Numerous mobile technologies have been designed to support various healthcare initiatives in the developing world. These technologies can be grouped into the following categories of mHealth applications.
1. Education and Awareness 2. Health Data Collection 3. Health Worker Support 4. Disease Surveillance 5. Treatment Compliance
6. Emergency Medical Response
First, mHealth applications have been used to educate communities and create awareness.
2.3.1 Education and Awareness
The prevention of infectious diseases is less costly than treatment (Earth Institute, 2010).
Consequently, more emphasis is now being placed on disease prevention. Diseases impose great economic burdens on society, making prevention efforts a worthwhile investment globally. This is especially the case in low-resource settings where infectious diseases and chronic conditions put a strain on existing healthcare infrastructure (p. 36).
To counteract this, the World Health Organization (WHO) identified three steps to ensuring more effective preventive patient care (Earth Institute, 2010, p. 36). These steps are (1) providing integrated preventive healthcare, (2) promoting financing systems and policies to support preventive healthcare, and (3) prioritizing preventive healthcare as a key component of every intervention. Unfortunately, service delivery is not often aimed at preventive care. Moreover, persuading patients to adopt healthier lifestyles poses a challenge (World Health Organization, 2008). In low-resource settings the rapid adoption of mobile technologies present numerous opportunities to enhance preventive care. For example, Short Message Service (SMS) messages could be transmitted to patients to promote smoking cessation (Earth Institute, 2010). In a study conducted of a low-income HIV-positive population, it was reported that respondents were equipped with free mobile handsets through which they received counselling. Findings indicated that 75% of participants abstained and 95% attempted to quit smoking (Lazev, Vidrine, Arduino and Gritz, 2004). A typical case of an mHealth application for education and awareness is highlighted in Box 2.1.
Box 2.1: mHealth Application for Education and Awareness
Source(s): (Earth Institute, 2010, p. 42)
‘Text to Change’ is an NGO that deploys mobile phones in an effort to enhance HIV/AIDS sensitization and prevention efforts in Uganda. It is part of a pilot project devised to scale up Voluntary Counseling and Testing (VCT), influence behavioural change through civic education, and monitor and evaluate HIV/AIDS prevention. Text to Change spearheaded the development of interactive multiple-choice quizzes to improve HIV/AIDS knowledge and awareness. Questions were sent through SMS to 15,000 mobile phone subscribers in the Greater Mbarara region. Over a three-month period from February to April of 2008, 2,610 out of 15,000 mobile phone users responded to these questions (Earth Institute, 2010). Some questions elicited more frequent responses than others. For instance, a question on ‘the accuracy of HIV tests’ elicited responses from approximately 2,500 participants. In comparison, a question on the ‘presence of HIV in body fluids’, elicited responses from between 1,000 and 1,500 participants (Earth Institute, 2010, p. 42).
Second, mHealth applications have been used to support data collection for patient care.
2.3.2 Health Data Collection
The collection of disease data in real-time can dramatically reduce morbidity and mortality (Earth Institute, 2010). The analysis of this data can impact the speed at which treatment reaches patients in low-resource settings. However, health data collection has often proven cumbersome due to the use of traditional paper-based systems (p. 22). The use of mobile technologies for data collection can resolve this. For instance, adopting mHealth tools over paper-based systems can significantly reduce data collection error rates (Earth Institute, 2010). In a study of health surveys in Gambia, it was observed that respondents using Personal Digital Assistants (PDAs) to collect malaria data reported error rates of between 0.1% and 0.6%, which indicated improved accuracy over paper-based forms (Forster, Behrens, Campbell and Byass, 1991). A typical case of an mHealth application for the collection of health data is highlighted in Box 2.2.
Box 2.2: mHealth Application for Data Collection
Source(s): (Vital Wave Consulting, 2009)
Third, mHealth applications have been used by field health workers for decision-support.
2.3.3 Support for Health Workers
The use of mobile technologies by field health workers can be used as decision support tools at the point-of-care or as an enabler of access to information (Earth Institute, 2010).
