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ID: <

10670/1.4krjmu

>

·

DOI: <

10.26226/morressier.5c7f9e3fb3003b000f4cf8c1

>

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Assessing key stakeholdersu2019 perspectives on the feasibility and acceptability of an mHealth innovation for managing emergency maternal care referrals in Northern Iraq
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Abstract

BackgroundConflict has weakened the health system in Iraq, with negative impacts on maternal and neonatal health, especially for three million people internally displaced. Mobile phone-based interventions may strengthen health care delivery and improve outcomes for women and newborns(1) through better communication, patient data management(2), and emergency referrals; however, there is minimal evidence on interventions from conflict-affected settings. This research aimed to assess the feasibility and acceptability of an mHealth intervention to reduce delays in reaching and receiving emergency obstetric care in northern Iraq.Methods:A qualitative study was conducted in northern Iraq in 2018 to inform the development of a mobile phone application to improve transport for obstetric referrals. Using purposive sampling, fifteen semi-structured interviews were conducted with key stakeholders including government health officials, non-government programme managers, and ambulance staff, to explore health service delivery, patient referral processes, mobile phone and application usage, and implementation strategies. Eleven focus group discussions were conducted with ambulance staff, hospital and primary health center staff, which incorporated innovative user-centered participatory activities such as a day in a life, patient vignettes and mobile application screen prototyping. Discussions in Kurdish, Arabic and English were audio-recorded, transcribed and translated into English. Data were coded iteratively to identify emerging concepts, and analysed thematically using the Three Delays Model, a conceptual framework used to understand maternal mortality (5). ResultsIn total there were 68 participants, 36 females and 32 males, with a mean age of 34. The following themes emerged:Conflict has resulted in diminished health resources, health personnel, and ambulances, and increased security measures. The displacement camps have NGO-run health facilities that refer patients to existing hospitals, however participants noted that patients have limited economic means to pay for transportation or private care and women are reluctant to be transported in an ambulance with only male staff.Participants reported that either doctors made the decision to refer a patient or calls were received directly from patients and family members. However, participants noted gaps in communication and coordination of services with the current paper-based system between health care providers, ambulance drivers, and hospital staff. Ambulance drivers reported incurring delays through lack of information about patient location, poor road conditions and security checkpoints. Drivers noted delays in patients receiving care at the hospitals due to lack of communication with the hospital about the incoming patient referral.Mobile phone application feasibility and acceptability focused on phone usage, access to information, connectivity and cost, and user-friendliness. Geolocalization was widely acknowledged to be an important element of the application. The potential for the app as an archive for case management and to close the referral loop was suggested. Advocacy Impact A mobile phone-based application for coordination of transport for obstetric referrals was considered to be acceptable in this setting and opportunities to strengthen coordination and communication of emergency obstetric referrals and to improve the mobile application design were identified. Challenges related to feasibility included the humanitarian crisis and resulting economic conditions, and cultural and gender norms regarding the provision of obstetric care. There was a perceived advantage in transitioning from a paper-based referral system to an electronic system; however, issues such as personal phone usage, airtime, and connectivity would need to be addressed. Communication and coordination of care with the receiving hospital was identified as a priority. However, a technological innovation would only address a targeted aspect of obstetric referrals. In order to have impact, the female healthcare workforce would need to be strengthened through gender equal education opportunities especially for medical and paramedical staff. Finally, scale-up implementation would require committed use and connectivity (3,4), with potential for advocacy of telecommunication private sector participation.

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