MobileActive.org

Background

Population movements following disasters can cause important increases in morbidity and mortality. Without knowledge of the locations of affected people, relief assistance is compromised. No rapid and accurate method exists to track population movements after disasters. We used position data of subscriber identity module (SIM) cards from the largest mobile phone company in Haiti (Digicel) to estimate the magnitude and trends of population movements following the Haiti 2010 earthquake and cholera outbreak.

Methods and Findings

Geographic positions of SIM cards were determined by the location of the mobile phone tower through which each SIM card connects when calling. We followed daily positions of SIM cards 42 days before the earthquake and 158 days after. To exclude inactivated SIM cards, we included only the 1.9 million SIM cards that made at least one call both pre-earthquake and during the last month of study. In Port-au-Prince there were 3.2 persons per included SIM card. We used this ratio to extrapolate from the number of moving SIM cards to the number of moving persons. Cholera outbreak analyses covered 8 days and tracked 138,560 SIM cards.

An estimated 630,000 persons (197,484 Digicel SIM cards), present in Port-au-Prince on the day of the earthquake, had left 19 days post-earthquake. Estimated net outflow of people (outflow minus inflow) corresponded to 20% of the Port-au-Prince pre-earthquake population. Geographic distribution of population movements from Port-au-Prince corresponded well with results from a large retrospective, population-based UN survey. To demonstrate feasibility of rapid estimates and to identify areas at potentially increased risk of outbreaks, we produced reports on SIM card movements from a cholera outbreak area at its immediate onset and within 12 hours of receiving data.

Conclusions

Results suggest that estimates of population movements during disasters and outbreaks can be delivered rapidly and with potentially high validity in areas with high mobile phone use.
 

Objective: South Africa has one of the highest human immunodeficiency virus (HIV) prevalence rates in the world, but despite the well-established benefits of HIV counseling and testing (HCT), there is low uptake of HCT. The study aimed to investigate the effectiveness of using short message services (SMSs) to encourage HCT while interrogating the impact of altering SMS content and dosage (the number of SMSs).

Materials and Methods: About 2,533 participants were recruited via an SMS sent to 24,000 mobiles randomly sampled from a pre-existing database. Recruits were randomly allocated to four intervention groups that received 3 or 10 informational (INFO) or motivational (MOTI) SMSs, and a control group. After the intervention, participants were prompted to go for HCT, and postintervention assessment was done after 3 weeks.

Results: In comparison with the control, receipt of 10 MOTI messages had the most impact on uptake of HCT with a 1.7-fold increased odds of testing (confidence interval 95%; p=0.0036). The lack of efficacy of three SMSs indicates a threshold effect, that is, a minimum number of MOTI SMSs is required. INFO SMSs, whether 3 or 10 were sent, did not have a statistically significant effect. The cost can be calculated for the marginal effect of the SMSs, that is, the cost to get people to test over and above those who were likely to test without the intervention. Use of 10 MOTI SMSs yielded a cost-per-tester of $2.41.

Conclusions: While there are methodological issues apparent in our study, the results demonstrate the potential of SMSs to influence the uptake of HCT, the importance of appropriate content, and the need to determine a threshold for SMS-based interventions. These results indicate a potential for SMSs to be used more generally for interventions encouraging people to take health-related actions, and the need for further research in this field. The reasonable cost-per-tester is promising for the scale-up of such an intervention.

This paper examines the current use of ICTs to advance family planning, reproductive health, and other health programs, and identifies the enabling conditions for further scale-up. The examples of ICTs at work are structured around specific elements of success that were captured in the 2008 USAID-funded report, Elements of Success in Family Planning Programming: (1) building a high-performing, welltrained staff; (2) providing strong leadership; (3) communicating effectively; (4) basing decisions on evidence; and (5) assuring contraceptive security with a strong logistics system.

