MobileActive.org

It is believed that once groups acquire information and communication technologies (ICTs), they will prosper. When the most marginalized members of society have better access to information and knowledge, the likelihood of improving their livelihoods also increases. Past literature has dealt with the difficulties that such groups have had in accessing and acquiring technology because of institutional obstacles. This thesis examines the institutional obstacles and constraints faced by groups once they have
acquired ICTs.

I intend to examine why, despite the rapid diffusion of ICTs in developing countries over the past decade, there has not been a dramatic improvement in the alleviation of poverty. In particular, this thesis will explore the use of mobile phones in the context of development and poverty reduction in Sub-Saharan Africa and the relationship between institutions and local stakeholders to strengthen livelihoods.

This thesis hypothesizes that development initiatives using a collaborative, hybrid approach that integrates effective institutional involvement with inclusive grassroots participation will be more sustainable and scalable than those that attempt solely topdown or bottom-up approaches. In other words, initiatives devised by institutions that rely upon structures incorporating local communities into projects will be found to be more successful in both the short-term and long-run. Case studies have been selected to illustrate how this hybrid approach is ultimately more successful in improving the livelihoods of the rural poor than approaches that are either primarily driven by the topdown or bottom-up.

The four cases considered in this thesis will describe the extent to which projects or initiatives using mobile phones have been successful in meeting the needs of local beneficiaries and improving their livelihoods.

This paper presents a case study of the efficiency gains resulting from the introduction of electronic technologies to monitor and support adherence to highly active antiretroviral therapy (HAART) in Guguletu, South Africa. It suggests that the rollout of HAART to such resource-poor communities can be assisted significantly by the introduction of modified cellphones (to provide home based support to people on HAART and improve the management of adherence data) and simple barcoding and scanning equipment (to manage drug supplies). The cellphones have improved the management of information, and simplified the working lives of therapeutic counsellors, thereby enabling them to spend less time on administration and to devote a constant amount of time per
patient even though their case loads have risen threefold. It has helped integrate the local-level
primary health service provision of HAART with the kind of centralised data capture and analysis
that could potentially support a national HAART rollout.

Handheld computers have untapped potential to improve HIV/AIDS programs in sub-Saharan Africa, particularly in the collection of survey data. We conducted an experiment in three neighborhoods of Luanda, Angola to assess the impact of the technology on people’s comfort and willingness to disclose sensitive personal information, such as sexual behavior.

Participants were asked about their HIV/AIDSrelated knowledge, attitudes, and practices by local interviewers using either handheld computers or paper surveys. T-tests showed no differences between participants’ self-reported comfort across handheld and paper conditions. However, participants in the handheld condition were more likely to give socially desirable responses to the sexual behavior questions than participants in the paper condition. These results suggest that using handheld computers in data collection in sub-Saharan Africa may lead to biased reports of HIV/AIDS-related risk behaviors.

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, evaluate the impact of mHealth implementations in LMICs and to examine programming, policy and research-related barriers to and gaps in mHealth scale and sustainability.

The paper is divided into two main sections. The first section reviews and summarizes the peer-reviewed literature on mHealth initiatives (focus on LMICS) to highlight trends and challenges. The second section examines the existing mHealth policy environment, barriers and gaps, and key drivers needed for an enabling policy environment.

The major thematic areas include:

• Treatment Compliance
• Data Collection and Disease Surveillance
• Health Information Systems and Point of Care Support
• Health Promotion and Disease Prevention
• Emergency Medical Response

The review identified significant gaps in mHealth knowledge stemming from the limited scale and scope of mHealth implementation and evaluation, a policy environment that does not link health objectives and related metrics to available mHealth tools and systems, and little investment in cost-benefit studies to assess mHealth value and health outcomes research to assess success factors and weed out poor investments.

A PDA-based program for data collection was developed using Open-Source tools. In two cross-sectional studies, we compared data concerning sexual behavior collected with paper forms to data collected with PDA-based forms in Ancon (Lima).

The first study enrolled 200 participants (18–29 years). General agreement between data collected with paper format and handheld computers was 86%. Categorical variables agreement was between 70.5% and 98.5% while numeric variables agreement was between 57.1% and 79.8%. Agreement and correlation were higher in those who had completed at least high school than those with less education.

The second study enrolled 198 participants. Rates of responses to sensitive questions were similar between both kinds of questionnaires. However, the number of inconsistencies (p = 0.0001) and missing values (p = 0.001) were significantly higher in paper questionnaires.

This study showed the value of the use of handheld computers for collecting sensitive data, since a high level of agreement between paper and PDA responses was reached. In addition, a lower number of inconsistencies and missing values were found with the PDA-based system. This study has demonstrated that it is feasible to develop a low-cost application for handheld computers, and that PDAs are feasible alternatives for collecting field data in a developing country.

Providing health information to low health literate audiences remains a challenge. Beyond message design, realistic delivery models are needed for delivering information to a traditionally hard-to-reach audience. This study investigated two e-health interventions to provide health information on mobile devices – one providing diabetes information and one offering childcare information. Both were well-received, and most of the subjects’ usability issues related to the translation of these interventions to the mobile device’s smaller screen. The diabetes website was effective in providing information to study participants (as measured by pre- and post-tests of knowledge), while the childcare website was not. Continued work in this area could explore improved design strategies for mobile devices – a delivery model that could be used in doctors’ offices, for example. Effective delivery of health information to low health literate audiences is an important issue, and this research highlights a critical element by targeting another potential delivery model.

Background: Survey data are traditionally collected using pen-and-paper, with double data entry, comparison of entries and reconciliation of discrepancies before data cleaning can commence. We used Personal Digital Assistants (PDAs) for data entry at the point of collection, to save time and enhance the quality of data in a survey of over 21,000 scattered rural households in southern Tanzania.

