A new WHO guideline on Digital Interventions for Health System Strengthening published on April 17th, 2019. The main objective of this new guideline is to provide evidence-informed recommendations to policy makers on key digital health interventions, to inform country investment plans. The guideline also describes potentially important implementation considerations for these interventions. And finally, the guideline identifies evidence gaps to inform member states and streamline future research investments and implementation planning. The guideline includes contributions from eleven Cochrane reviews.
Nine of these reviews were commissioned by the WHO for the guideline. The other two reviews were already in progress but were finalised in collaboration with the WHO. Two of the reviews are qualitative evidence syntheses and two reviews are mixed methods reviews.
Simon Lewin and Claire Glenton, from Cochrane's Effective Practice and Organisation of Care (EPOC) Group, have played central roles in the development of the guideline. As part of the technical team, they helped to scope the guideline, commission the reviews, prepare the evidence, and support the decision-making process. They have also been closely involved as editors or co-authors of most of the reviews. In addition, Cochrane Response – the systematic review unit set up to increase Cochrane’s capacity to respond to the needs of commissioners – has worked on most of the reviews and has played a key part in review production.
In this interview we asked Simon Lewin and Claire Glenton from the Cochrane Effective Practice and Organisation of Care Group (EPOC) to tell us more.
Tell us about this guideline…
To give you an overview, the guideline looks at different ways of using digital technology to organise health services, primarily through mobile phones. Some of the recommendations involve service users – for example, people receiving text messages from the health services, or people receiving different types of healthcare services via mobile phone or tablet. However, most of the recommendations focus on health workers using mobile phone technology to improve service delivery, for instance through keeping track of supplies or commodity levels in health facilities, notifying births and deaths, linking with other health workers to receive advice or support on clinical questions, and accessing in-service training.
How/when did your relationship start with WHO on this topic?
This guideline has involved the preparation of eleven Cochrane Reviews, seven of which are from the EPOC Group.
Were some of these reviews specially commissioned by WHO? How were Cochrane Response involved?
Most of the reviews were specially commissioned by WHO. Cochrane EPOC played a key role in shaping the scope of these reviews, providing technical support to the review teams, such as with searching and assessing how much certainty to place in the review findings, and ensuring that the reviews have moved rapidly through the necessary Cochrane editorial processes.
Cochrane Response has also played a central role in getting this large body of work done on time, and the collaboration between WHO, Cochrane Response, Cochrane EPOC and the review author teams has been excellent. Cochrane Response came on board very early on in the process and helped us and the WHO to plan most of the reviews, together with the leads for those reviews. Since then, the Cochrane Response team has worked closely with the lead authors to prepare the reviews and helped to present the results to the WHO Guideline Development Group who were responsible for making the recommendations. Cochrane Consumers and Communication are also involved through two reviews, and they have also been very supportive.
None of the reviews were published before the guideline was finalised. We relied on preliminary summary of findings tables and evidence profiles for the guideline process. We’re now busy finalising the reviews for final peer review and publication and hope to see all of them published before the end of 2019.
Can you tell us about the Cochrane Reviews that have contributed to the guideline?
Most of the reviews were intervention reviews and focused on the effectiveness of these digital health interventions included in the guideline. However, two of the intervention reviews also included other types of data that could tell us something about how people are using these digital systems in practice and what influences their use. And two of the reviews were qualitative evidence syntheses. We used these qualitative evidence syntheses to answer questions about the acceptability of the interventions to different stakeholders, including service users and health care providers, as well as the feasibility of implementing these interventions and their impacts on equity and human rights. These qualitative evidence syntheses add to the growing body of such reviews within the Cochrane Public Health and Health Systems Network.
The guideline uses the GRADE Evidence to Decision Framework, why do you think this is important?
The GRADE Evidence-to-Decision framework is a key tool for helping decision makers with the process of moving from the best available evidence to a decision or recommendation. It helps decision makers, such as Guideline Development Groups, consider all important factors in a systematic and balanced way and makes the decision process more transparent to others, such as users at the country level. The framework presents in a condensed format the best available evidence for pros and cons of each option or intervention, including evidence on effectiveness and on the acceptability and feasibility of interventions. WHO has used the GRADE Evidence-to-Decision framework in this guideline – this means that there is a call for different types of evidence in addition to evidence of effectiveness.
How valuable do you think the Cochrane reviews have been in terms of their contribution to the guideline?
Despite widespread enthusiasm in many settings around the use of digital interventions delivered via mobile phones, the reviews showed a number of evidence gaps, and the evidence we did find was often of low or very low certainty. There was some evidence of impacts on health outcomes, but in many other cases, the available evidence suggests that these types of interventions may make little or no difference to the outcomes that were measured. The qualitative evidence can perhaps explain some of these results – it pointed to quite a few problems with the feasibility of these types of programmes, particularly in settings with weak health systems. The qualitative evidence also showed a number of acceptability issues, for instance tied to the privacy and confidentiality of information, as well as equity issues.
Although most of the digital interventions have been recommended by the WHO, the guideline made some recommendations conditional in response to some of the feasibility and acceptability issues identified. The WHO also highlighted acceptability, feasibility and equity issues – drawing on evidence from Cochrane qualitative evidence syntheses – when presenting implementation considerations to its end users. As all interventions have benefits and harms, use resources and need to be accepted by those to whom they are directed, it is important that recommendations are not simply based on enthusiasm and assumptions about benefits that may not be valid. The Cochrane reviews helped ensure that the recommendations were informed by the best available global evidence. Based on the findings of these reviews and the deliberations of the Guideline Development Group, the guideline also describes important research gaps to inform future studies in this field.