Male circumcision for HIV prevention in young men in Kisumu, Kenya : a randomised controlled trial. Commentary

Caroline Free and colleagues systematically review controlled trials of mobile technology interventions to improve health care delivery processes and show that current interventions give only modest benefits and that high-quality trials measuring clinical outcomes are needed.

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The effectiveness of mobile-health technologies to improve health care service delivery processes: a systematic review and meta-analysis.

Mark Tomlinson and colleagues question whether there is sufficient evidence on implementation and effectiveness to match the wide enthusiasm for mHealth interventions, and propose a global strategy to determine needed evidence to support mHealth scale-up.

https://scholar.sun.ac.za/bitstream/handle/10019.1/79633/tomlinson_scaling_2013.pdf;sequence=1

Scaling up mHealth: where is the evidence?

Background: Mobile health (mHealth) describes the use of portable electronic devices with software applications to provide health services and manage patient information. With approximately 5 billion mobile phone users globally, opportunities for mobile technologies to play a formal role in health services, particularly in low- and middle-income countries, are increasingly being recognized. mHealth can also support the performance of health care workers by the dissemination of clinical updates, learning materials, and reminders, particularly in underserved rural locations in low- and middle-income countries where community health workers deliver integrated community case management to children sick with diarrhea, pneumonia, and malaria. Objective: Our aim was to conduct a thematic review of how mHealth projects have approached the intersection of cellular technology and public health in low- and middle-income countries and identify the promising practices and experiences learned, as well as novel and innovative approaches of how mHealth can support community health workers. Methods: In this review, 6 themes of mHealth initiatives were examined using information from peer-reviewed journals, websites, and key reports. Primary mHealth technologies reviewed included mobile phones, personal digital assistants (PDAs) and smartphones, patient monitoring devices, and mobile telemedicine devices. We examined how these tools could be used for education and awareness, data access, and for strengthening health information systems. We also considered how mHealth may support patient monitoring, clinical decision making, and tracking of drugs and supplies. Lessons from mHealth trials and studies were summarized, focusing on low- and middle-income countries and community health workers. Results: The review revealed that there are very few formal outcome evaluations of mHealth in low-income countries. Although there is vast documentation of project process evaluations, there are few studies demonstrating an impact on clinical outcomes. There is also a lack of mHealth applications and services operating at scale in low- and middle-income countries. The most commonly documented use of mHealth was 1-way text-message and phone reminders to encourage follow-up appointments, healthy behaviors, and data gathering. Innovative mHealth applications for community health workers include the use of mobile phones as job aides, clinical decision support tools, and for data submission and instant feedback on performance. Conclusions: With partnerships forming between governments, technologists, non-governmental organizations, academia, and industry, there is great potential to improve health services delivery by using mHealth in low- and middle-income countries. As with many other health improvement projects, a key challenge is moving mHealth approaches from pilot projects to national scalable programs while properly engaging health workers and communities in the process. By harnessing the increasing presence of mobile phones among diverse populations, there is promising evidence to suggest that mHealth can be used to deliver increased and enhanced health care services to individuals and communities, while helping to strengthen health systems. [J Med Internet Res 2013;15(1):e17]

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Mobile Health (mHealth) Approaches and Lessons for Increased Performance and Retention of Community Health Workers in Low- and Middle-Income Countries: A Review