Examples of ICT are being applied to support or advance family planning and reproductive health programs in many African countries. Examples from Ethiopia, Kenya, Rwanda, Senegal, Tanzania, Malawi and Uganda are examined here, complemented by a review of efforts in Bangladesh and India as well as several virtual global programs. The paper also takes a look at how digital platforms and mobile technology are being integrated into the overall health systems strengthening approach. The collective review of these programs illustrates the myriad ways in which technology is adapted to respond to local needs as well as to support national health programs and global health initiatives.

Despite the strong promise demonstrated by mHealth tools and applications, the current landscape of mHealth development in developing country contexts is characterized by a proliferation of unsustainable pilot projects that often expire once initial funding is exhausted. For example, in Uganda alone there were 23 mHealth initiatives in 2008 and 2009 that did not scale up after the pilot phase. In India, there were over 30 mHealth initiatives in 2009 that did not go beyond the pilot phase.

Current policy environments, business models and funding schemes around mHealth have fueled the proliferation of pilot projects without enabling them to scale up in a meaningful, replicable way. An additional, and perhaps most significant, obstacle to improving and scaling the implementation of mHealth initiatives is the lack of monitoring and evaluation (M&E) and use of meaningful, consistent indicators and rigorous evaluation methods.

Given the obstacles within the current landscape, this white paper was commissioned by Advanced Development for Africa (ADA) to assess current implementations of successful mHealth programs in developing country contexts. The objective is to identify elements necessary for successfully scaling up, with the aim of highlighting best practices and specific programmatic, operational, policy and global strategy recommendations that can promote scale up of mHealth.

Profiled in this report are several select mHealth programs that have been piloted and are currently in the scale up phase, and have proven enough success that they should be considered as models for other initiatives to follow. As the following case studies will demonstrate, through more accurate and timely data, disease surveillance, decision support and health information management, mHealth can effectively inform policy-making and planning within healthcare systems and improve the health of local communities, particularly remote populations. The scale up of mHealth within national health agendas should be supported by all departments within the Ministry of Health and across other relevant ministries and agencies including Telecommunications. Both internal stakeholders, such as end-users and beneficiaries, and external stakeholders, such as mobile network operators and donors, should be engaged in the planning and business model design and scalability assessments. The primary goal of this white paper is to provide evidence and recommendations that will allow mHealth initiatives to better plan their own scale up beyond successful pilot phases.

Midwives in Ghana provide the majority of rural primary and maternal healthcare services, but have limited access to data for decision making and knowledge work. Few mobile health (mHealth) applications have been designed for midwives. The study's purpose was to design and test an mHealth application (mClinic) that can improve data access and reduce the reporting burden for midwives at the Millennium Villages Project site in Ghana.

From the design science field, the Information Systems Research Framework guided this study through two research cycles: 1) Relevance, and 2) Design. The first phase of the Relevance Cycle took a user-centered approach to assess the people, organizations, and technology of the midwives’ environment through participant observation, contextual inquiry, and interviews. In the second phase, structured requirements specification was used to categorize the data into goals, system qualities, and constraints. From the categorized data, use cases were developed for patient registration, antenatal care, malaria, family planning, and referrals. Use cases then informed the development of functional requirements. In the Design Cycle, we first used functional requirements for patient registration and malaria to develop the mClinic prototype as part of a coded-in-country initiative. Next, we examined usability of the mClinic prototype by conducting field testing, heuristic evaluation, and usability surveys. Additionally, low-fidelity prototyping was used to determine applicability of the other use cases to the midwives’ environment.

Midwives reported inability to access critical data, high patient loads, and extensive reporting requirements. Low technical self-efficacy and inadequate infrastructure were identified as barriers to implementation. Heuristic evaluation noted issues related to hardware selection, workflow, and security. Midwives ranked the tool as useful in the usability survey; however, ease-of-use rankings were neutral. Interviews indicated this was related to low technical self-efficacy. Applicability checks found support for touch-entry prototypes over those that included lengthy forms or text-entry.

