed, constraining real-time analytics and equitable planning. Existing literature has primarily emphasized isolated platforms or high-level policy discussions, leaving a critical gap in empirically grounded, methodologically rigorous frameworks for integrating disparate datasets into unified, decision-oriented architectures. This study addresses that gap by designing and evaluating a Kimball-based dimensional data warehousing framework tailored to Botswana's healthcare ecosystem. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, a systematic review of 72 peer-reviewed articles published between 2021 and 2025 was conducted, focusing on modeling approaches, interoperability practices, and operational outcomes. Results reveal a clear preference for Kimball's bottom-up dimensional modeling, particularly star schemas, due to their incremental deployment, user-centered design, and suitability for resource-constrained environments. Thematic synthesis highlights medicine stockouts, staffing mismatches, and budget execution delays as recurring bottlenecks, with evidence that robust ETL pipelines and source-to-target mapping significantly improve data reliability and decision-making. Findings demonstrate that a localized Kimball framework can transform fragmented health data into actionable intelligence, enabling real-time visibility of staffing, inventory, and financial flows. The study concludes that such an approach not only strengthens efficiency and equity in Botswana's healthcare system but also offers a transferable model for other LMICs seeking to align technical innovation with governance realities and operational needs.
To further understand young people's perceptions of using online arts and culture and how it impacts on mental health. This qualitative study was embedded in a proof-of-principle randomised controlled trial (RCT) comparing the effectiveness of two different online arts and culture experiences on mental health in young people (aged 16-24 years). The RCT compared the Ashmolean website (Ash) a generic museum website and Ways of Being (WoB), a codesigned stories based web experience. Three sources of data were analysed; focus group transcripts, free text responses and viewpoints. We adopted an interpretive phenomenological approach allowing deductive and inductive hybrid thematic analysis to gain critical insight into how young people make sense of phenomena relating to mental health in a complex context within a critical realist paradigm. In total, 117 free text responses relevant to the interventions were received. The first focus group was attended by seven Ash participants and the second by six WoB participants. A total of 108 separate viewpoints were entered. The main themes identified across sources were of human connection, the content and journey of the online experience, the features, setting and when it was used, positive mental health impacts and neutral/negative effects. Positive mental health impacts were often described in association with human connection in WoB participants. Neutral and negative effects were more commonly described in participants allocated to Ash. Continued development of online arts and culture for diverse populations using participatory and mixed methods to identify potential mechanisms are promising future areas of mental health research. NCT04663594; Results.