Module 6: Mobile Technology and Community Health Workers

In 2009, the majority of the 3.3 billion cell phone users worldwide lived in developing countries.  In “Harnessing the Mobile Revolution,” Thomas Kalil advocates for the United States to include in its development agenda the expansion of mobile services abroad to promote advancements such as “safe drinking water, new vaccines, therapies, point-of-care diagnostics, clean energy, and improved crops.”(1) 

Kalil argues that mobile technology can improve public health by “increasing the effectiveness of community health workers, creating new mobile diagnostics, improving the collection of public health data, and persuading people to adopt healthier behaviors”.(2)  Mobile technology can be used by CHWs to enhance their services, and by community members to improve communication with healthcare professionals.  Studies in Bangladesh, Laos, and Egypt, for example, revealed that mobile phones are used by patients, especially mothers, to solicit health information from CHWs, and to seek more health services.(3) However, Dr. Larry Chang, a researcher at Johns Hopkins, cautions that while using mobile phones to improve public health “seemed obvious” as mobile phone use increased rapidly worldwide, there is a lack of “rigorous evaluation” of mobile technology’s effectiveness in health care delivery systems.  Fortunately, many studies investigating mobile technology’s role in health care are in progress.  As of May 2012, the Johns Hopkins Global mHealth Initiative was running 51 projects investigating mobile technology’s effectiveness in health care delivery.  In March 2013, the Johns Hopkins Bloomberg School of Public Health will offer two courses on integrating mobile technology into public health programs.   

Point-of-Care Support

For CHWs, numerous new technologies are being invented to increase their efficacy in diagnosis, treatment, and delivery.  Researchers from the University of Washington and University of California at Berkeley have developed a mobile phone-based software called CommCare that aids CHWs in a variety of tasks, including screening for illnesses such as TB and malaria, providing accurate information on family planning and safe drinking water, noting upcoming follow-up visits, and keeping track of new births or deaths.(4) CommCare is an example of “point-of- care” support, which includes “mobile telemedicine devices and patient monitoring systems in low- to middle- income countries.”  Moreover, CHWs can use these devices to transmit patient information, to more quickly refer and transport patients to health facilities, and to improve detection, diagnosis, treatment, and monitoring.  They can also improve CHW adherence to standardized protocols and treatment guidelines.(5) 

CommCare also allows for CHWs to “organize their work, track patient visits, access health protocols, and collect and access data.” With the improved documentation of public health data with mobile technology, CHWs can help guide a more appropriate allocation of resources. Lastly, the developers of CommCare are attempting to develop electronic education with this application that would enable CHWs to engage in refresher courses and continuing education.(6) Innovations continue to develop to improve and ensure the effectiveness of CHWs.

Rapid Diagnostics

Also out of the University of California at Berkeley is the development of a high-resolution camera that can be attached to a cell phone. With this camera, health personnel, including CHWs, can take pictures of blood smears or infected skin and send them to professionals around the world to analyze them.  This technology allows for accessible and rapid diagnosis.(7)

Adherence

Mobile communication can also be useful for strengthening adherence and spreading health education messages.  As stated in other modules, many CHWs work as adherence counselors for those with tuberculosis (TB) or HIV.  For example, in Cape Town, South Africa, a doctor has created a database of his TB patients’ cell phone numbers, and his computer automatically sends out a personalized text message that reminds them to take their medications. This allows the healthcare staff, many of whom were spending significant amounts of time to ensure patient compliance, to focus on other health issues, and specifically on those patients who have the most trouble with adherence.  In order to entertain and further educate his patients, the doctor includes jokes and lifestyle tips in the texts. Similarly, researchers are beginning to test the ability of mobile communication to influence healthy behaviors such as physical exercise, nutritious diets, and avoidance of risky sexual practices. CHWs could similarly use texts to amplify their impact on the health of their communities.(8)

Technology and Health Care in the United States

Case Study: Text4Baby

In the United States, 90% of women have a cell phone, and texting is widespread.  Text4baby, launched in 2010, uses text messages to improve maternal and infant health outcomes.  As the first free national mobile health service in the United States, Text4Baby sends pregnant women and new mothers text messages with health care reminders specific to their infant’s age, including facts about prenatal vitamins, infant immunization, safe sleep, and proper nutrition.  It also helps to connect them to public clinics and other services for prenatal and infant care.  Once women sign up for the service (by texting BABY or BEBE to 511411), they receive three free text messages per week.(9)  The information distributed via text was produced by the National Healthy Mothers, Healthy Babies Coalition (HMHB), working closely with the Centers for Disease Control and Prevention (CDC) to ensure that the messages contained accurate and evidence-based information.  Text content was further reviewed by an expert panel that included “nurses, obstetricians, nurse-midwives, pediatricians, medical epidemiologists, mental health professionals, nutritionists, lactation consultants and a clinical geneticist”.(10)

