M-HEALTH

The World Health Organization (WHO) has defined mHealth as the use of mobile and wireless
technologies to support the achievement of health objectives.

The word “support” in this definition is key, because mHealth is most appropriately understood as
a tool for promoting healthy behaviors and strengthening health systems.

Examples of mHealth include:

 A citizen uses a free text-message service to obtain information about family planning
methods.
 A community health worker consults a maternal and child health job aid on a mobile
phone to guide her as she counsels a client.
 Health facility staff use their personal mobile phones to receive and send messages
containing supply chain information for 20 essential medicines.
 

mHealth solutions are being used to support a range of health programs, including:

 Family planning
 Maternal and child health 
 HIV/AIDS 
 Malaria
 Tuberculosis
 

mHealth solutions also support cross-cutting health system functions, for example, by helping
to reduce stock-outs of medicines and commodities and by improving health workers' adherence to
treatment guidelines.

 mHealth's Potential Benefits

Results to date indicate that mHealth solutions have the potential to help improve access to health
information and services for underserved populations, generate cost efficiencies and improve the
capacity of health systems to provide quality health services.

Because of these potential benefits, many countries are embracing mHealth as a complementary
strategy for strengthening health systems and achieving their Millennium Development Goals for
health.

For an informative introduction to the practice of mHealth, please see this short, animated
video narrated by Patty Mechael, Executive Director of the mHealth Alliance. 
 mHealth, eHealth and information and communication technology (ICT)

How are the fields of mHealth, eHealth and information and communication technology
(ICT) related?
People often confuse these three fields. Let's begin by defining ICT.

ICT: Tools that facilitate communication and the collection, storage, processing and transmission of
information and the sharing of knowledge by electronic means.

Information and communication technologies include the Internet, computers, servers,

teleconference systems, radios, televisions, landline telephones, telemedicine devices, mobile
telephones and other wireless devices.

Both mHealth and eHealth involve the application of ICTs to support health and health-related

activities.

mHealth is the use of mobile and wireless ICTs for health, including mobile phones, tablets and
other mobile devices, but not laptops or servers.

eHealth is the application of ICTs for health, including laptop and desktop computers and servers,
television and radio, teleconferencing systems, and all of the devices used in mHealth.

In other words, mHealth is a subset of the field of eHealth, as illustrated below.

Mobile Technology in mHealth

At the center of mHealth practice are, of course, mobile phones and other wireless technologies.
These include basic phones, feature phones, smartphones and tablets, as well as remote
sensors and wireless-enabled diagnostic devices. Each of these offers different features that
may be used in mHealth. 

Common Mobile Phone and Tablet Features

Below are the features commonly available on different types of mobile devices. mHealth solutions
may make use a number of these features.

To familiarize yourself with new terms introduced here, please click on highlighted terms or review
the Glossary located in the pop-out menu to the right, under the 'G' tab.

 Basic phone:
Features:

 Voice calls and voice mail

 SMS
 USSD
 SMS- or USSD-based services (mobile money, instant messaging)
  Feature phone:

As basic mobile phone, plus:

 MMS
 Still picture camera 
 Music player
 2.5G data access
 GPS (Global Positioning System) (Most phones)
 Java-enabled
 Removable memory card (Some phones)
 Ability to install and use applications (Some phones)
 Web browser, limited features (Some phones)
  

Smartphone:
As feature phone, plus:

 Video camera
 Web browser
 GPS
 Internet access (3G, 4G)
 Mobile operating platform (Android, iOS, Blackberry)
 Ability to install and use applications
 VoIP
 Removable memory card
 Video calls (some phones)
 Touchscreen with virtual or physical keyboard

Tablet:
Features:

 Video and still-picture cameras

 Web browser
 GPS
 Internet access
 Ability to download and use applications
 VoIP
 Large screen size and memory
 Faster processor, enabling video playback
 Touchscreen with virtual keyboard

The Power of a Basic Mobile Phone

mHealth solutions often make very effective use of basic voice and text features. Though simple,
these can be powerful tools for health. 

Mobile for Reproductive Health, or m4RH, is a free text message service that provides information
about family planning methods and can be used on a simple mobile phone. Users request the
service, or “opt-in,” by sending the text “m4RH” to a toll-free, four-digit number, or short code. A user
then receives a menu-based message as shown in the phone image at right.

