Improving health awareness through mobile based health messages in Bangladesh

Mafruha Alam,¹Ananya Raihan,¹Atik Ahsan^1
1D. Net, Bangladesh

Journal MTM 1:4S:25, 2012
DOI:10.7309/jmtm.47

Abstract

Background: MAMA Bangladesh is poised to reach approximately 3 million pregnant women, new mothers and their families within 3 years of national scale service with voice (IVR) and text (SMS) messages and achieve sustained improvements in health knowledge, behaviors, and outcomes under the brand name “ Aponjon” (meaning the ‘trusted one’). During a successful pilot phase, “Aponjon” served 1403 subscribers in a few selected urban and rural areas of Bangladesh. A core research team had evaluated various aspects of the service before large scale roll out at a national level.

Purpose: Formative research attempted to evaluate and understand users’ acceptance level of the service, get closer understanding of willingness to pay for the service, understand role of community health workers and popular media campaigns in subscriber acquisition, analyze the mobile technology and regulatory landscape to run such an innovative mHealth service etc.

Method: Formative research collected feedback from 359 subscribers through extensive in-depth interviews, phone surveys, field visits and system generated reports.

Results: Receiving information through mobile phone was well accepted by women and gatekeepers. Women who were less educated chose to receive recorded voice messages while women who were educated chose text messages. Not all women had access to mobile phones, 41% of women depended on the handset of their family members. A significant number (53%) of gatekeepers opted to receive the service alongside the women. Families were following advice on immunization, nutrition, family planning, hygiene, breastfeeding and household healthy practices towards pregnant members, infants and mothers. Though trust on mobile content is high (91%) willingness to pay for mobile based messages is low across all socio-economic classes. Willingness to pay differs between women and gatekeepers; gatekeepers tend to pay more for the service as they control the phone bills.

Conclusion: Inclusion of gatekeepers/important family members in the service is essential both from the perspective of sustained behavioral change as well as additional revenue generation. Engaging community agents is an effective way of registering the underprivileged women in rural Bangladesh. Longer term financial sustainability would depend on successful implementation of a potential business model which suggest alternative source of revenue generation and cross subsidies.infrastructure to trace and bring patients back to treatment. Treatment outcomes, such as sputum-smear or culture, testing is low. Further research is needed to evaluate this interactive intervention’s potential.

TextTB: A parallel design randomized control pilot study to evaluate acceptance and feasibility of a patient-driven mobile phone based intervention to support adherence to TB treatment

Sarah Iribarren,¹ Christina Chirico,²  Mirta Echevarrria,²  Daniel Cardinali^2
1University of Utah, College of Nursing, USA, ²Health Region V TB Program, Hospital Dr A Cetrangolo, Argentina

Journal MTM 1:4S:23-24, 2012
DOI:10.7309/jmtm.46

Abstract

Background: Argentina’s treatment success rate remains well below the World Health Organization (WHO) TB key target of 85%, averaging 46% from 2008-2010. Few studies have applied mobile phone-based interventions for TB management. This study assessed feasibility, acceptance and explored the initial efficacy of a short message service (SMS)-based intervention to improve patient adherence and support TB patients in a setting where self-administration is the standard care.

Methods: Newly diagnosed TB patients were screened from November 2011 – September 2012 from a hospital-based outpatient clinic within a pulmonary specialized reference hospital in Argentina. Patients were randomized into control and intervention in a 1:1 allocation ratio in block randomization of 10. The intervention arm received standard of care plus a SMS-based intervention which included instructing patients to ‘text-in’ after self-administration of medication; reminders/check-in when patient did not ‘text in’; receipt of bi-weekly SMS education messages; and the option to consult during the first two month intensive treatment phase. Educational messages were selected based on the Informational-Motivational-Behavioral Skills Model. FrontlineSMS open-source software was used as the SMS platform. Semi-structured, in depth, individual interviews were conducted with 9 patients and 3 others responded to structured questions via text-messages. Outcomes of feasibility (e.g. number of potential participants with mobile phones), acceptability (e.g. participant and staff perceptions, type of messages) and initial efficacy (e.g. notification rates, sputum conversion) were assessed.

