Patricia Mechael

The Case for mHealth in Developing Countries

exists and how to define it, most people will agree that individuals around the world are using mobile technologies to access health services and information and that health professionals are formally and informally integrating mobile technologies into public health and clinical activities. As mobile phones and other mobile devices become part of everyday life, people become better equipped to respond to emergencies, consult with peers and health professionals about health issues as they arise, and access health services that are increasingly being delivered through mobile phone based systems, such as remote patient monitoring. In developing countries, people frequently acquire mobile phones just in case of emergencies, including a taxi driver I interviewed in Upper Egypt in 2002, who shared the following experience with me:

mHealth for HIV Treatment & Prevention: A Systematic Review of the Literature

This systematic review assesses the published literature to describe the landscape of mobile health technology (mHealth) for HIV/AIDS and the evidence supporting the use of these tools to address the HIV prevention, care, and treatment cascade. The speed of innovation, broad range of initiatives and tools, and heterogeneity in reporting have made it difficult to uncover and synthesize knowledge on how mHealth tools might be effective in addressing the HIV pandemic. To do address this gap, a team of reviewers collected literature on the use of mobile technology for HIV/AIDS among health, engineering, and social science literature databases and analyzed a final set of 62 articles. Articles were systematically coded, assessed for scientific rigor, and sorted for HIV programmatic relevance. The review revealed evidence that mHealth tools support HIV programmatic priorities, including: linkage to care, retention in care, and adherence to antiretroviral treatment. In terms of technical features, mHealth tools facilitate alerts and reminders, data collection, direct voice communication, educational messaging, information on demand, and more. Studies were mostly descriptive with a growing number of quasi-experimental and experimental designs. There was a lack of evidence around the use of mHealth tools to address the needs of key populations, including pregnant mothers, sex workers, users of injection drugs, and men who have sex with men. The science and practice of mHealth for HIV are evolving rapidly, but still in their early stages. Small-scale efforts, pilot projects, and preliminary descriptive studies are advancing and there is a promising trend toward implementing mHealth innovation that is feasible and acceptable within low-resource settings, positive program outcomes, operational improvements, and rigorous study design

Impacts of e-health on the outcomes of care in low-and middle-income countries: where do we go from here?

Introduction Difficulties in achieving health targets, such as the Millennium Development Goals, and growing consumer demand have forced health planners to look for innovative ways to improve the outcomes of health-care and public-health initiatives while controlling service costs. Health systems must address diverse population needs, provide high-quality services even in remote and resource-poor environments, and improve training and support for health-care workers. Services that can be scaled up and are reliable (despite any infrastructural deficits) and cost-effective are in high demand worldwide, especially in low- and middle-income countries. E-health systems have the potential to support these objectives in ways that are both economically viable and sustainable. E-health tools are designed to improve health surveillance, health-system management, health education and clinical decision-making, and to support behavioural changes related to public-health priorities and disease management. (1) Some systematic evidence of the benefits of e-health in general, (2-4) and of specific areas of e-health, such as decision-support systems for clinicians (5,6) or patient-targeted text messaging, (7-10) already exists. The objectives of the current review were to highlight gaps in our knowledge of the benefits of e-health and identify areas of potentially useful future research on e-health. There were three main topics of interest: outcomes among patients with chronic health conditions, the cost-effectiveness of various e-health approaches, and the impact of e-health in low- and middle-income countries. Evidence collection We focused on evidence for the impact of e-health in three areas identified by prior reviews: (1) systems facilitating clinical practice; (2) institutional systems, and (3) systems facilitating care at a distance. (3,4) Systems facilitating clinical practice include electronic medical record systems, picture archiving and communication systems for managing digital medical images, and laboratory information systems that automate laboratory workflow and reporting. Institutional systems include systems for health information and management, early disease warning and disaster management. These systems aggregate data from health facilities and patients to create community-wide views of disease trends and clinical activity. (11,12) Systems facilitating care at a distance include the use of a short message service (SMS) or other text messaging to improve outcomes through patient reminders; between-visit monitoring and/or health education; videoconferencing facilities for live consultations and asynchronous communication between clinicians, and automated telephone calls with recorded messages (sometimes called interactive voice response calls). Multiple systematic reviews have been conducted on some of these e-health approaches, whereas the rest are barely covered in the peer-reviewed literature. To provide a rapid updated summary of the evidence for decision-makers, we conducted a scoping review by gathering information through targeted scans of scientific databases, reviews of reference lists and conversations with other experts. (13) Emphasis was given to projects that provided insights on the impact of e-health on the outcomes of chronic disease management and the scalability of e-health tools and/or data relevant to low- and middle-income countries. Throughout the review we highlight priorities for future research. Systems facilitating clinical practice Examples In developed countries, usage of electronic medical-record systems varies widely. For example, such systems are used for nearly all primary care patients in Denmark, the Netherlands, Sweden and the United Kingdom of Great Britain and Northern Ireland, but for less than 20% of such patients in the United States. (14,15) In low- and middle-income countries, electronic medical record systems, such as Dream, OpenMRS, Baobab Health (in Malawi) and the ZEPRS antenatal system (in Zambia), are available in some larger specialist hospitals but are rarely available in smaller health centres. …