To request information about a particular method, the user texts the two-digit code shown in the
menu (such as, "21" for IUD). The user then receives a text message with information on the
method’s effectiveness, how long it works or how often it is used, any side effects, and return to
fertility after stopping. Here is an m4RH message on progestin-only injectables:

Injection in arm or hip, like Depo. Effective for 1-3 months. Get on time, return even if late.
Irregular or no monthly bleeding not harmful. May gain weight. For married and singles. After
stopping may take a few months to get pregnant. No infertility or pregnancy loss. Private.

What Is mHealth Knowledge Recap

Now that you’ve completed this session, test your knowledge on this subject. Taking this quiz will
reinforce key points and identify gaps in learning.

After taking the Knowledge Recap, you’ll get to review the correct answers, and in some cases, read
an explanation.

TOPIK 2

The Importance of mHealth: Four Factors

mHealth programs and projects are proliferating across the globe. According to the GSMA mHealth
Tracker, there are nearly 1,000 mHealth interventions worldwide, many in developing countries.

Why are so many governments and organizations embracing mHealth?

For the developing world, the transformative potential of mHealth and its rapid growth are due
primarily to four converging factors:

1. Unprecedented growth of mobile phone users

2. Rapid expansion of mobile networks
3. Innovation in mobile technology
4. Task shifting and other health system needs in developing countries
 

Let’s look at each of these factors in more detail.

Source: World Bank 2012; Lemaire 2011; Van Heerden 2012; GSMA 2013.

Factor 1: Growth of Mobile Phone Users

According to the International Telecommunications Union (ITU), by the end of 2011 there were an
estimated 6 billion mobile subscriptions worldwide, equivalent to about 86 percent of the world
population. In 2001, worldwide mobile subscriptions equaled about 16 percent of the total
population.

This astonishing growth is being driven by demand in developing countries, which accounted for
more than 80 percent of the 660 million new mobile subscriptions added in 2011.

From 2000 to 2010, the number of mobile subscriptions in low- and middle-income countries
increased by more than 1,500 percent, from 4 to 72 per 100 inhabitants.

Factor 2: Expansion of Mobile Networks

 
Seeking new markets, mobile telecommunications companies are extending their networks further
into rural areas, surpassing the reach of other infrastructure such as roads, running water, electricity
and fixed telephone lines.

In Sub-Saharan Africa in 2010, 80 percent of the population had mobile phone coverage, while
61 percent of the population had access to improved water and just 31 percent had access to
improved sanitation facilities. 

 
Globally, access to a mobile cell signal is available to approximately 90 percent of the world’s
population, including 80 percent of the population living in rural areas. In contrast, before the
expansion of mobile networks, many people in developing countries did not have access to a phone
of any kind.

Factor 3: Innovation in Mobile Technology

Mobile technology companies constantly innovate and improve mobile phones, other wireless
devices and software applications to keep up with the competition. These rapid technology advances
offer new possibilities for supporting health and health systems.

Software developers working in international development have produced a range of innovative

mobile technology applications that can be adapted for different contexts and needs.

Examples: 

FrontlineSMS is a free, open-source group-messaging platform that works with a laptop connected

to a mobile phone or modem. It allows users to send, receive and manage text message interactions
with large groups of people. The software works without Internet access, is easy to set up and
simple to operate.

CommCare, is a case management application for community health workers (CHWs) that has been
used in community-based maternal and child health projects. The free software runs on low
cost, java-enabled mobile phones as well as more sophisticated Android smartphones. The
application contains registration forms, checklists, danger sign monitoring and client education tools. 

Factor 4: Task Shifting and Other Health System Needs

 
 Critical health system needs of developing countries, including task shifting, improved quality of
health services, increased service utilization and efficiency in health system
management, require innovative solutions, and mHealth is uniquely suited to respond.

 mHealth solutions can help facilitate task shifting and improve quality of care by providing

health workers with checklists, decision tools and counseling algorithms on mobile phones to
support their client care responsibilities. Through task shifting, mHealth can help support the
expansion of community-based services.
 mHealth solutions also have the potential to generate demand for services and promote
healthy behaviors by providing vital health education and behavior change messages directly to
citizens.
 mHealth data collection, medical records and logistics solutions can introduce efficiencies in
health systems.
Source: Callan, et al., 2011 

mHealth's Potential: Example and Summary

Learning exercise:
After reviewing these contributing factors, how would you now explain to a colleague why mHealth is
an important new field? 

You may find it helpful to think about health challenges in your country as you view the video below.
It provides a brief overview of the mHealth section of the Malawi Knowledge for Health (K4Health)
Mobile Learning Pilot, which helped connect community health workers to supervisors and district
clinics via SMS.

