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Posted on Dec 5, 2013 in Conference | 0 comments

Monitoring MAMA: Gauging the Impact of MAMA South Africa

Jesse Coleman1

1Wits Reproductive Health & HIV Institute

Journal MTM 2:4S:9, 2013

DOI: 10.7309/jmtm.2.4S.7


Introduction In South Africa a number of Millennium Development Goals relating to maternal health have been worsening while the use of mobile phones to support health services (mHealth) has been shown to improve health outcomes in the developing world. South Africa is one of the focus countries for the Mobile Alliance for Maternal Action (MAMA) which also includes Bangladesh and India. MAMA South Africa (MAMA-SA) uses a multi-channel mHealth approach to communicate healthy pregnancy and newborn child support behaviours, with a country specific focus on prevention of mother to child transmission (PMTCT) of HIV. This presentation provides an overview of MAMA-SA’s five mHealth communication channels and details the monitoring and evaluation (M&E) that is being conducted on each.

Methods MAMA SA’s five ‘channels’ are SMS, USSD, Mobi, MXit (a South African mobile phone-based chat platform) and voice. With such a variety of communication methods on offer, a detailed M&E plan was necessary to gauge MAMA-SA’s impact on women within the country. To ensure similar levels of M&E across multiple countries, MAMA-Global (MAMA’s global coordination team) supported the initial M&E planning. This process established standardized indicators for all MAMA countries, while leaving room for adding additional indicators for country specific circumstances. Building on the standardized indicators, South Africa has added a number of additional indicators, some of which are based on national PMTCT indicators. Automated and manual data collection methods have been implemented, as well as focus group discussions and user feedback and testing.

Results Since the launch, over 20,000 unique users have interacted with MAMA SA which translates into over 67,000 unique page views, hundreds of mobi-site comments, and more than 110,000 SMS’s and 8500 USSD messages being sent thus far. Most registered mobi-site users (73.01%) have already delivered and are looking for information to care for him/her, while the rest (26.99%) have yet to deliver. A large portion of SMS users (21.88%) opted to receive HIV-related messages, while this is lower than the national HIV rate which currently stands at 29.5%. Focus groups and user testing has shown that users of the service have found MAMA-SA valuable.

Conclusions Preliminary MAMA-SA data indicates high acceptability and satisfaction with the project. Detailed planning of M&E for such a diverse mHealth service offering has been essential. Service uptake has been satisfactory, but strategies for greater publicity are necessary. Further research is necessary (and planned) to ascertain health outcomes of HIV-positive women.

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Posted on Dec 5, 2013 in Conference | 0 comments

TEXT TO MOVE – Randomized Controlled Trial of Personalized Text Messaging to Improve Physical Activity in a Diverse Patient Population with Type 2 Diabetes Mellitus

Stephen Agboola, MD, MPH1,2, Lenny Lopez, MD, MPH, MDiv2, Meghan Searl, PhD, ABBP-CN1,2, Sandra O’Keefe 2, Joseph Kvedar, MD1,2, Kamal Jethwani, MD, MPH1,2

1Center for Connected Health, Partners Healthcare; 2Massachusetts General Hospital, Boston, MA, USA

Journal MTM 2:4S:8, 2013

DOI: 10.7309/jmtm.2.4S.6


Physical activity (PA) is one of the recommended self-care behaviors that have been shown to improve outcomes in the management of type 2 diabetes mellitus (T2DM), but it is difficult to initiate and sustain for patients with T2DM. Text messages (SMS) are rapidly becoming a means of reaching out to diverse patient populations because of the low cost and the ubiquitous nature of mobile phones.

This study examined the effect of personalized text messages on PA, as measured by a pedometer, and clinical outcomes (HbA1C) in patients with T2DM in a 2-arm randomized controlled trial. Following guidelines set by the American Diabetes Association, patients in the program were staged using the Trans-theoretical Model of behavior change, into one of the five stages of behavior change, from pre-contemplation to maintenance, and set personal PA goals. The control group received a pedometer too without personalized messages, in addition to standard diabetes care at Massachusetts General Hospital (MGH). The intervention group received a pedometer, interactive personalized messages twice a day and standard diabetes care. The messages consist of practical educational and motivational information tailored to a 4th grade reading level, their stage of behavior change, and language (English or Spanish). Both groups used a pedometer with wireless upload of data into a SMS engine, which then transmitted customized SMS based on a pre-set algorithm. The morning message delivered subjects’ activity data from the previous day, in context to their goal, while an evening message provided the other messages. The intervention was successfully tested for feasibility in a total of 20 subjects, for 3 weeks. Subjects tested whether the appropriate messages were sent based on the algorithm, whether they were sent on time, and whether the frequency of the messages was appropriate.

This intervention is ongoing at 4 MGH community health centers – Revere, Chelsea, Charlestown and Everett.