Access to mobile phone technology has rapidly expanded in developing countries. In Africa, mHealth is a relatively new concept and questions arise regarding reliability of the technology used for health outcomes. This review documents strengths, weaknesses, opportunities, and threats (SWOT) of mHealth projects in Africa. A systematic review of peer-reviewed literature on mHealth projects in Africa, between 2003 and 2013, was carried out using PubMed and OvidSP. Data was synthesized using a SWOT analysis methodology. Results were grouped to assess specific aspects of project implementation in terms of sustainability and mid/long-term results, integration to the health system, management process, scale-up and replication, and legal issues, regulations and standards. Forty-four studies on mHealth projects in Africa were included and classified as: “patient follow-up and medication adherence” (n = 19), “staff training, support and motivation” (n = 2), “staff evaluation, monitoring and guidelines compliance” (n = 4), “drug supply-chain and stock management” (n = 2), “patient education and awareness” (n = 1), “disease surveillance and intervention monitoring” (n = 4), “data collection/transfer and reporting” (n = 10) and “overview of mHealth projects” (n = 2). In general, mHealth projects demonstrate positive health-related outcomes and their success is based on the accessibility, acceptance and low-cost of the technology, effective adaptation to local contexts, strong stakeholder collaboration, and government involvement. Threats such as dependency on funding, unclear healthcare system responsibilities, unreliable infrastructure and lack of evidence on cost-effectiveness challenge their implementation. mHealth projects can potentially be scaled-up to help tackle problems faced by healthcare systems like poor management of drug stocks, weak surveillance and reporting systems or lack of resources. mHealth in Africa is an innovative approach to delivering health services. In this fast-growing technological field, research opportunities include assessing implications of scaling-up mHealth projects, evaluating cost-effectiveness and impacts on the overall health system.

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Systematic review on what works, what does not work and why of implementation of mobile health (mHealth) projects in Africa

There is growing momentum and enthusiasm to capitalize on the rapid spread of telecommunications infrastructure and uptake of mobile phones and mobile broadband services in low and middle income countries to support the achievement of global, national, district, community, and individual level health priorities. Still in its infancy, mHealth, the use of mobile technologies for health, runs the risk of not realizing its full potential due to small‐scale implementations and pilot projects with limited reach. To help shed light on these issues, the mHealth Alliance commissioned an in‐depth exploration of the policy barriers and research gaps facing mHealth. This White Paper, written by a team of researchers at the Center for Global Health and Economic Development at the Earth Institute, Columbia University, examines and synthesizes the existing mHealth literature to assess the current state of mHealth knowledge and identify barriers and gaps.

Barriers and Gaps Affecting mHealth in Low and Middle Income Countries: Policy White Paper

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:

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The Case for mHealth in Developing Countries

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.

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

E-health encompasses a diverse set of informatics tools that have been designed to improve public health and health care. Little information is available on the impacts of e-health programmes, particularly in low- and middle-income countries. We therefore conducted a scoping review of the published and non-published literature to identify data on the effects of e-health on health outcomes and costs. The emphasis was on the identification of unanswered questions for future research, particularly on topics relevant to low- and middle-income countries. Although e-health tools supporting clinical practice have growing penetration globally, there is more evidence of benefits for tools that support clinical decisions and laboratory information systems than for those that support picture archiving and communication systems. Community information systems for disease surveillance have been implemented successfully in several low- and middle-income countries. Although information on outcomes is generally lacking, a large project in Brazil has documented notable impacts on health-system efficiency. Meta-analyses and rigorous trials have documented the benefits of text messaging for improving outcomes such as patients' self-care. Automated telephone monitoring and self-care support calls have been shown to improve some outcomes of chronic disease management, such as glycaemia and blood pressure control, in low- and middle-income countries. Although large programmes for e-health implementation and research are being conducted in many low- and middle-income countries, more information on the impacts of e-health on outcomes and costs in these settings is still needed.

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

Partnerships among health care and information technology researchers and designers worldwide are creating mobile health tools tailored to local community needs and resources. Much of the hardware and infrastructure comes from developed countries of the so-called global North. From both these countries as well as developing countries in the global “South” are coming applications that enable health workers to collect and organize data, access diagnostic and treatment support, and promote healthy behavior. Most are still in pilots or demonstration phases, but their use is accelerating.

Patricia Mechael

Papers

Barriers and Gaps Affecting mHealth in Low and Middle Income Countries: Policy White Paper

The Case for mHealth in Developing Countries

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

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

Enhancing ‘M-Health’ With South-To-South Collaborations