- Video courtesy of TechChange.  Published on  Dec 5, 2012

Summary
The explosive growth of mobile subscriptions in the developing world combined with advances in
mobile technology and expansion of mobile networks offer unprecedented opportunities to extend
health information and services to underserved populations.

mHealth offers the potential to provide life-enhancing and life-saving health information directly to
the general public, to family caretakers, and to clients; to improve the quality of health services, and
to support task shifting to help fill the health worker gap.

This is why mHealth is often regarded as a game-changing practice for the developing world.

Limitations of mHealth
While mHealth offers many potential benefits, there are also several limitations that affect the extent
to which mHealth interventions can be beneficial.
Reflect for a moment on your experience in global health. What do you think are some of the key
limiting factors for mHealth in the country or countries where you work?

Key limiting factors in mHealth include:

Gender inequities in mobile phone ownership: Ownership and access to mobile phones in the
developing world is currently still dominated by men. Women in developing countries are 21 percent
less likely to own mobile phones than men. This figure increases to 23 percent for women living in
Africa, 24 percent for women in the Middle East, and 37 percent for women in South Asia.  

Barriers to women’s phone ownership include cost and perception of need. Studies show that people
who share or "borrow" phones are mostly female and that there are twice as many phone borrowers
in rural areas than in urban areas.

Availability of mobile services is still limited in many rural areas. At least 10 percent of the global
population and 40 percent of people in the least developed countries are not covered by a mobile
network. Where services are available, coverage is often spotty or not reliable. A user may have to
walk to the next village or to the top of a hill to use their phone.

The cost of phones and voice/text services is still very high compared to monthly income in many
areas. By 2011 mobile cellular prices in Africa had dropped to 19.6 percent of gross national income
per person, while in South Asia they were at 4 percent.

Literacy (reading ability and technology literacy). In some areas, less than half of the population
is literate, and many people don’t know how to use a basic mobile phone or how to send a text
message.

Lack of electricity to recharge phones limits their use. Innovative solutions to this problem include
using solar-power and car batteries to recharge phones.

 Source: Wesolowski A, et.al, 2012; Blumenstock 2010; GSMA and A.T. Kearney 2012; UNDP

2012; ITU, Measuring the Information Society, 2012

TOPIK 3

Overview of mHealth Applications

In this session we'll categorize and describe the range of mobile technology tools and applications
used in mHealth to give you a panorama of possible mHealth solutions. 

In general there are six main types of mHealth applications, categorized by the functions that
they fulfill or support. These six types of applications serve as building blocks for mHealth solutions:

mHealth solutions often integrate two or more types of applications to address a health need or
health system constraint.

There are many ways to classify mHealth applications, and, as is common in an emerging field,
there is as yet no universal consensus on which way is best. These six categories are based on the
work of the World Health Organization's mHealth Technical Evidence Review Group (mTERG). For
two other classification schemes, see an article by Alain Labrique, et. al., in Global Health Science
and Practice, and the mHealth HIP Brief.

Source: WHO mTERG Taxonomy Task Force, 2013; Labrique, et.al., 2013; L'Engle et al., 2013.

Social and Behavior Change

 

Communication

Social and behavior change

communication (SBCC) applications provide health information directly to clients or the general
public and help link people with services. Message content may increase individuals’ knowledge or
influence their attitudes and behaviors.

One example is Mobile for Reproductive Health (m4RH), which provides information about family

planning methods and a clinic locator service via text messages. 

Another example is CycleTel™, a text-message service piloted in India that delivers the Standard
Days Method® (SDM) of family planning to a user’s mobile phone.

How CycleTel works:

1. To request the service, a woman texts “JOIN” to a designated number.

2. The system asks her questions to determine eligibility to use SDM.
3. If she is eligible, the woman texts the date of her last period.
4. She then receives personalized SMS alerts on the days on which she is likely to become pregnant
if she has unprotected sex (her “unsafe” days).
5. When problems or questions arise, users can call the CycleTel helpline.

CycleTel Implementing Partners

Georgetown University Institute for Reproductive Health, ThoughtWorks Inc., Unicel, Indian Society of
Healthcare Professionals. For more information, see the CycleTel Brief.
 SBCC – Support for Treatment
Adherence
SBCC applications also include client support for treatment adherence, such as text-message
appointment reminders and support for medication adherence.

