New technologies, old diseases
May 14th, 2013
The global health community has been quick to recognize the potential of new technologies to improve health care around the world. One such technology that is widely used in such settings is the mobile telephone. Short message service (SMS) through mobile phones is considered a potentially suitable means of improving patient care because it is inexpensive and easy to use.
SMS is currently being utilized in 2 END in Africa countries (Sierra Leone and Ghana) for the control of neglected tropical diseases (NTDs). Sierra Leone health officials are using SMS for social mobilization during mass drug administration campaigns. In Ghana, the national NTD control program, with support from Catholic Relief Services, is developing an SMS system for improving communication between the central level and field officers and volunteers at the regional, district and community levels. However, since SMS is not universally available to all residents in these countries, there may also be disadvantages to its use for NTD control programs. SMS usage for such programs needs to be evaluated in both countries to determine its impact on NTD control and to identify areas needing adjustments in order to improve the technology’s impact on program performance.
USING SHORT MESSAGE SERVICE (SMS) FOR NEGLECTED TROPICAL DISEASE CONTROL IN END IN AFRICA COUNTRIES
Nana Kwadwo Biritwum1, Santigie Sesay2, Joseph B. Koroma3*, Bolivar Pou4, Katherine Sanchez4, Mary H. Hodges5, Mustapha Sonnie5, John K. Marfoh6
The global health community has been quick to recognize the potential of new technologies to improve health care around the world. In fact, the World Health Organization (WHO) has included the use of new technologies to support health care delivery in resource-limited settings among its priorities.
One example of a technology that has been widely used in resource-limited settings is the mobile telephone. More reliable and less difficult to use than landlines, mobile phones have become increasingly popular in developing countries in recent years, with Africa leading the way as the region with the highest mobile phone growth rate in the world (1,2,3). Over 60% of the population uses mobile phones in Kenya (4); and in Cameroon, mobile phone subscriptions increased by 270% per annum between 2000 and 2005. By 2008, some 37% of adults owned mobile phones in that country. However, while research shows that a large and growing proportion of African adults now own and use mobile phones in their personal lives and in business transactions, the data suggest that the growth in mobile phone usage is not uniform and that ownership seems to be more common in urban areas (1,4). As the global health community begins utilizing this technology to provide health services, it needs to monitor the effects of using mobile phone applications on health outcomes in African countries. In particular, it is important to gauge the impact of mobile application usage on health service delivery in rural areas and in the least developed countries, where mobile phone service is not yet wide-spread (1,2,3).
Short message service (SMS) or text messaging is an emerging mobile phone technology that is already being used for health care delivery in Africa (5) due to its low cost, flexibility and ease of use. It allows healthcare professionals to deliver customized, non-invasive messages to patients quickly and efficiently (6). In South Africa, health personnel send SMS messages to caregivers and patients with human immunodeficiency virus (HIV) to remind them about appointments. Koshy et al. (5) describe a study in the UK that tested the effectiveness of SMS appointment reminders to decrease non-attendance and improve efficiency of outpatient health care delivery. That study found that the use of SMS reminders for ophthalmology outpatient appointments was associated with a significant reduction in the likelihood of patients missing their appointments, compared to no appointment reminder. Downer et al. (6) evaluated the effect of using appointment reminders sent as SMS text messages to patients’ mobile telephones on attendance at outpatient clinics in Australia. They observed a reduction in the no-show rate similar to that found using traditional reminder methods. In addition, they reported that forgetting about appointments is the main reason why patients fail to keep their appointments; and that using SMS significantly reduced missed appointments at outpatient clinics. Such research suggests that SMS appointment reminders offer a more cost-effective and time-efficient means of decreasing non-attendance and improving efficiency in outpatient healthcare delivery, as they require less labour than traditional appointment reminders (5).