For instance, nurses in Dangme West, Ghana, have used mobile phones to consult senior medical colleagues on handling complex maternal and newborn cases (Mechael, 2009). In
‘EpiHandy’, is a health data collection and record access system sponsored by the Centre for International Health in Norway, enabled by mobile devices to help mitigate the high costs and inefficiencies of large-scale paper-based surveys. Despite its deployment in various countries since its launch in 2003, it has largely been used in Uganda, Zambia, and Burkina Faso. For instance, in Uganda, mobile phones were deployed to participating clinics and public health experts trained the local staff on using its open source ‘JavaRosa’ software to complete and submit filled medical forms.
The data on these forms were transmitted through services made available on the local mobile network. EpiHandy has yielded positive results during a 5-year assessment in which 14 interviewers collected information on breastfeeding habits and child anthropometry in rural Eastern Uganda.
Notable outcomes of this initiative include a reduction in data entry errors and improved cost effectiveness over paper-based surveys.
Cameroon, it was similarly observed that resident medical students used mobile phones to consult their supervisors through voice and SMS whilst completing their training in a rural setting (Scott, Ndumbe and Wootton, 2005). A typical case of an mHealth application for health worker support is highlighted in Box 2.3.
Box 2.3: mHealth Application for Health Worker Support
Source(s): (Vital Wave Consulting, 2009)
Fourth, mHealth applications have been used by field health workers for disease surveillance.
2.3.4 Disease Surveillance
The use of mobile technologies for disease surveillance and reporting at the point-of- care could contribute to more integrated health systems. This is aided by the use of mobile devices to detect epidemics early (Earth Institute, 2010). Mobile technologies offer the added advantage of providing accurate data for the effective delivery of patient care (p.
22). Uses of mobile technologies for disease surveillance have been cited (Earth Institute, 2010). For example, in a ten-day field study conducted to facilitate effective patient follow-ups in Mozambique, Global Positioning System (GPS)-enabled mobile phones were used to map 4,855 households across 32 villages in 8 districts (Krishnamurthy, Frolov, Wolkom, Vanden and Hightower 2006). A typical case of an mHealth application for real-time disease surveillance is highlighted in Box 2.4.
Box 2.4: mHealth Application for Disease Surveillance
Source(s): (Vital Wave Consulting, 2009)
The ‘Tamil Nadu Health Watch’, sponsored by ‘Voxiva’, was a phone-based disease surveillance platform deployed in India’s hard-hit Tamil Nadu State. The platform, launched in May 2005, supported field workers to relay disease incidence data to health officials in real time. As part of this initiative, Voxiva was used to train over 300 primary health centre doctors. This was achieved through interactive sessions conducted with local authorities to promote and reinforce outbreak surveillance.
The Ugandan Health Information Network (UHIN), an initiative sponsored by Uganda Chartered HealthNet (UCH), AED-SATELLIFE, Makerere University Medical School, Connectivity Africa, and the International Development Research Centre (IDRC) used PDAs to provide medical education services to health personnel in Uganda. The PDAs transmitted messages via infrared beams transmitting signals to battery operated access points. The program was launched in 2003, and so far 350 PDAs connected to 20 access points in various districts in Uganda have been used. Health workers now using these devices have reported improved job satisfaction and staff retention.
Fifth, mHealth applications have been used to facilitate treatment compliance among patients.
2.3.5 Treatment Compliance
Treatment compliance involves the adherence of patients to medication. For instance, patients must adhere to prescribed antibiotics used to treat tuberculosis or anti-retroviral therapy for HIV/AIDS (Earth Institute, 2010). Mobile technologies could enable treatment compliance (p. 14). Uses of mobile technologies for treatment compliance have been cited (Earth Institute, 2010). For instance, in a study of 31 HIV patients in Peru, it was reported that mobile phone use significantly improved their adherence to anti-retroviral treatment (Curioso and Kurth, 2007). A typical case of an mHealth application for treatment compliance is highlighted in Box 2.5.
Box 2.5: mHealth Application for Treatment Compliance
(Source: Vital Wave Consulting, 2009)
Sixth, mHealth platforms have been used to support prompt responses to medical emergencies.