In a randomized clinical trial known as the WelTel Kenya1 trial, clinic nurses in three Kenyan clinics
sent weekly SMS messages to adult clients who had recently begun antiretroviral therapy (ART).

How it worked:

1. The messages asked patients how they were doing, and patients were required to respond
within two days.
2. The clinic nurses called patients who did not respond or who responded that they had a
problem.
3. Patients who received the text messages had significantly higher self-reported ART
adherence and improved rates of viral suppression compared to the group receiving standard care
 
Source: Lester et al, 2010.

Workforce Development and

Support

Workforce development and support applications include provider training and education, work
planning and scheduling, supervision, and human resource management.
 In an mHealth study conducted in Kenya, health workers in rural health facilities received daily text
messages that reinforced information the health workers’ had received during training. The
purpose of the reminders was to improve and maintain health workers’ adherence to national
guidelines for the management of outpatient pediatric malaria.

 Each week the health workers received 10 different messages—two messages a day,
Monday through Friday.
 Messages reflected key recommendations from the guidelines and training manuals.
 Each one included an entertaining or motivating quote to make it appealing. 
 

Source: Zurovac et al., 2011

Service Delivery

Service delivery applications help support health worker performance related to diagnosis,

treatment, disease management and referrals, as well as preventive services.

They include telemedicine (remote provider-client consultation), and provider-to-provider

communication, such as the mobile phone networks of health providers in Ghana, Liberia and
Tanzania set up by the non-profit organization Switchboard. These networks enable group members
to make voice calls to each other for free or for a very low cost, facilitating consultation and
knowledge sharing.

Service delivery applications also include the provision of checklists, treatment algorithms and

other point-of-care tools for health workers to guide their work and facilitate task-shifting. 
  

An example is the e-FP Job Aid for community health workers (CHWs) that runs on Nokia feature
phones.

Key features: 

 It provides an algorithm to guide CHWs in counseling, screening and referring family

planning clients.
 It is based on evidence-based family planning counseling tools, including the Balanced
Counseling Strategy Plus, the Pregnancy Checklist, the Checklist for Screening Clients Who Want
to Initiate Combined Oral Contraceptives, and the Decision-Making Toolkit.
 It also includes client registration, collection of follow-up client data and monitoring of referral
status, which are information systems applications.
 

e-FP Job Aid Implementing Partners

FHI 360, D-tree International, Pathfinder International, Tanzania Ministry of Health.

Financial Transactions and

Incentives
 Financial transactions and incentives applications help improve access to health services,
expedite payments to providers and reduce cash-based operating costs. They include savings
accounts and insurance as well as performance-based incentives.

Using SMS to reimburse reproductive health service providers

As of March 2013, Marie Stopes Madagascar had distributed more than 29,000 subsidized
vouchers in 12 rural regions of Madagasgar to make it easier for very low-income clients to obtain
family planning services.

 A voucher costs just 200 Ariary (US $0.10). A client

can give the voucher to one of 143 franchised providers in exchange for family planning services
that normally would cost 4,000-10,000 Ariary. 
 Marie Stopes Madagascar uses an SMS-based money transfer system to reimburse these
providers for their services.
 

How it works: 

1. To receive their payment, providers send the unique code on a client’s voucher by SMS to a
phone number linked to Marie Stopes Madagascar's online database.
2. The database automatically verifies that the phone number used to send the SMS was that
of a participating service provider and acknowledges that it received a valid code.
3. The system then notifies the Marie Stopes voucher manager and finance director, who
checks and authorizes the codes for payment.
4. Marie Stopes Madagascar then transfers the payment to the provider using a mobile money
service. The provider is notified of the payment via SMS.
For more information about this USAID-funded voucher program, click here to download the report. 

Supply Management

Supply management applications help track and manage supplies of medicines and other essential
commodities, help prevent stock-outs and facilitate equipment maintenance.

For example, the ILS Gateway is a mobile phone-based system that supports Tanzania’s

Integrated Logistics System. It helps improve the availability of commodities by making facility-
level logistics data more available to decision-makers. 

In the ILSGateway, which is active in more than 2,300 health facilities across Tanzania, staff
members use their personal mobile phones to report stock levels of 20 essential family planning
commodities. 

How it works:

1. After receiving a text message requesting stock information, health workers send stock-on-
hand data by SMS to a toll-free short code.
2. The data is transmitted to a user-friendly website that analyzes and displays the information
for health system decision-makers.
3. The system also sends monthly SMS and email summary reports to district, regional and
central level staff.
 