For the first time the World Health Organization’s (WHO) Global Observatory for eHealth (GOe) has sought to determine the status of mHealth in Member States; its 2009 global survey contained a section specifically devoted to mHealth. Completed by 114 Member States, the survey documented for analysis four aspects of mHealth: adoption of initiatives, types of initiatives, status of evaluation, and barriers to implementation. Fourteen categories of mHealth services were surveyed: health call centres, emergency toll-free telephone services, managing emergencies and disasters, mobile telemedicine, appointment reminders, community mobilization and health promotion, treatment compliance, mobile patient records, information access, patient monitoring, health surveys and data collection, surveillance, health awareness raising, and decision support systems.

The survey shows there is a groundswell of activity.  The majority of Member States (83%) reported offering at least one type of mHealth service. However, many countries offered four to six programmes. The four most frequently reported mHealth initiatives were: health call centres (59%), emergency toll-free telephone services (55%), managing emergencies and disasters (54%), and mobile telemedicine (49%). With the exception of health call centres, emergency toll-free telephone services, and managing emergencies and disasters, approximately two thirds of mHealth programmes are in the pilot or informal stage.

The survey results highlight that the dominant form of mHealth today is characterized by small-scale pilot projects that address single issues in information sharing and access. There were only limited larger mHealth implementations (primarily supported by public-private partnerships). While it is anticipated that large-scale and complex programmes will become more common as mHealth matures, strategies and policies that integrate eHealth and mHealth interoperability into health services would be wise. mHealth is no different from other areas of eHealth in its need to adopt globally accepted standards and interoperable technologies, ideally using open architecture. The use of standardized information and communication technologies would enhance efficiency and reduce cost. To accomplish this, countries will need to collaborate in developing global best practices so that data can move more effectively between systems and applications. 

FrontlineSMS is a software platform that enables structured communication via text messaging, using only a computer and a mobile phone or GSM (Global System for Mobile) modem. The platform enables two-way messaging between users and groups of people via mobile networks without the need for an Internet connection.

The purpose of this guide is to provide FrontlineSMS users designing, implementing, and monitoring programs with data integrity concerns in mind with a data integrity framework. The guide is intended to help users to understand, analyze, and address the vulnerabilities, risks and threats that can affect the integrity of the information communicated through the FrontlineSMS platform.

Around the world, countless lives are lost due to insufficient access to quality health information. The availability of accurate, timely, and analyzed data is directly relevant to the quality of an individual’s health and the healthcare system in general, the delivery of individual care, and the understanding and management of overall health systems.

This discussion paper:

1) Examines the role ICTs, and mobile technology in particular, can play in improving access to quality health information, review the ecosystem of health information related to patients,

2) Traces the data throughout the continuum of care, examine health information flows from patients in villages to international health organizations and the most important steps in between,

3) Identifies common ground on which technologists and public health professionals can develop innovative strategies and tools to strengthen health care systems by supporting health data flows, working from the premise that better data collection will lead to better health policies and health outcomes,

4) Focuses on three healthcare domains – surveillance systems, supply chain, and human resources – and through the perspectives of experts in these domains, identify critical gaps in health information flows that technology-based solutions could address. In the case of each of these three domains, we use maternal health as an example to show how technology-backed interventions can improve health information flows,

5) Identifies barriers, choke points, and other inefficiencies to guide the discussion of how modern ICTs can improve health information flows and health outcomes in the developing world,

6) Provides recommendations for using modern ICTs to make health information flow more efficiently and perhaps even transform the process of care delivery itself.

The Vodafone Health Debate series is part of our continuing commitment to thought leadership in healthcare. It brings together senior pharma, public and private health stakeholders to learn, share and debate on issues and new thinking brought forward by renowned thought leaders and industry experts. Our aim is to provide some evidence- based stimulus that will encourage all those working in the different areas of healthcare to consider the innovation opportunities that are now available to them.

We believe that real progress can only be initiated when all stakeholders look beyond traditional horizons and share ideas that challenge the status quo so that together we can identify new ways of addressing current issues. Regulatory complexity, financial constraints, entrenched infrastructures and poor investment in technology combined with a lack of understanding by technology providers has meant that digital innovation in healthcare has been slow to take hold.