2.3.6 Emergency Medical Response Systems
In low-resource settings, Emergency Medical Response Systems (EMRSs) are not often prioritized (Earth Institute, 2010). This has been attributed to the prohibitive costs of transportation and advanced clinical care (Kobusingye, Hyder, Bisha, Hicks, Mock and Joshipura, 2005). The use of mobile devices as EMRSs is a simple and effective solution to these prohibitions (Earth Institute, 2010). During emergencies, mobile technologies can facilitate human resource support, transport and communications, patient transfers, and disaster planning (p. 45). The use of mobile phones as EMRSs in low-resource settings has been cited (Earth Institute, 2010). For example, in a study in Egypt it was reported
‘SIMpill’ is a solution designed to help improve TB treatment compliance through the attachment of a SIM card and transmitter to pill bottles. When a patient opens one, an SMS message is sent to the nearest health worker. If it is not opened as expected, the patient receives an SMS reminder to take his or her medication. If the patient fails to comply, the health worker is prompted to call or visit the patient to encourage medication adherence. Following a 2007 pilot study conducted in South Africa to test system efficacy, it was reported that 90% of patients using ‘SIMpill’ complied with their medication regimen.
that during emergencies, participants preferred using mobile phones to hire transport because their calls were routed to a call centre thereby reducing response times (Mechael, 2006). A typical case of an mHealth application for emergency medical responses is highlighted in Box 2.6.
Box 2.6: mHealth Application for Emergency Medical Responses
(Source: May et al., 2009; Vital Wave Consulting, 2009)
In summary, a review of the existing literature indicates that mHealth applications could enhance preventive care by promoting healthy patient behaviour (Ladzev et al., 2004). In addition, mHealth applications could improve data collection by reducing error rates (Yu et al., 2009). Moreover, mHealth applications could facilitate consultation between field workers and health professionals on complex medical cases (Mechael, 2009).
Furthermore, GPS-enabled mHealth applications could facilitate the mapping of households for disease monitoring (Krishnamurthy et al., 2006), treatment compliance through SMS adherence reminders transmitted to patients (Curioso et al., 2009), and emergency interventions for timely access to medical care (Mechael, 2006). It is important to recognize that the applications identified can be tools used as part of developing country mHealth projects. Examples of mHealth projects in the aforementioned application categories are provided in Table 2.1.
Table 2.1. mHealth Projects in Developing Countries
Category Project Intervention Country
Education and
Awareness
Project Masiluleke Send SMS messages to encourage HIV/AIDS testing and treatment.
South Africa
SMS for Health Promote HIV prevention through an SMS Quiz.
Uganda
Learning About Living Promote learning about HIV/AIDS through question and answer platform.
Nigeria
Health Data Collection EpiHandy Collect data and access patient Uganda,
‘Alerta DISAMAR’, is a multi-platform emergency alert system deployed in Peru and supported by the US Navy. The system allows users to transmit or access data using multiple technologies, including mobile phones and the Internet. Alerts of disease outbreaks are sent as text, voice, and e-mail messages. Following an evaluation of the project conducted in 2003, it was found that within the first year of deployment, disease outbreak responses in remote areas were improved. Since its launch, the system has been used to report more than 80,500 health cases of diphtheria, yellow fever, snakebites, diarrhoea, and acute respiratory infection.
records enabled by PDAs. Zambia, Burkina Faso
EpiSurveyor Create, share, and deploy health surveys and forms on mobile devices.
Kenya, Uganda, Zambia
Pesinet Use of a mobile application collect and transfer child health data.
Mali
Uganda Health
Information Network (UHIN)
Use of PDAs to collect health data and provide medical information to physicians.
Uganda
Mobile E-IMCI Use of PDAs to promote health worker adherence to Integrated Management of Childhood Illness (IMCI) protocols.
Tanzania
Disease Surveillance GATHER Use of data entry tools for weekly disease surveillance for 20 health
Treatment Compliance Cell-Life Use of data-enabled mobile phones to record HIV/AIDS patient details such medication adherence.
South Africa
SIMpill Sending SMS messages to health workers monitoring TB patient medication adherence.
Source(s): Vital Wave Consulting (2009); LeMaire (2011)
The significance of implementing mHealth projects in low-resource settings is discussed in Section 2.4.