(Click here to see an infographic on the ILS Gateway System.)

ILS Gateway Implementing Partners

JSI, under the USAID | DELIVER PROJECT, and the Tanzanian Ministry of Health and Social Welfare.

Information Systems
 

Information systems applications encompass a very broad

range of activities, including data collection and reporting of patient health and service provision,
electronic health records (EHR), registries and vital events tracking, surveillance and household
surveys.

These systems increase the speed and accuracy of survey or patient data reporting by freeing
health workers and managers from cumbersome paper-based systems. Data collected on mobile
devices can be fed into central servers, enabling monitoring and analysis of health system, service
delivery and disease statistics at district, state and national levels.

In 2011 the Nepal Demographic and Health Survey (DHS) was completed using tablet personal
computers (tablet PCs) rather than paper-based questionnaires. It was the first time that mobile
technology was used to conduct the DHS in Nepal.

Interviewers recorded questionnaire responses directly into the tablets and submitted the data to
their supervisors at the end of each day via Bluetooth. 

Supervisors transferred data to the main office via a mobile network.

  

Source: Labrique et al., 2013; Paudel et al., 2013

Information Systems - continued

mCARE, a maternal and child health solution in Bangladesh links community health
workers and their clients (pregnant women and newborns). 

The goal of mCARE is to improve

pregnancy registration and support the survival of preterm infants. The mCARE health
information system uses several applications that support or provide:

 Pregnancy surveillance and registration

 Scheduling and delivery of antenatal and postnatal care
 Automated reminders for antenatal and postnatal visits
 Home-based newborn care checklists
 Labor and birth notification
 Referral and emergency mobilization
Note that mCARE blends information systems (surveillance and registration), workforce
development (scheduling), SBCC (automated reminders), and service
delivery (checklists, notifications, referral) applications.

mCARE Implementing Partners

The Johns Hopkins Bloomberg School of Public Health, JiVitA Maternal Child Health and Nutrition
Research Project, in partnership with the Ministry of Health, Government of Bangladesh and social
enterprise company mPower Health.

 
 A Tool for Strengthening Health
Systems
Combining several types of applications in a unified mHealth solution that is integrated into health
system components is important, because this approach can potentially help strengthen health
systems.

In Session 1 we defined mHealth as the use of mobile and wireless technologies to support the
achievement of health objectives. After seeing these examples, let’s add to that definition:

mHealth is a set of tools and applications that can enhance the delivery of proven public
health interventions through helping to improve health system performance, such as in
coverage, quality, equity or efficiency.

Source: Labrique et al., 2013

Strengthening Health Systems - Dristhi

Project
The Dristhi Project is an example of a multi-faceted solution that helps improve health system
performance.

Dristhi, also known as the Dristhi Smart Registries Platform, uses Android tablets and multiple

applications to improve reproductive, maternal, newborn and child health (RMNCH) care among
rural populations in Karnataka State, India.   

The Dristhi system combines previously discrete applications, including:

 A client registry for enumeration and continuity of care

 Electronic forms with embedded logic and decision-support
 Work planning, scheduling and service reminder tools
 Multimedia and interactive voice response content for client counseling
 Automated reporting into sub-district and national reporting systems
As shown in the illustration, the Dristhi applications support every major point along the RMNCH
continuum of care and are integrated into health information systems to strengthen continuuity of
care.

The Android tablets have an efficient, user-friendly interface, so skilled health workers, primarily
Assistant Nurse Midwives, have more time to provide health services, particularly to those in
greatest needed. The unifying registry enables a consistent approach across all health domains. For
more information, see the Dristhi Project description.

Types of mHealth Applications -

Summary
To summarize, in this session we reviewed these six types of mHealth applications:
Social and behavior change communication applications provide information and behavior
change messages to clients or the general public and help link people to services.

Workforce development and support applications facilitate training and education, provider work
planning and scheduling, supportive supervision and human resource management.

Service delivery applications support health worker performance for diagnosis, treatment, referral
and preventive services, and include electronic decision support, checklists, point-of-care diagnostic
tools, and provider-to-provider communication.

Supply management applications help track and manage commodities and prevent stock-outs.

Financial transactions and incentives applications facilitate timely provider payments, insurance

and savings accounts.

Information systems applications include service updates to patient health records, electronic

health records, registries and household surveys.

 
TOPIK 4

What Is the Evidence Base for mHealth?