Results: Thirty-seven participants were enrolled from 122 screened, of whom 3 potential participants did not have access to a phone and 3 did not know how to send text message. Other feasibility issues included: varying mobile phone coverage (58% interviewed notified having some technical difficulties, e.g. missed sent/received messages), modem partially capturing data, feature limitations of FrontlineSMS (e.g. manual individual entry of each educational message, time stamp 2 hours early), computer security and challenges with infrastructure/staffing to track and bring patients who did not notify back to treatment. Most participants found intervention acceptable (82% would highly recommend to others), reported being “cared for” and “having a friend when all others wanted nothing to do with them” and that notifying made them feel that they were “responsible for their treatment”. Four participants were not included in final analysis (1 transferred care, 1 withdrew, 2 due to modem technical problems). Average notification rate (n=14) over 60-day period was 77% (22-100%), of those 83% (53-100%) notified without reminder. Running out of credit and technical difficulties were reported as reasons for missing notification. On average, participants texted in 2 questions (2-6) and 1.5 messages that reported side-effects (0-8). Only 15 (45%) had follow-up sputum smear or culture tests, the difference between groups was non-significant.

Conclusions: Mobile phones and text messaging was prevalent among potential participants making intervention contextually appropriate in this setting. Intervention was largely accepted. Feasibility issues may be improved with adjunct programs to manage educational texts, free-to-text in number and strengthening infrastructure to trace and bring patients back to treatment. Treatment outcomes, such as sputum-smear or culture, testing is low. Further research is needed to evaluate this interactive intervention’s potential.

Twitter + Health: The psychosocial impact of short-form text-based messages on wellbeing

Lauren Wagner^1
1University of Oxford, Oxford Internet Institute, Oxford UK

Journal MTM 1:4S:22, 2012
DOI:10.7309/jmtm.45

Abstract

Social relationships are one of the most well-documented psychosocial factors influencing physical and mental health. Benefits include decreased mortality and levels of distress, increased feelings of security, belonging, and self worth, and a source of regulation for maintaining healthy behaviors.

Over one billion people are a member of at least one online social network, designed to forge and maintain social ties, and 75% of the world’s population communicates through a mobile phone. This study quantifies how digital exchanges impact wellbeing and feelings of perceived social support among users. Hypotheses were tested using Twitter, the interactive microblogging service that is utilized on a mobile device by 300 million active users.

My research puts forth a new theory known as the theory of perceived companionship, concluding that short-form text-based communication presents unique affordances to facilitate the development of companionate relationships known to improve health. Hypotheses were tested with an online survey of 61 Twitter users, which evaluated network structure, expectations for interactions, and explicit reactions to digital correspondences along metrics known to boost wellbeing.

Results indicate that Twitter users are not directly connected through channels outside of Twitter but nonetheless accrue some personal benefit from interactions with these weak ties, especially during interactive exchanges such as retweets and replies. Reciprocal online interactions enhanced wellbeing for users, notably through a perceived boost when a tweet is acknowledged. In addition, subjects experienced feelings of heightened recognition, connectedness, and appreciation, especially in the retweet and reply scenarios.

By identifying digital interactions known to improve wellbeing, researchers and developers may employ these principles in order to configure interactions that consider the psychological impact of online use and advance its known benefits. The study underscores the influential role that interaction and social design plays in influencing user perception of digital conversationpartners and community, which promotes engagement and impacts user wellbeing.

Electronic Decision Support for Cardiovascular High-Risk Patients Management in Tibet, China

MaoyiTian,¹JiakeChen,² LiqunXu,² HaoChen,³ RuilaiLi,¹KaWingCho,^1,4 YangfendWu,¹LijingL Yan,^1,5
1The George Institute for Global Health, Beijing, China, ²China Mobile Research Institute, Beijing, China, ³Beijing Hospital, Beijing, China ⁴Columbia University, New York, USA ⁵Northwestern University, Illinois, USA

Journal MTM 1:4S:21, 2012
DOI:10.7309/jmtm.44

Abstract

Background: An electronic decision support (EDS) system in the health sector is a computer or smartphone based application used to assist clinicians in medical decision making. Community healthcare workers (CHWs) who usually have little professional training may particularly benefit from EDS to better equip them for community-based chronic disease care. To our knowledge, there are no studies in China on EDS for CHWs.