Methods: Pendragon Forms 4.0 software was used to develop a modular questionnaire designed to record information on household residents, birth histories, child health and health-seeking behaviour. The questionnaire was loaded onto Palm m130 PDAs with 8 Mb RAM. One hundred and twenty interviewers, the vast majority with no more than four years of secondary education and very few with any prior computer experience, were trained to interview using the PDAs. Logical checks were performed and skip patterns taken care of at the time of data entry. Data records could not be edited after leaving each household, to ensure the integrity of the data from each interview. A small group of interviewees from the community, as well as supervisors and interviewers, were asked about their attitudes to the use of PDAs.

Results: Following two weeks of training and piloting, data were collected from 21,600 households (83,346 individuals) over a seven-week period in July-August 2004. No PDA-related problems or data loss were encountered. Fieldwork ended on 26 August 2004, the full dataset was available on a CD within 24 hours and the results of initial analyses were presented to district authorities on 28 August. Data completeness was over 99%. The PDAs were well accepted by both interviewees and interviewers.

Conclusion: The use of PDAs eliminated the usual time-consuming and error-prone process of data entry and validation. PDAs are a promising tool for field research in Africa.

Results of proof-of-concept testing for an mHealth solution for reproductive health in Uttar Pradesh, India. The text messaging tool based on FrontlineSMS, is a family planning service that relies on the Standard Day Method system of birth control. This method of birth control depends on the woman's fertility cycles to avoid pregnancy. Women can text the date of their menses and user receives their fertility status. Additionally, women can receive information about other family planning options, and support. Presented are observations on the appropriatenss of the technology from focus group discussions. The authors share the input given by target users in the product and service design. Women tested the solution to give insight on feasibility and design.

This paper provides an overview of the implications of this trend for the delivery of healthcare services and population health. In addition to addressing how mobile phones are changing the way health professionals communicate with their patients, a summary is provided of current and projected technologic capabilities of mobile phones that have the potential to render them an increasingly indispensable personal health device. Finally, the health risks of mobile phone use are addressed, as are several unresolved technical and policy-related issues unique to mobile phones. Because these issues may influence how well and how quickly mobile phones are integrated into health care, and how well they serve the needs of the entire population, they deserve the attention of both the healthcare and public health community.

Background: There is a recognised problem with drug taking in South Africa. In socially deprived areas immediate help for drug users and their families is a problem. As part of their work in a community in tension, Impact Direct Ministries (IDM) and Reconstructed Living Lab (RLabs) in Cape Town provide a drug advisory service using mobile phone technology that can support multiple conversations. It is staffed by trained volunteers and is available to drug users and their families.

Methods: This article investigates historical counselling help for drug users. It explains the importance of family involvement in the life-changing process of a drug user and the importance of co-operative counselling. The Drug Advice Support (DAS) service provided by IDM and RLabs is introduced as a case study to explore how mobile phone technology can support the co-operative counselling model in a Living Lab context.

Results: The advantages of the DAS technology and what it offers to community-based organisations are discussed. Data on relatives of drug users using the system are included.

Conclusion: The use of mobile phone technology has advantages for community-based organisations acting as a first point of contact to drug users and their families. Minimal cost to the person in crisis and the organisation serves as an example. The co-operative counselling model it employs is also of benefit. As the community experiencing tension due to the problem of drug abuse becomes aware of this service, help and support for family members will increase in time.

The aim of this paper is to encourage reflection and discussion around the
potential of mHealth in developing countries and to consider how early experiences
can inform the way forward. Toward this aim, I synthesize many reviews and
presentations from the eight years I have been studying the evolution of mobile
phones and health in developing countries. I include observations and discussions
that are now shaping the creation of mHealth as a field, to highlight the ingredients
we need to move from a series of pilot projects and isolated business opportunities
to a full-scale maximization of health-related benefits.

I begin by reviewing the strategic priorities within global health, where mobile
telephony can have the greatest impact, along with organic health-related uses of
mobile phones, and examples of formal mHealth interventions. I then demonstrate
the potential for mobile phones to become an extension and an integral
component of eHealth, describing how information and communication technology
(ICT) can be used in health care, as well as mHealth, as a subset of mServices:
using mobile devices to deliver services such as banking and health. I also show
how trends and interests are converging among key stakeholders within the
mHealth ecosystem, thus forming a foundation on which we can scale up and sustain
more and better mHealth activities. Finally, I present some tactical guidance
for a way forward that will further the objectives of both public health and business,
particularly in outreach efforts to emerging markets, the bottom of the pyramid,
and the next billion mobile phone subscribers.

Mobile phone text messaging is a potentially powerful tool for behavior change because it is widely available, inexpensive, and instant.

This systematic review provides an overview of behavior change interventions for disease management and prevention delivered through text messaging. Evidence on behavior change and clinical outcomes was compiled from randomized or quasi-experimental controlled trials of text message interventions published in peer-reviewed journals by June 2009. Only those interventions using text message as the primary mode of communication were included. Study quality was assessed by using a standardized measure. Seventeen articles representing 12 studies (5 disease prevention and 7 disease management) were included. Intervention length ranged from 3 months to 12 months, none had long-term follow-up, and message frequency varied.

Of 9 sufficiently powered studies, 8 found evidence to support text messaging as a tool for behavior change. Effects exist across age, minority status, and nationality. Nine countries are represented in this review, but it is problematic that only one is a developing country, given potential benefits of such a widely accessible, relatively inexpensive tool for health behavior change.

Methodological issues and gaps in the literature are highlighted, and recommendations for future studies are provided.