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Integration of Mobile Technologies with Routine Healthcare Services in Mozambique
Örebro University, Orebro University School of Business, Örebro University, Sweden.ORCID iD: 0000-0001-8933-2906
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Mobile technologies are emerging as one way to help address health challenges in many countries, including in Least Developed Countries. Mobile technology can reach a large share of the population but in order to provide effective support to healthcare services, technology, information collection and dissemination, and work processes need to be well aligned. The thesis uses a design science methodological approach and mixes qualitative and quantitative data analysis to address the question of, How can mobile technologies be effectively integrated with routine healthcare services?

The study concerns the design, implementation, and evaluation of a mobile technology-based system, called SMSaúde, with the aim of improving the care of patients with HIV/AIDS and tuberculosis in Mozambique. The work started with the elicitation of functional and user requirements, based on focus group discussions. An important challenge, as in many mHealth interventions, was the integration with routine healthcare services and the existing IT systems, as well as developing a scalable technical structure. The system has now been in routine use since 2013 in more than 16 healthcare clinics in Mozambique. Evaluation was done by a randomised controlled study. Analysis of patient records showed that retention in care in urban areas was significantly higher in the intervention group than in the control group. In a user study both patients and health professionals were very positive to the system. The thesis contributes to research by demonstrating how information system artefacts can be constructed and successfully implemented in resource-constrained settings. The practical contributions include the designed artefact itself as well as improved healthcare practices and mHealth policy recommendations.

Place, publisher, year, edition, pages
Örebro: Örebro University , 2017. , 136 p.
Series
Örebro Studies in Informatics, 13
Keyword [en]
mobile technologies, mobile health, mHealth, Least Developed Countries, Mozambique, mobile phones, information systems artefact, design science research
National Category
Information Systems, Social aspects
Identifiers
URN: urn:nbn:se:oru:diva-56948ISBN: 978-91-7529-195-6 (print)OAI: oai:DiVA.org:oru-56948DiVA: diva2:1086770
Public defence
2017-06-12, Örebro universitet, Musikhögskolan, Hörsal M, Fakultetsgatan 1, Örebro, 13:00 (English)
Opponent
Supervisors
Available from: 2017-04-04 Created: 2017-04-04 Last updated: 2017-05-24Bibliographically approved
List of papers
1. Mobile Technologies and Geographic Information Systems to Improve Health Care Systems: A Literature Review
Open this publication in new window or tab >>Mobile Technologies and Geographic Information Systems to Improve Health Care Systems: A Literature Review
2014 (English)In: JMIR mhealth and uhealth, E-ISSN 2291-5222, Vol. 2, no 2, e21Article in journal (Refereed) Published
Abstract [en]

Background: A growing body of research has employed mobile technologies and geographic information systems (GIS) for enhancing health care and health information systems, but there is yet a lack of studies of how these two types of systems are integrated together into the information infrastructure of an organization so as to provide a basis for data analysis and decision support. Integration of data and technical systems across the organization is necessary for efficient large-scale implementation.

Objective: The aim of this paper is to identify how mobile technologies and GIS applications have been used, independently as well as in combination, for improving health care.

Methods: The electronic databases PubMed, BioMed Central, Wiley Online Library, Scopus, Science Direct, and Web of Science were searched to retrieve English language articles published in international academic journals after 2005. Only articles addressing the use of mobile or GIS technologies and that met a prespecified keyword strategy were selected for review.

Results: A total of 271 articles were selected, among which 220 concerned mobile technologies and 51 GIS. Most articles concern developed countries (198/271, 73.1%), and in particular the United States (81/271, 29.9%), United Kingdom (31/271, 11.4%), and Canada (14/271, 5.2%). Applications of mobile technologies can be categorized by six themes: treatment and disease management, data collection and disease surveillance, health support systems, health promotion and disease prevention, communication between patients and health care providers or among providers, and medical education. GIS applications can be categorized by four themes: disease surveillance, health support systems, health promotion and disease prevention, and communication to or between health care providers. Mobile applications typically focus on using text messaging (short message service, SMS) for communication between patients and health care providers, most prominently reminders and advice to patients. These applications generally have modest benefits and may be appropriate for implementation. Integration of health data using GIS technology also exhibit modest benefits such as improved understanding of the interplay of psychological, social, environmental, area-level, and sociodemographic influences on physical activity. The studies evaluated showed promising results in helping patients treating different illnesses and managing their condition effectively. However, most studies use small sample sizes and short intervention periods, which means limited clinical or statistical significance.