The evidence base for mHealth is still small but growing exponentially. Since about 2008
there has been an explosion of mHealth studies appearing in the peer-reviewed literature.

The sharing of successes, challenges and lessons learned in journals and other
published literature help define when and under what circumstances mHealth is useful and
most likely to be effective.

Recent studies
In 2012 the Journal of Health Communication published an mHealth-themed special issue
and the Bulletin of the World Health Organization published a special e-health issue that
focused primarily on mHealth.

More high quality research is on the horizon. A recent search identified 215 unique mHealth
studies registered on the U.S. federal clinical trials database. Most of the studies use a
classical randomized trial design. Soon new, rigorous evidence will be available on a larger
scale.

Source: Free et al. 2013a and 2013b; Cole-Lewis and Kershaw 2010; Gurman
2012; Labrique et al. 2012; Deglise 2012; Kallander et.al. 2013; Philbrick 2013

What Do We Know About the

Effect of mHealth Solutions?
The growing body of evidence on mHealth in developing countries supports just a handful of
preliminary conclusions about the effect of mHealth on health behavior, health systems and
health outcomes.
 In this session we will review
some key mHealth studies on mHealth solutions that apply the following types of
applications: 

 Social and behavior change communication 

 Workforce development
 Service delivery 
 Supply management 
 Information systems
 

Social and Behavior Change

Communication (SBCC)
Let's begin by reviewing studies on Mobile for Reproductive Health (m4RH) (introduced in Session
1), a free, automated service that provides essential information on nine family planning methods
and a clinic locator via SMS messages.

Evaluating feasibility, reach and potential impact of a text message family planning
information service in Tanzania
Data collection: During the 10-month pilot in 2010-2011, the m4RH system electronically logged
users’ requests for information on specific methods. In addition, the researchers sent four text
questions to each user, asking about gender, age, how the user learned about m4RH, and how
m4RH had changed their use of family planning.

Results: During the pilot, 2,870 unique users accessed m4RH, resulting in 4,813 queries about
contraceptive methods. About 56% of the users responding to the text questions were female and
60% were 29 or younger. Users mentioned a variety of changes in family planning use, such as, “I
am using injection,” and “my partner is using the injection.”

The authors concluded:

Reaching younger people, women and men of reproductive age with family planning information
delivered via mobile phone is recommended.

Source: L’Engle et al., 2013

SBCC - Youth Responses to

m4RH
A related study of the m4RH service in Kenya involved 26 in-depth interviews with users, 22 with
youth 18–24. Users said that they liked the confidentiality and convenience of the service, the clear
phrasing of text messages, and the information about family planning methods. Their comments
include the following:

 
I like [m4RH] a lot! It is time saving—only you and your phone, and confidential—only you
and your phone! (Female, 20) 

There are some questions you may not ask in a clinic or may be difficult or you may feel shy
when asking. (Female, 23)

 
 

I like the advice provided on family planning and the way clients are handled – there is no
bad language used. (Female, 20) 

I learned about different methods of FP, the ones I did not know existed... I did not know
other FP methods like implants existed. (Female, 22)

 
 

I would have sex without CD [condom] hence I was exposed to STIs, HIV and pregnancy on
the part of my girlfriend, but I cannot have sex without condoms after m4RH. (Male, 20)

Source: Vahdat et al., in press

SBCC - Support for Treatment

Adherence
Mobile phone technologies improve adherence to antiretroviral treatment in a resource-
limited setting
 

Study overview: This randomized controlled trial tested the effect of SMS reminders on adherence
to antiretroviral therapy (ART) among male and female patients attending a rural clinic in Kenya.

Study participants were adult patients (about 66% female) who had initiated ART within three
months of enrollment. Each participant received a mobile phone and phone credit, and an ART
medication bottle with a medication event monitoring system (MEMS) cap.
 The intervention consisted of SMS reminders that were either short or long and
sent to the participants either once daily or once weekly. 

Results:

 The weekly SMS reminders increased the percentage of participants achieving 90%
adherence to ART by approximately 13–16% compared with no reminders.  
 The weekly reminders were also effective at reducing the frequency of treatment
interruptions.
 Daily reminders did not have any effect, which could indicate habituation to the frequent
message or that the daily reminders were considered intrusive.
The authors concluded:

Despite SMS outages, phone loss, and a rural population, these results suggest that simple SMS
interventions could be an important strategy to sustaining optimal ART response.

This conclusion echoed the findings of the WelTel Kenya1 study, which found that the SMS
intervention improved both ART adherence and HIV viral load suppression rates among new ART
patients (65% female).
 