Beyond their basic usage as appointment reminders, researchers are also continuing to investigate the potential of SMS applications for improving health care delivery and health outcomes in resource-limited settings (1,2,3). For example in Kenya, clinical trials to evaluate the effectiveness of using mobile phone text messages to remind patients to take their medications have shown improvements in patient adherence to antiretroviral therapy (ART) and reductions in viral load and treatment interruptions (1). Lester et al. (4) describe a study assessing the effectiveness of SMS in improving indicators for adherence, quality of life, retention, and mortality, compared to standard care in a population receiving ART in Nairobi, Kenya. The authors reported significant improvements in all these parameters with the use of SMS reminders. Mbuagbaw et al. (1,2,3) describe a trial at a clinic in Yaoundé, Cameroon, that showed that sending patients weekly reminders and motivational text messages significantly improved their adherence to Highly Active Antiretroviral Treatment. Poor adherence has been linked with poor virological and immunological response and is also responsible for the development of drug-resistant strains of HIV. High acceptance of SMS messages and their reported utility as a tool for providing support and motivation to help people living with HIV adhere to treatment and overcome treatment-related difficulties, have led some authors to suggest that structured mobile phones communications may significantly improve clinical management of patients with HIV in resource-limited settings (4). However, it is worth noting that the authors also recommend that further research be undertaken to determine how to best use the technology as well as adapt it to suit individual needs. Issues such as the possibility of inadvertent disclosure of disease status, loss of privacy, and technical difficulties have to be addressed before text messages can be used on a large scale for people living with HIV and other diseases (1,2,3).
Beyond improving communication between patients and healthcare providers, SMS may also have potential as a tool for improving operational efficiencies in health service delivery. Barrington et al. (7) documented how three districts in rural Tanzania used SMS to improve management of anti-malarial drugs and other medicines, and successfully stop medicine stock-outs. Health officials at the central level used SMS to improve coordination with rural health facilities, which enabled them to ensure that anti-malarials and other medicines were always available. Such findings suggest that SMS may be useful for facilitating two-way communication and collaboration across agencies and among the various levels of healthcare within African countries.
National Neglected Tropical Disease Control Programs (NTDCP) in several END in Africa countries–notably Sierra Leone and Ghana—have also begun to use SMS to improve program operations and outcomes. Sierra Leone’s NTDCP is using SMS for social mobilization during mass drug administration (MDA) campaigns. In addition to other social mobilization activities, such as community meetings at the chiefdom and village levels, radio/television discussions, airing of jingles, and announcement in newspapers, SMS messages were sent to all residents living in districts targeted for NTD treatment to remind them to take the drugs. In addition, during radio and television discussions about NTDs, the audiences and people at home are asked to send their questions, concerns and comments to the radio/television stations via SMS so that they can be addressed.
Ghana’s national NTDCP is also beginning to devise creative SMS applications with potential for improving the country’s NTD control efforts. Catholic Relief Services has supported Ghana’s national NTDCP in developing an SMS system to improve communication among health officials at the central and field levels, and volunteers at the regional, district and community levels. The national NTDCP set up a system that uses a database of health workers, teachers and volunteers at regional, district and community levels as a platform through which both central- and field-level program officials as well as collaborators in the regions and districts can send messages and receive feedback. The system allows field officers and volunteers at the regional, district and community levels to use SMS to report preliminary MDA data. It also lets the central level issue alerts, update collaborators at various levels on impending NTD activities, and send feedback on reports received. This system was established and piloted during the October 2012 school-based MDA. The NTDCP intends to use lessons learnt to improve and up-scale its usage during future NTD activities (8).
Although SMS appears to have substantial potential for improving healthcare in resource-limited settings, there may also be disadvantages to its use as a means of communicating with patients in African countries. For example, those who do not have mobile phones may be left out of any health project that uses SMS, which is concerning considering that the proportion of people with mobile phones in African countries is still comparatively low (6). This is particularly true in rural areas of Africa, where the proportion of people who own mobile phones may be very low (1,4), in part because mobile phone service is not always available in every rural or remote community. It will also be important to address issues involving data security and patient privacy, as suggested by the authors of studies involving SMS use for healthcare service provision to HIV patients.