Capitalizing on the Characteristics of mHealth to Evaluate Its Impact

The field of mHealth has made significant advances in a short period of time, demanding a more thorough and scientific approach to understanding and evaluating its progress. A recent review of mHealth literature identified two primary research needs in order for mHealth to strengthen health systems and promote healthy behaviors, namely health outcomes and cost-benefits (Mechael et al., 2010). In direct response to the gaps identified in mHealth research, the aim of this paper is to present the study design and highlight key observations and next steps from an evaluation of the mHealth activities within the electronic health (eHealth) architecture implemented by the Millennium Villages Project (MVP) by leveraging data generated through mobile technology itself alongside complementary qualitative research and costing assessments. The study, funded by the International Development and Research Centre (IDRC) as part of the Open Architecture Standards and Information Systems research project (OASIS II) (Sinha, 2009), is being implemented on data generated by 14 MVP sites in 10 Sub-Saharan African countries including more in-depth research in Ghana, Rwanda, Tanzania, and Uganda. Specific components of the study include rigorous quantitative case-control analyses and other epidemiological approaches (such as survival analysis) supplemented by in-depth qualitative interviews spread out over 18 months, as well as a costing study to assess the impact of mHealth on health outcomes, service delivery, and efficiency.

Unmet Need: Improving mHealth Evaluation Rigor to Build the Evidence Base

mHealth—the use of mobile technologies for health—is a growing element of health system activity globally, but evaluation of those activities remains quite scant, and remains an important knowledge gap for advancing mHealth activities. In 2010, the World Health Organization and Columbia University implemented a small-scale survey to generate preliminary data on evaluation activities used by mHealth initiatives. The authors describe self-reported data from 69 projects in 29 countries. The majority (74%) reported some sort of evaluation activity, primarily nonexperimental in design (62%). The authors developed a 6-point scale of evaluation rigor comprising information on use of comparison groups, sample size calculation, data collection timing, and randomization. The mean score was low (2.4); half (47%) were conducting evaluations with a minimum threshold (4 + ) of rigor, indicating use of a comparison group, while less than 20% had randomized the mHealth intervention. The authors were unable to assess whether the rigor score was appropriate for the type of mHealth activity being evaluated. What was clear was that although most data came from mHealth projects pilots aimed for scale-up, few had designed evaluations that would support crucial decisions on whether to scale up and how. Whether the mHealth activity is a strategy to improve health or a tool for achieving intermediate outcomes that should lead to better health, mHealth evaluations must be improved to generate robust evidence for cost-effectiveness assessment and to allow for accurate identification of the contribution of mHealth initiatives to health systems strengthening and the impact on actual health outcomes.

Using social networking to understand social networks: analysis of a mobile phone closed user group used by a Ghanaian health team.

Background The network structure of an organization influences how well or poorly an organization communicates and manages its resources. In the Millennium Villages Project site in Bonsaaso, Ghana, a mobile phone closed user group has been introduced for use by the Bonsaaso Millennium Villages Project Health Team and other key individuals. No assessment on the benefits or barriers of the use of the closed user group had been carried out. Objective The purpose of this research was to make the case for the use of social network analysis methods to be applied in health systems research—specifically related to mobile health. Methods This study used mobile phone voice records of, conducted interviews with, and reviewed call journals kept by a mobile phone closed user group consisting of the Bonsaaso Millennium Villages Project Health Team. Social network analysis methodology complemented by a qualitative component was used. Monthly voice data of the closed user group from Airtel Bharti Ghana were analyzed using UCINET and visual depictions of the network were created using NetDraw. Interviews and call journals kept by informants were analyzed using NVivo. Results The methodology was successful in helping identify effective organizational structure. Members of the Health Management Team were the more central players in the network, rather than the Community Health Nurses (who might have been expected to be central). Conclusions Social network analysis methodology can be used to determine the most productive structure for an organization or team, identify gaps in communication, identify key actors with greatest influence, and more. In conclusion, this methodology can be a useful analytical tool, especially in the context of mobile health, health services, and operational and managerial research.

