Evaluating AVADAR Mobile Health Intervention Using a Multi-prong Approach
Authors: Akpan Godwin Ubong , Ticha Johnson , Lau Fiona , Ngofa Reuben , Mamadou Diallo , Mpoyi Raoul , Kipterer John , Bello Isah Mohammed , Touray Kebba , Paige Lara , Senouci Kamel , Stein Andrew , Oyaole Daniel , Rankin Kathleen , Moraes Albertina , Kanmodi Kehinde , Seaman Vincent , Galway Michael , Mkanda Pascal 
Published: January 2021

Abstract
Background
The Auto-Visual AFP Detection and Reporting (AVADAR) digital health intervention programme is a programme that was introduced to Africa in 2016. The programme adopts the use of the AVADAR SMS – based smartphone application (app) in community-based AFP surveillance activities in order to enhance the detection and reporting of AFP (polio) cases and improve AFP surveillance quality. As at 2020, the AVADAR application is being used in 11 African countries. The need to conduct regular and relevant evaluations of the AVADAR programme is very essential towards improving polio eradication programme performance and effectiveness in Africa. Hence, this study aimed to review and evaluate the quality of the AFP cases reported through the AVADAR intervention and as well evaluate the documentation process of AVADAR alerts and investigations, and the assimilation of AFP cases found via AVADAR into the national databases.
Methods
This study reviewed and evaluated the quality of AVADAR-involved AFP case reporting and documentation process in 7 of the 11 African countries implementing the AVADAR programme (Cameroon, Chad, the DRC, Liberia, Mali, Niger, and South Sudan). Case validations of all AFP cases reported via AVADAR app, iterations of methods used for peer reviewing AVADAR reporting and documentation, informal interview of community informants (CIs) and health workers (HWs), as well as the development of interactive dashboard to showcase the results of peer reviews, were the approaches used for the review and evaluation process.
Results
Thirty-nine districts, cutting across the participating 7 African countries were selected for the study. A total of 581 AFP cases were reviewed in the selected districts; of which 496 AFP cases were physically seen with 384 cases confirmed as true AFP cases by the peer reviewers. Thematic findings obtained the interview with CIs and HWs identified key areas (communication, multi-disease reporting, and periodic evaluation) that needs to be improved in the AVADAR surveillance system. Also, the interactive dashboard gave a summary of the peer review outcomes at few glances.
Conclusions
The findings of the AVADAR AFP peer reviews revealed the app’s efficacy in reporting AFP cases and improving surveillance indicators at district level. However, its documentation at health facility level needs to be re-emphasized and improved via a systematic accountability framework implementation for the actors in the reporting cycle. In order to significantly improve AFP surveillance, we recommend on-going commitment to improve knowledge and collaboration between all AVADAR surveillance reporting teams involved in identifying children presenting with AFP.
Keywords: AVADAR, Mobile Health, Peer Review, Acute Flaccid Paralysis, surveillance , Africa