However, given changing healthcare needs of an increasingly aging population and the challenges presented by the current economic crisis, there is renewed interest in the potential of mHealth and Internet solutions to help reduce costs, increase efficiencies and effectiveness. This paper explores the practical reasons behind the slower than expected adoption of digital health technologies and discusses experiences from other sectors that could potentially help create wide scale adoption.

The GSM Association—the global trade association for mobile network operators—and its Development Fund believe that health hotlines can transform healthcare for poor people just as mobile phones are revolutionizing financial services (‘mobile money’). Health hotlines are simple to understand (“call a doctor”), provide immediate assistance, and are available to anyone with a mobile phone. The reach and branding of a mobile network operator (MNO), and the scalability of call center technology may mean that health hotlines serve vast numbers of people in the coming years.

As a first scan of the approach, this report tracks hotlines operating in developing countries, assesses their social and commercial success to date, and offers suggestions for governments, industry bodies and development agencies to advance this approach.

In the first section we define the health hotline model and present a brief landscape of health hotlines in operation today. Section 3 spotlights four of the most prominent health hotlines in developing countries, and compares their business approaches. In Section 4 we assess their commercial viability and potential for growth, and in Section 5 we evaluate their potential for social impact. Finally, Section 6 offers thoughts on how development agencies and governments can support the health hotline phenomenon.

This case study analyses the ways in which the Cell-Life initiative, a collaboration between UCT‘s (University of Cape Town) departments of Civil and Electrical Engineering and the Cape Peninsula University of Technology (CPUT), utilises technology-based solutions (in particular, cellphone technology) for the life management of patients living with HIV/AIDS.
 

Cell-Life is a model example of a socially responsive endeavor which utilizes technology to overcome limitations and constraints. The use of cellphones to save lives by aiding adherence to the ARV medication regime and gather data is a remarkable contribution to the fight against the HIV/AIDS pandemic and signifies an intersection between the academic endeavour, innovation and the lives of ordinary people on the ground. The open approach taken by the organisation in sharing its work also illustrates how research is able to contribute to the 'undead count' (i.e. the number of lives saved) of academic research, which must surely be considered the greatest achievement of any endeavor.

After extensive studies of BRAC’s health services for mothers, neonates and children in rural and urban areas (MNCH and Manoshi, respectively), ClickDiagnostics has developed a mobile phone-based solution for streamlining BRAC’s data collection procedures in Manoshi, enabling BRAC to take a more pro-active approach in strategizing and reaching the women most in need in the urban slums.

ClickDiagnostics is in the concluding stages of piloting thissolution jointly with BRAC, and after the completion of the project in January, will support BRAC in refining the model and scaling up for nationwide implementation in MNCH and Manoshi projects, and possibly also in BRAC Health’s other program.

One important reason why many pregnant mothers succumb to death or preventable miscarriages is that it is expensive for government or non-government health organizations to track pregnant mothers to assess their level of risk and prioritize its limited resources for targeted intervention. A model in which community health-workers use ICT to gather real-time information about pregnant women and send to a specialist can help to address this gap and help health organizations take precautionary measures about risky cases of pregnancies.

In this paper, we present D-tree International’s work with medical algorithms and mobile applications to improve the standards of care in clinical and community settings. In particular, we present a mobile phone-based application called CommCare which helps community health workers (CHWs) to provide home-based care and social support to HIV, tuberculosis and other chronic patients. The application guides the CHWs through a series of questions which they answer using the phone’s number pad. The data then can be submitted directly to a central database over a cellular GPRS network.

We report on our experience developing and testing the application in Tanzania, including the iterative development process with the CHWs and training them to use the program. We include an account of some of the hardware and software issues encountered and resolved during the process, and some initial reactions from the first CHWs and clients to use the program. While the formal evaluation of the program is still in progress, initial findings show that the phonebased system is generally viewed positively by the users and by the clients as more discreet and better for privacy than the paper-based system.