A study of connectivity in millennium villages in Africa

The Millennium Villages Project (MVP) is a community-based comprehensive multi-sectoral approach to achieving the Millennium Development Goals (MDGs) in Africa over a five-year period. MVP and Ericssons Consumer Lab collaborated to investigate the baseline conditions for enhanced connectivity and integrating mobile telephony in MVP sites. It is hypothesized that this will accelerate the achievement of the MDGs through improved communication and availability of information. Using quantitative and qualitative methods, the research team aimed to assess the effects of network strengthening and strategic integration in the context of a rural village in a low-income African country. Four Millennium Village sites were examined for this study on connectivity: Bonsaaso, Ghana; Dertu, Kenya; Ikaram, Nigeria; and Mbola, Tanzania. The survey results from the sites showed common attributes for mobile phone owners but usage trends differed across study sites. Given the results, in three of the four sites, there is a significant market to be explored for voice services to be strengthened and made more easily available in terms of infrastructure and costs. Lessons drawn from these sites can provide us with useful insights into the potential for development and use of mobile phones in the rest of the continent, in addition to providing useful policy implications.

Mobile phones and social structures: an exploration of a closed user group in rural Ghana

BackgroundIn the Millennium Villages Project site of Bonsaaso, Ghana, the Health Team is using a mobile phone closed user group to place calls amongst one another at no cost.MethodsIn order to determine the utilization and acceptability of the closed user group amongst users, social network analysis and qualitative methods were used. Key informants were identified and interviewed. The key informants also kept prospective call journals. Billing statements and de-identified call data from the closed user group were used to generate data for analyzing the social structure revealed by the network traffic.ResultsThe majority of communication within the closed user group was personal and not for professional purposes. The members of the CUG felt that the group improved their efficiency at work.ConclusionsThe methods used present an interesting way to investigate the social structure surrounding communication via mobile phones. In addition, the benefits identified from the exploration of this closed user group make a case for supporting mobile phone closed user groups amongst professional groups.

El impacto de la cibersalud en los resultados de la asistencia en países con ingresos bajos y medios: ¿cómo actuar a partir de ahora?

Introduction Difficulties in achieving health targets, such as the Millennium Development Goals, and growing consumer demand have forced health planners to look for innovative ways to improve the outcomes of health-care and public-health initiatives while controlling service costs. Health systems must address diverse population needs, provide high-quality services even in remote and resource-poor environments, and improve training and support for health-care workers. Services that can be scaled up and are reliable (despite any infrastructural deficits) and cost-effective are in high demand worldwide, especially in low- and middle-income countries. E-health systems have the potential to support these objectives in ways that are both economically viable and sustainable. E-health tools are designed to improve health surveillance, health-system management, health education and clinical decision-making, and to support behavioural changes related to public-health priorities and disease management. (1) Some systematic evidence of the benefits of e-health in general, (2-4) and of specific areas of e-health, such as decision-support systems for clinicians (5,6) or patient-targeted text messaging, (7-10) already exists. The objectives of the current review were to highlight gaps in our knowledge of the benefits of e-health and identify areas of potentially useful future research on e-health. There were three main topics of interest: outcomes among patients with chronic health conditions, the cost-effectiveness of various e-health approaches, and the impact of e-health in low- and middle-income countries. Evidence collection We focused on evidence for the impact of e-health in three areas identified by prior reviews: (1) systems facilitating clinical practice; (2) institutional systems, and (3) systems facilitating care at a distance. (3,4) Systems facilitating clinical practice include electronic medical record systems, picture archiving and communication systems for managing digital medical images, and laboratory information systems that automate laboratory workflow and reporting. Institutional systems include systems for health information and management, early disease warning and disaster management. These systems aggregate data from health facilities and patients to create community-wide views of disease trends and clinical activity. (11,12) Systems facilitating care at a distance include the use of a short message service (SMS) or other text messaging to improve outcomes through patient reminders; between-visit monitoring and/or health education; videoconferencing facilities for live consultations and asynchronous communication between clinicians, and automated telephone calls with recorded messages (sometimes called interactive voice response calls). Multiple systematic reviews have been conducted on some of these e-health approaches, whereas the rest are barely covered in the peer-reviewed literature. To provide a rapid updated summary of the evidence for decision-makers, we conducted a scoping review by gathering information through targeted scans of scientific databases, reviews of reference lists and conversations with other experts. (13) Emphasis was given to projects that provided insights on the impact of e-health on the outcomes of chronic disease management and the scalability of e-health tools and/or data relevant to low- and middle-income countries. Throughout the review we highlight priorities for future research. Systems facilitating clinical practice Examples In developed countries, usage of electronic medical-record systems varies widely. For example, such systems are used for nearly all primary care patients in Denmark, the Netherlands, Sweden and the United Kingdom of Great Britain and Northern Ireland, but for less than 20% of such patients in the United States. (14,15) In low- and middle-income countries, electronic medical record systems, such as Dream, OpenMRS, Baobab Health (in Malawi) and the ZEPRS antenatal system (in Zambia), are available in some larger specialist hospitals but are rarely available in smaller health centres. …