Text4Baby was founded by HMHB, Voxiva, and CTIA, sponsored by Pfizer, Johnson & Johnson, and Care First, and is a partner of the White House Office of Science and Technology Policy, the Department of Health and Human Services, and the Department of Defense Military Health System.  Text4Baby’s government partners have also helped initiate research evaluating the program’s efficacy.  Researchers at George Washington University and Madigan Army Medical Center in Fort Lewis, Washington are conducting a randomized study to investigate Text4Baby’s effectiveness in improving prenatal care and infant and maternal health.  Pregnant women participating in the study will either receive standard prenatal care at Madigan, or Text4Baby messages (in addition to prenatal care at the medical center).(11)  Although data collection for the Madigan study will likely not be complete until late 2012, Text4Baby had 155,000 enrollees nationwide by June 2011 and 240,000 participants by May 2012.(12)(13)  Five % of participants receive the Spanish version of the text messages, and 61% of enrollees live in zip codes where the household median annual income is less than $50,000, suggesting that Text4Baby is making progress in reaching its target population.(14)

Case Study: Special Care Center, New Jersey

Technology has also helped local health care providers improve patient health and reduce health care costs.  The Special Care Center in Atlantic City, New Jersey, introduced in Module 1, implemented an open-access scheduling system, which guarantees same-day appointments when patients need immediate care, and an electronic information system that tracks patients’ progress toward their health goals.  The clinic’s staff also realized that many patients called 911 for non-emergency reasons because they did not know the Special Care Center’s twenty-four-hour call number, or did not know how to save it on their cell phones.  Once clinic staff began helping patients use the speed dial function of their cell phones to save the clinic’s number, the frequency of emergency room visits made by the center’s patients was greatly reduced, minimizing costs for the patient and the state.(15)  The experiences of the Special Care Center emphasize that availability of mobile technology and patient competency in using the technology are both essential for effective health care delivery.

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Footnotes

(1) Kalil, Thomas. “Harnessing the Mobile Revolution.”  New Policy Institute 2008.

(2) Ibid.

(3) Mechael, Patricia N. “The Case for mHealth in Developing Countries.”  innovations 2009.

(4) Kalil, Thomas. “Harnessing the Mobile Revolution.”  New Policy Institute 2008.

(5) Mechael, Patricia N. “The Case for mHealth in Developing Countries.”  innovations 2009.

(6) Mechael, Patricia, Gerry Douglas, Neal Lesh, Ada Kwan.  “Mobile point-of-care support and data collection tools for health workers in low- and middle- income countries.”  AMIA Spring Congress (2009).  Accessed on 14 February 2011.

(7) Kalil, Thomas. “Harnessing the Mobile Revolution.”  New Policy Institute 2008.

(8)  Ibid.

(9) Anderson, Jane. (2010). "Baby text program launched." Family Practice News, 1: 52.

(10) Jordan, E.T., Ray, E.M., Johnson, P., Evans, W.D. (2011). Text4Baby: Using text messaging to improve maternal and newborn health. Nursing for Women’s Health, 15(3): 206-212.

(11) Evans, W.D., Abroms, L.C., Poropatich, R., Nielsen, P.E., Wallace, J.L. (2012). Mobile health evaluation methods: the Text4Baby case study. Journal of Health Communication: International Perspectives, 17(sup1):22-29.

(12) Parker, R.M., Dmitrieva, E., Frolov, S., Gazmararian, J.A. (2012). Text4Baby in the United States and Russia: an opportunity for understanding how mHealth affects maternal and child health. Journal of Health Communication: International Perspectives, 17(sup1):30-36.

(13) Jordan, E.T., Ray, E.M., Johnson, P., Evans, W.D. (2011). Text4Baby: Using text messaging to improve maternal and newborn health. Nursing for Women’s Health, 15(3): 206-212.

(14) Ibid.

(15) Atul Gawande. January 2011.  “The Hot Spotters: Can we lower medical costs by giving the neediest patients better care?”The New Yorker Magazine.