Conclusions: A vast majority of the papers report positive results, including retention rate, benefits for patients, and economic gains for the health care provider. However, implementation issues are little discussed, which means the reasons for the scarcity of large-scale implementations, which might be expected given the overwhelmingly positive results, are yet unclear. There is also little combination between GIS and mobile technologies. In order for health care processes to be effective they must integrate different kinds of existing technologies and data. Further research and development is necessary to provide integration and better understand implementation issues.

Keyword
health care, mobile technology, mobile phone, SMS, text messaging, geographic information systems, GIS
National Category
Information Systems, Social aspects
Research subject
Informatics
Identifiers
urn:nbn:se:oru:diva-40865 (URN)10.2196/mhealth.3216 (DOI)25099368 (PubMedID)
Available from: 2015-01-12 Created: 2015-01-12 Last updated: 2017-05-17Bibliographically approved
2. SMSaude: design, development and implementation of a remote/mobile patient management system to improve retention in care for HIV/AIDS and tuberculosis patients
Open this publication in new window or tab >>SMSaude: design, development and implementation of a remote/mobile patient management system to improve retention in care for HIV/AIDS and tuberculosis patients
2015 (English)In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 3, no 1, e26Article in journal (Refereed) Published
Abstract [en]

Background: The widespread and low cost of mobile phones and the convenience of short message service (SMS) text messaging suggest potential suitability for use with alternative strategies for supporting retention in care and adherence to the treatment of various chronic diseases, such as HIV and tuberculosis (TB). Despite the growing body of literature reporting positive outcomes of SMS text message-based communication with patients, there is yet very little research about the integration of communication technologies and electronic medical records or electronic patient tracking systems.

Objective: To design, develop, and implement an integrated mobile phone text messaging system used to follow up with patients with HIV and TB in treatment in Mozambique.

Methods: Following the design science research methodology, we developed a Web-based system that provides support to patients. A case study involving three health care sites in Mozambique was a basis for discussing design issues for this kind of system. We used brainstorming techniques to solicit usability requirements, focus group meetings to discuss and define system architecture, and prototyping to test in real environments and to improve the system.

Results: We found six sets of system requirements that need to be addressed for success: data collection, telecommunication costs, privacy and data security, text message content, connectivity, and system scalability. A text messaging system was designed and implemented in three health facilities. These sites feed data into a central data repository, which can be used for analysis of operations and decision support. Based on the treatment schedule, the system automatically sent SMS text message appointment reminders, medication reminders, as well as motivational and educational messages to patients enrolled in antiretroviral therapy and TB treatment programs.

Conclusions: We successfully defined the requirements for, designed, and implemented a mobile phone text messaging system to support HIV and TB treatments. Implementation of this system could improve patients' self-management skills and strengthen communication between patients and health care providers.

Place, publisher, year, edition, pages
Toronto, Canada: J M I R Publications, Inc., 2015
Keyword
Mobile health, text messaging, SMS system, patient management, design science research, Mozambique
National Category
Information Systems
Research subject
Informatics
Identifiers
urn:nbn:se:oru:diva-42527 (URN)10.2196/mhealth.3854 (DOI)000359791000019 ()25757551 (PubMedID)
Available from: 2015-02-06 Created: 2015-02-06 Last updated: 2017-05-17Bibliographically approved
3. SMSaude: Evaluating Mobile Phone Text Reminders to Improve Retention in HIV Care for Patients on Antiretroviral Therapy in Mozambique
Open this publication in new window or tab >>SMSaude: Evaluating Mobile Phone Text Reminders to Improve Retention in HIV Care for Patients on Antiretroviral Therapy in Mozambique
Show others...
2016 (English)In: Journal of Acquired Immune Deficiency Syndromes, ISSN 1525-4135, E-ISSN 1944-7884, Vol. 73, no 2, E23-E30 p.Article in journal (Refereed) Published
Abstract [en]

Objective: We evaluated whether regular mobile phone text reminders improved patients' retention in antiretroviral therapy (ART) care in Mozambique.

Design: SMSaude was a randomized control trial of HIV-infected patients on ART who received regular text message reminder vs. standard of care at 3 public health facilities in Maputo Province, Mozambique. The primary outcome was retention in HIV care. Between November 2011 and March 2012, 830 eligible HIV-infected patients on ART were randomized 1: 1 to the text reminder intervention or standard of care.

Methods: We used Kaplan-Meier estimators and log-rank tests to compare proportions of patients who received SMS reminders who were retained in HIV care compared to the control group who received standard of care. Post hoc analyses were performed using Cox proportional hazards models stratified by urban/rural facility and when initiated ART (<= 3 months vs. >3 months). Hazard ratios and confidence intervals (CIs) are reported. Analysis was with intention to treat.