Source: Pop-Eleches et al., 2011; Lester et al., 2010.

Workforce Development and

Support
The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to
malaria treatment guidelines: a cluster randomised trial
  

Study overview: This trial tested the effect of text message

reminders on health workers’ adherence to guidelines for the management of outpatient pediatric
malaria.

The intervention: 119 outpatient health workers at 54 rural facilities received text messages (in
English) on Kenya pediatric malaria case management guidelines for six months.

 Messages reflected the in-service training and national guideline documents that the health

workers had received.
 Each week they received 10 different messages—two messages a day.
 Each one included an entertaining or motivating quote to make it appealing.
The primary outcome measure was correct management of artemether-lumefantrine (indicated as
“AL” in the text messages) as an indicator of treatment according to national guidelines.

Results:
In the intervention group, AL management improved by 23.7% immediately after the
intervention and by 24.5% six months later. In particular, higher percentages of the intervention
group completed four dispensing and counseling tasks that were rarely done before the study.

The authors concluded:

Our intervention provided large and sustained improvements in the quality of care given to children
with malaria, but resulted in only about half the children being correctly managed. Therefore, we
recommend that text-message reminders should be used to complement existing interventions—
which themselves should be qualitatively improved—to target weak points in malaria case-
management practices. ... Findings from remote districts in Tanzania suggest that large scale text-
messge applications in health are feasible.

Source: Zurovac et al., 2011

Supply Management
SMS for Life: a pilot project to improve anti-malarial drug supply management in rural
Tanzania using standard technology
 

This 21-week pilot study examined the feasability and effect of using mobile phones to
facilitate accurate stock counts of anti-malarial medications. The study involved 129 rural
health facilities in Tanzania.

The intervention had two parts, an SMS management tool and a web-based

reporting tool.

Once a week on Thursdays,

the SMS application sent an SMS to registered health workers requesting stock counts.

Health workers counted medication stocks and transmitted their stock counts via SMS to a
free short code.
 The web-based reporting tool compiled data on stock levels and visualized it on a secure
website. The District Medical Officer assigned staff in each district to redistribute medicines
in response to stock-outs.

Results:

 The response rate and data accuracy were high throughout the pilot.
 By the end of the pilot, the proportion of health facilities with stock-outs of an anti-
malarial medicine fell to 26%, compared to 78% at week one.
 In one district, stock-outs were eliminated by week eight.
 Across all districts, stocks of artemether-lumefantrine increased by 64% and quinine
stock increased 36% during the pilot period.
The study’s authors noted that giving health workers phone credit for sending stock counts
before 17:00 on Fridays was a crucial incentive. Other factors that contributed to the
success of the pilot included government commitment, good mobile network coverage,
weekly visibility of stock data, the use of a short code and the use of health workers’
personal mobile phones.

Source: Barrington, et al. 2010

Service Delivery
Early infant diagnosis of HIV infection in Zambia through mobile phone texting of blood test
results
 

The Project Mwana study tested whether an automated, SMS-based notification system could

reduce turnaround times in the diagnosis of infant HIV infection in Zambia. It was conducted 2008–
2011 in two health districts in Zambia.

Context: Diagnosing infant HIV infection requires a PCR test, available only in regional laboratories
that often are located long distances from clinics. Paper copies of test results can take several
weeks to arrive or can become lost in transit. 

Study participants included staff from 10 public health facilities. Two staff members from each
facility were trained on the SMS-based system.

The intervention used a mobile technology application, “Results 160,” to deliver PCR test results
from the laboratory via SMS to health workers at the originating clinics.
 Source: Seidenberg, et al. 2012

Service Delivery - continued

Results:
The SMS-based system significantly shortened turnaround times for results
notification to both the health facilities and the infants’ caregivers.

 The average turnaround time for result notification to a health facility fell from 44.2
days before the study to 26.7 days post-implementation. (Statistically significant in nine of
the 10 facilities.)
 The average time to notification of a caregiver also fell significantly, from 66.8 days
pre-implementation to 35 days post-implementation.
 Only 0.5% of the texted reports investigated differed from the corresponding paper
reports.
 The authors concluded:

Despite some remaining challenges and the need for continued research on the impact of
mobile-phone-based health interventions, the simple, sustainable SMS system described in
this paper has great potential in Zambia and elsewhere.