While SMS may appear to be an ideal solution for managing many of the challenges facing national NTDCPs and other health programs working in resource-limited settings, there are still some concerns around the prospect of adopting it as a main means of communication for NTDCPs, suggesting the need to proceed with caution. NTDCPs should carefully plan and test new technologies such as SMS on a pilot basis in a variety of localized settings prior to adopting them nation-wide. Traditional methods of conducting business should remain available while such tests are taking place to ensure that patients who lack access to the new technologies are not precluded from receiving health services. Furthermore, programs should carefully document and assess the impact of using new technologies throughout the test period; and they should develop and implement a plan to address any issues that arise (such as those mentioned previously for SMS) and to use lessons learned to improve health service delivery and outcomes prior to adopting new technologies program-wide. Finally, they should periodically evaluate the impact of SMS and other new technologies on NTD control, both to monitor and resolve any potential issues that arise from their use as well as to ensure that they deliver the expected results.
In the case of the use of SMS in the END in Africa countries, several studies should be conducted to assess effectiveness and impact on NTD control. First, a study should be conducted in Sierra Leone to determine if the use of SMS increases compliance with NTD treatments. Second, Ghana’s new SMS platform for data reporting and multi-level communication and collaboration should be evaluated and its effectiveness should be assessed. Given the nature of NTD control efforts, which demand full participation and treatment of every eligible resident in each targeted community during MDA campaigns, NTDCP managers cannot afford to risk missing people who have not yet started using the latest technologies. As such, although NTDCP and other health program managers may be tempted to embrace new technologies that appear to offer cost and operational efficiencies, they would be wise to take a measured approach to change, involving careful planning, testing, evaluation and fine-tuning prior to full-scale implementation of any new technology into mainstream health program operations. Only then can they be sure that the new technology will be effective in helping eliminate NTDs in their countries.
- Mbuagbaw L, Thabane L, Ongolo-Zogo P, Lester RT, Mills E, Volmink J et al. (2011) The Cameroon mobile phone SMS (CAMPS) trial: a protocol for a randomized controlled trial of mobile phone text messaging versus usual care for improving adherence to highly active anti-retroviral therapy. Trials, 12:5. http://www.trialsjournal.com/content/12/1/5.
- Mbuagbaw L, Bonono-Momnougui RC and Thabane L (2012) Considerations in using text messages to improve adherence to highly active antiretroviral therapy: a qualitative study among clients in Yaoundé, Cameroon. HIV/AIDS – Research and Palliative Care 4: 45–50.
- Mbuagbaw L, Thabane L, Ongolo-Zogo P, Lester RT, Mills EJ, Smieja M, Dolovich L, Kouanfack C (2012) The Cameroon Mobile Phone SMS (CAMPS) Trial: A Randomized Trial of Text Messaging versus Usual Care for Adherence to Antiretroviral Therapy. PLoS ONE 7(12): e46909. doi:10.1371/journal.pone.0046909.
- Lester RT, Mills EJ, Kariri A, Ritvo P, Chung M, Jack W et al. (2009) The HAART cell phone adherence trial (WelTel Kenya1): a randomized controlled trial protocol. Trials 10:87. Http://www.trialsjournal.com/content/10/1/87.
- Koshy E, Car J and Majeed A (2008) Effectiveness of mobile-phone short message service (SMS) reminders for ophthalmology outpatient appointments: Observational study. BMC Ophthalmology, 8:9 BMC Ophthalmology, 8:9. Http://www.biomedcentral.com/1471-2415/8/9.
- Downer SR, Meara JG and Da Costa AC (2005) Use of SMS text messaging to improve outpatient attendance. MJA 183 (7): 366-368.
- Barrington J, Wereko-Brobby O, Ward P, Mwafongo W, Kungulwe S (2010) SMS for Life: a pilot project to improve anti-malarial drug supply management in rural Tanzania using standard technology. Malaria Journal 9:298.
- FHI360 (2012) End Neglected Tropical Diseases in Africa (END in Africa) Annual Work Plan Oct. 2012 – Sept. 2013.
- National Neglected Tropical Diseases Control Programme (NTDCP), Ghana Health Services (GHS), Accra, Ghana
- National NTDCP, Ministry of Health and Sanitation, Freetown, Sierra Leone
- Family Health International 360 (FHI360), END in Africa Project, Ghana Country Office, Accra, Ghana
- FHI360, END Project, Washington DC, USA
- Helen Keller International (HKI), PO Box 369, Freetown, Sierra Leone
- Catholic Relief Services (CRS), Ghana Program, 16th Labone Crescent, P.O.Box AN 6333,Accra-North, Ghana