Methods: We will incorporate an EDS component in a cluster-randomized controlled trial currently being conducted in 23 villages in 2 counties in Tibet, China whose aim is to develop, pilot test, and evaluate a guideline-based yet simplified cardiovascular management program delivered by CHWs (also called village “doctors”) for high cardiovascular risk patients.

The EDS system is a smartphone-based application that aims to help CHWs better follow up and manage their high cardiovascular risk patients on a monthly basis during the 12 months intervention period. The application consists of prompts regarding patient’s medical history, new conditions, medication use, lifestyle habits, physical examination findings, and appropriateness for prescribing two types of CVD risk lowering medications (aspirin and low- dose diuretics). These monthly records from the cellphone can easily be uploaded by CHWs to a central server to generate key performance indicators and provide performance feedback to the CHWs to improve the quality of their care.

Current Status: The EDS application were supplied to all CHWs between May and June 2012 and will be used for about one year. Interim process evaluation on EDS will be conducted by October 2012 with final data collection by May 2013.

Significance: As the first study with an EDS component for CHWs to manage cardiovascular high-risk patients in China, this project provides an opportunity to evaluate the feasibility and effectiveness of this innovative technology in capacity building and medical decision support.

A Computer Adaptive Testing (CAT) approach to Patient Reported Outcomes (PROs) for mobile devices

Michael Bass,¹Maria Varela Diaz^1
1Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University

Journal MTM 1:4S:20, 2012
DOI:10.7309/jmtm.43

Abstract

The NIH PROMIS system consists of validated measures and software for assessing a patient’s health status across physical, mental and social well-being domains.

Assessment Center, the accompanying software developed by PROMIS utilizes computer adaptive testing techniques that tailor respondent’s questions based on their previous responses. This results in reliable, flexible and precise scores with low patient burden when compared to traditional static PRO measures.

The software was written by developers at the Department of Medical Social Sciences (MSS) at Northwestern University Feinberg School of Medicine. It was initially designed as a turn-key solution for patient-reported outcomes research. In an effort to better target mobile devices, we have recently ‘wrapped’ the adaptive technology and workflow of Assessment Center in a REST API that permits developers and researchers to write applications for any connected mobile device.

This presentation will provide a background and history of the PROMIS measures, describe the REST API, demonstrate a smartphone application that utilizes the REST API and conclude with a look at the impact and future use of mobile applications that provide broader distribution of PROMIS tools.

Tailored SMS Messaging to Increase Exercise in Cancer Survivors: A Qualitative Pilot Study

Karen Basen-Engquist,¹Melissa Karlsten^1
1UT MD Anderson Cancer Center, Houston, TX, United States

Journal MTM 1:4S:19, 2012
DOI:10.7309/jmtm.42

Abstract

BACKGROUND: Exercise is recommended for cancer survivors, but we know little about increasing exercise in this population. Ecological momentary assessment (EMA) can help us understand behavioral processes by examining within day influences on behaviors. We used EMA to measure self-efficacy (SE) and positive and negative outcome expectations (OE+, OE-) each morning in order to tailor motivational exercise messages to participants and increase their daily moderate-vigorous intensity exercise minutes and steps.

METHOD:  Ten endometrial, breast and colorectal cancer survivors with a mean age of 58 (±9.2) participated in a 5-day pilot study, completing EMAs each morning and evening. Participants were provided with an Android smartphone with EMA and self-monitoring exercise applications and a pedometer. Based on the cumulative scores of SE, OE+, OE- and logic rules, up to 4 tailored, motivational messages based on Social Cognitive Theory (SCT) constructs were sent randomly throughout the day. Upon completion, a semi-structured individual interview was held to assess difficulties experienced, preferred features, and future directions.

RESULTS:  The daily exercise minutes and steps increased over the 5 days that participants used the program (p for linear trend = 0.018 and 0.055 for minutes of exercise and steps, respectively). Mean daily minutes of exercise increased from 19.4 on day 1 to 32.2 on day 5; mean daily steps increased from 5,957 to 7,085. 80% of participants said that they would be willing to use the program for 6 months or longer. Participants found the messages to be good reminders with useful content. Common themes included desiring a future version with goal setting, self-monitoring and feedback features.

CONCLUSION:  The preliminary data from this group of cancer survivors suggest that the use of technology to provide personalized motivational support for increasing exercise is an acceptable and feasible intervention and a formalized, expanded SMS-based exercise intervention should be developed.