Article Text

Download PDFPDF

Original research
Dissemination and implementation of the e-MCHHandbook, UNRWA’s newly released maternal and child health mobile application: a cross-sectional study
  1. Seif Nasir1,2,
  2. Ryunosuke Goto2,3,
  3. Akiko Kitamura4,
  4. Sahar Alafeef2,
  5. Ghada Ballout2,
  6. Majed Hababeh2,
  7. Junko Kiriya5,
  8. Akihiro Seita2,
  9. Masamine Jimba5
  1. 1University of Nebraska Medical Center, Omaha, Nebraska, USA
  2. 2Health Department, United Nations Relief and Works Agency for Palestine Refugees in the Near East, Amman, Jordan
  3. 3Department of Pediatrics, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
  4. 4World Bank, Washington, District of Columbia, USA
  5. 5Department of Community and Global Health, The University of Tokyo, Graduate School of Medicine, Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
  1. Correspondence to Dr Ryunosuke Goto; ryunosukegoto{at}


Objectives In April 2017, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) released the electronic Maternal andChildHealth Handbook, the e-MCH Handbook application. One of the first mobile health (m-Health) interventions in a refugee setting, the application gives pregnant women and mothers access to educational information and health records on smartphones. This study investigated factors associated with the dissemination and implementation of m-Health in the refugee setting.

Setting and participants A cross-sectional study was conducted in 9 of 25 UNRWA health centres for Palestine refugees in Jordan. Self-administered questionnaires were distributed for 1 week to pregnant women and mothers with children aged 0–5 years.

Outcome measures The outcomes were whether participants knew about, downloaded or used the application. Multiple regression analyses were conducted to determine factors associated with application download and usage.

Results 1042 participants were included in the analysis. 979 (95.5%) had a mobile phone and 862 (86.9%) had a smartphone. 499 (51.3%) knew about, 235 (23.8%) downloaded and 172 (17.4%) used the application. Having other mobile applications (OR 6.17, p<0.01), staff knowledge of the application (OR 11.82, p<0.01), using the internet as a source of medical information (OR 1.63, p=0.01) and having internet access at home (OR 1.46, p=0.05) were associated with application download. The age of the husband was associated with application usage (OR 1.04, p=0.11).

Conclusions Though m-Health may be a promising means of promoting health in refugees, multiple barriers may exist to its dissemination and implementation. Those who regularly use mobile applications and get medical information from the internet are potential targets of m-Health dissemination. For successful implementation of a m-Health intervention, health staff should have thorough knowledge of the application and users should have access to the internet. Husband-related factors may also play a role.

  • mobile health
  • e-health
  • dissemination and implementation
  • refugee
  • palestine refugees
  • maternal and child health

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • SN and RG are joint first authors.

  • SN and RG contributed equally.

  • Contributors SN and RG are joint first authors and contributed equally to this paper. SN, RG, AK, MJ and JK designed the research. GB, MH and AS gave critical feedback on the study design and implementation. RG and SA distributed and collected the questionnaires. SN directed the supplementary focus group discussions. RG analysed the data and created the tables and figure. RG wrote the final version of the manuscript, and all authors provided critical feedback on the research. AK, AS and JK directed the project.

  • Funding This research was funded by United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA).

  • Competing interests During the study period, SN, RG and SA were interns, AK was the Public Health Specialist/Epidemiologist, GB was the e-Health Project Coordinator, MH was the Chief of Health Protection and Promotion and AS was the Director of Health Programs at the Department of Health, UNRWA HQ, Amman, Jordan. The authors have no other conflicts of interest to declare.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the research ethics committees of the University of Tokyo and UNRWA.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Deidentified participant data are available from Ryunosuke Goto ( on reasonable request. Reuse will be permitted only when RG grants permission.