 
Source: Seidenberg, et al. 2012

Information Systems
Successful use of tablets and wireless technologies for the Nepal DHS
 

In 2011, teams of interviewers and supervisors used tablets to conduct the Nepal Demographic and
Health Survey (DHS). Previous DHS data collection using paper questionnaires usually took five to
six months, and it was usually a year before the final report was available. In 2011 the preliminary
report was published less than two months after data collection, and the final report within nine
months.

Review sessions with interviewers highlighted key benefits, challenges and lessons

learned related to using the tablets and other mobile technologies for the DHS. 

Benefits included:

 Improved data quality 

 Reduced data collection time 
 Ease of using tablets, Bluetooth and the mobile network 
 An improved feedback loop between interviewers and the central office backstop team
Interviewers said the survey software features, such as built-in skip patterns and automatic error
messages, guided them through the interview, making it easier to administer the questionnaires.

Challenges included:

 Safe storage and transport of the tablet PCs

 Limited options for confidential interview spaces
 Lack of consistent electricity
Because tablet PC screens are difficult to read outdoors, interviewers often had to conduct the
interviews in the small living quarters of rural Nepali homes, which made it difficult to maintain
privacy.

Lessons learned:

1. Careful selection and thorough training of interviewers is crucial. The Nepal DHS

interviewers received five weeks of training.
2. Maintain data security through daily backup.
3. Provide immediate feedback on data quality. 
4. Allow sufficient time for designing and pretesting the electronic questionnaire.
5. Purchase mobile technology locally. It makes servicing equipment easier and ultimately
cheaper.
Source: Paudel et al., 2013

mHealth Evidence Initial

Conclusions
The mHealth studies reviewed here along with other studies in the mHealth evidence base suggest
the following initial conclusions.

Social and behavior change communication:

 SMS messages and voice calls may improve medication and treatment compliance.
 SMS messages have potential for stimulating healthy behaviors.
 SMS messages for health promotion appear to be well-accepted by beneficiaries.
 Workforce development, service delivery, and supply management:

 SMS messages and decision tools may improve health worker performance (compliance
with clinical care or treatment guidelines).
 mHealth may reduce the time required to obtain test results and refer clients in developing
country settings.
 Mobile technology may help improve supply chain management for small groups of
commodities.
 

Source: Sources cited previously in this session, plus: Free et al. 2013a and 2013b; Cole-Lewis and
Kershaw 2010; Gurman 2012; Labrique et al., 2012; Deglise 2012; Kallander et.al. 2013; Philbrick
2013.

mHealth Evidence Database

To help identify, rate and disseminate the evidence generated by growing numbers of mHealth studies,
the Knowledge for Health Project set up the mHealth Evidence database. It contains a searchable
catalogue of peer-reviewed and grey literature on mHealth in high, middle and low-income countries.

mHealth Evidence Gaps and

Priorities
Although the studies reviewed here and other mHealth studies suggest promising
outcomes, the current evidence base is insufficient to make strong recommendations for
mHealth practice. More evidence is needed to inform the development, implementation and
scale-up of mHealth solutions.

Exercise:
 Based on the evidence we have reviewed and other mHealth literature you may have read,
what do you still want to know about mHealth? What would you need to know to guide the
development of an mHealth solution? Write your answers in your notebook and share them
with us in the course evaluation after you complete this course.

What the mHealth Field Still Needs

Major gaps in the mHealth evidence base, and therefore priorities for future mHealth
research, include: 

1. Rigorous standards in study designs, including:

o Collecting baseline data
o Using comparison groups and sufficient sample sizes
o Using evidence-based theoretical frameworks and theories of change
o Fully describing the mobile technology solution, research methodology,
limitations and null results
2. The effect of mHealth strategies on clinical and behavioral outcomes in low-
resource settings
3. How mHealth contributes to strengthening health systems and scaling up and
integrating health services
4. The cost-effectiveness of mHealth solutions
5. How mHealth solutions can be sustainably financed and supported
6. How mHealth addresses social determinants of health, such as gender-related
power imbalances and health inequities
7. Best practices and guidelines for design and delivery of mobile phone content
 

Sources: Piette et. al, 2012; Philbrick 2013; Tomlinson et al., 2013.

WHO mHealth Evidence Group

In 2012, the World Health Organization (WHO) formed the mHealth Technical and Evidence Review
Group (mTERG) on Evidence, Impact and Scale in Reproductive, Maternal, Newborn and Child
Health. Its purpose is to foster evidence generation and knowledge synthesis related to use of
mHealth for health systems strengthening.