Results: Patients who received text messages had lower attrition from HIV care at 12 months, though the difference was nonsignificant (RR: 0.68, 95% CI: 0.41 to 1.13). Among urban patients, text messages improved retention in HIV care (RR: 0.54, 95% CI: 0.31 to 0.95). Intervention patients newly initiated on ART (<3 months) had lower attrition than control patients (HR: 0.54; 95% CI: 0.23 to 0.91), especially urban newly initiated patients (HR: 0.20, 95% CI: 0.06 to 0.64). Text messages had no effect on retention among rural patients.

Conclusions: Text messages did not improve retention in HIV care for all patients on ART but improved retention in care of urban patients and those who recently started ART and received text reminders compared with standard of care.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2016
Keyword
SMS reminders, text messages, retention in care, Mozambique, ART
National Category
Infectious Medicine Immunology in the medical area
Research subject
Infectious Diseases; Immunology
Identifiers
urn:nbn:se:oru:diva-53172 (URN)10.1097/QAI.0000000000001115 (DOI)000384109800002 ()2-s2.0-84988336269 (ScopusID)
Note

Funding Agencies:

Ark

Vodacom Mozambique

UCLA Postdoctoral Fellowship Training Program in Global HIV Prevention Research T32MH080634

Available from: 2016-10-24 Created: 2016-10-24 Last updated: 2017-05-17Bibliographically approved
4. Mobile health treatment support intervention for HIV and tuberculosis in Mozambique: Perspectives of patients and healthcare workers
Open this publication in new window or tab >>Mobile health treatment support intervention for HIV and tuberculosis in Mozambique: Perspectives of patients and healthcare workers
2017 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, no 4, e0176051Article in journal (Refereed) Published
Abstract [en]

Background: Studies have been conducted in developing countries using SMS to communicate with patients to reduce the number of missed appointments and improve retention in treatment, however; very few have been scaled up. One possible reason for this could be that patients or staff are dissatisfied with the method in some way. This paper reports a study of patients' and healthcare workers' (HCW) views on an mHealth intervention aiming to support retention in antiretroviral therapy (ART) and tuberculosis (TB) treatment in Mozambique.

Methods: The study was conducted at five healthcare centres in Mozambique. Automated SMS health promotions and reminders were sent to patients in a RCT. A total of 141 patients and 40 HCWs were interviewed. Respondents rated usefulness, perceived benefits, ease of use, satisfaction, and risks of the SMS system using a Likert scale questionnaire. A semi-structured interview guide was followed. Interviews were transcribed and thematic analysis was conducted.

Results: Both patients and HCW found the SMS system useful and reliable. Most highly rated positive effects were reducing the number of failures to collect medication and avoiding missing appointments. Patients' confidence in the system was high. Most perceived the system to improve communication between health-care provider and patient and assist in education and motivation. The automatic recognition of questions from patients and the provision of appropriate answers (a unique feature of this system) was especially appreciated. A majority would recommend the system to other patients or healthcare centres. Risks also were mentioned, mostly by HCW, of unintentional disclosure of health status in cases where patients use shared phones.

Conclusions: The results suggest that SMS technology for HIV and TB should be used to transmit reminders for appointments, medications, motivational texts, and health education to increase retention in care. Measures must be taken to reduce risks of privacy intrusion, but these are not a main obstacle for scaling up systems of this kind.

Place, publisher, year, edition, pages
Public Library of Science, 2017
National Category
Information Systems, Social aspects
Identifiers
urn:nbn:se:oru:diva-57686 (URN)10.1371/journal.pone.0176051 (DOI)000399875200064 ()28419149 (PubMedID)2-s2.0-85017624472 (ScopusID)
Available from: 2017-05-17 Created: 2017-05-17 Last updated: 2017-05-22Bibliographically approved
5. Use of Mobile Technologies to Improve Healthcare in Mozambique: Key Failure/Success Factors, Challenges, and Policy Implications
Open this publication in new window or tab >>Use of Mobile Technologies to Improve Healthcare in Mozambique: Key Failure/Success Factors, Challenges, and Policy Implications
(English)Manuscript (preprint) (Other academic)
National Category
Information Systems, Social aspects
Identifiers
urn:nbn:se:oru:diva-57687 (URN)
Available from: 2017-05-17 Created: 2017-05-17 Last updated: 2017-05-17Bibliographically approved

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