The low cost and design of the messages makes it possible for the program to be easily scaled across a diverse patient population regardless of age, educational, economic or ethnic background and sustained for a longer duration; thereby, facilitating sustained behavior change. Given the level of evidence of PA for improved outcomes in DM, personalized SMS could be a means to achieving and sustaining this necessary but difficult behavior to change in T2DM.

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WelTel BC1: A Qualitative Investigation Adapting the WelTel Text Messaging Intervention to Improve HIV Care in British Columbia, Canada

Kirsten Smillie 1, Natasha Van Borek1, Karen Friesen2, Joshua Abaki1, Rebecca Graham2, Evelyn J. Maan2, Juanita Maginley2, Neora Pick2,3,4, Melanie C.M. Murray2,3,4, Mia L. van der Kop5,6, Richard T. Lester1,7, the WelTel BC1 Study Team

1British Columbia Centre for Disease Control, Vancouver, BC; 2Oak Tree Clinic, BC Women’s Hospital & Health Centre; 3Women’s Health Research Institute, BC Women’s Hospital; 4UBC Department of Obstetrics and Gynecology; 5UBC Centre for Disease Control;6Department of Public Health Sciences, Karolinska Institutet; 7UBC Department of Medicine, Division of Infectious Diseases

Journal MTM 2:4S:6–7, 2013

DOI: 10.7309/jmtm.2.4S.5


Background Patient engagement in care and adherence to medication are critical to achieving the full benefits of antiretroviral therapy (ART) among people with HIV infection. A randomized controled trial in Kenya, WelTelKenya1, showed that an interactive mobile phone text messaging intervention can improve adherence and viral load suppression. We conducted a pilot study among individuals taking HAART to assess the acceptability of the WelTel model in a Canadian setting.

Purpose (1) To adapt the WelTel intervention to a Canadian setting, and (2) Assess acceptability by health care providers (HCP) and HIV + clients taking HAART at the Oak Tree Clinic, a women and family centred HIV clinic.

Methods Between April and June 2012, we recruited five participants each from five patient groups: “Youth” (14–24 years), “Mature” (≥50 years), “ESL”, “Remote” (≥3 hours travel time to clinic) and “CD4 < 200”. Participants were sent weekly “How are you?” messages, to which they were required to respond within 48 hours either that they were well or had a problem. Nurses responded to negative and non-responses. Focus group discussion and semi-structured interviews were conducted with health care providers (HCP) (n=5), and participants at baseline (n=25) and study end (n=20). Questionnaires were also administered at baseline (n=25) and study end (n=17). Analysis was guided by two theoretical frameworks: The Technology Acceptance Model and the Theory of Reasoned Action.

Results Of 25 client participants, 80% (20/25) were female, the median age of participants was 46 (range 16–60) and the median time since HIV diagnosis was 13.7 years (range 2.6–20.6 years). 76% (19/25) of participants completed the study. Client participants and HCP indicated high acceptance and satisfaction with the program. Client participants reported the intervention to be a convenient and useful method to engage in communication with their HCP, thus increasing their ability to access support services, report side effects and attend appointments. HCP reported improved contact with clients and a faster response time to clients’ health concerns. Challenges with the intervention included non-responses, cell phone functionality and lost/stolen phones. Recommendations to improve the intervention included varying message frequency, tailoring messages and sending clinical test results via text messages. At study end, all client participants asked (17/17) would recommend the intervention to a peer.

Conclusions Clients and HCP at a Canadian HIV care centre were enthusiastic about the WelTel intervention, believing that regular communication via text messaging was an acceptable and useful approach to maintaining engagement in HIV care.

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Use of the WelTel mobile health intervention at a tuberculosis clinic in British Columbia: a pilot study

Mia L van der Kop1,2, Kirsten Smillie3, Kadria Alasaly3, Natasha Van Borek3, Jesse Coleman4, Jasmina Memetovic3, Darlene Taylor5, Richard Lester5, Fawziah Marra5

1University of British Columbia Centre for Disease Control, Vancouver, BC, Canada; 2Karolinska Institutet, Stockholm, Sweden; 3British Columbia Centre for Disease Control, Vancouver, BC, Canada; 4Wits Reproductive Health & HIV Institute, Johannesburg, South Africa; 5University of British Columbia, Vancouver, BC, Canada

Journal MTM 2:4S:5, 2013

DOI: 10.7309/jmtm.2.4S.4


Successful treatment of latent tuberculosis infection (LTBI) is critical to reduce the impact of TB; however, treatment completion in North America is less than 50%. Evidence has shown that weekly text messages can improve treatment adherence in HIV. One of these evidence-based interventions is WelTel, a service involving weekly text-message “check-ins” with patients. The aim of this study was to determine the feasibility of adopting the WelTel intervention, originally developed and tested in Kenya, for use in the context of TB care in British Columbia (BC).

(1) Determine prevalence of mobile phone ownership, text-message use, and patient attitudes towards receiving text messages from the clinic. (2) Determine the technological feasibility of the WelTel mobile health intervention, and patient and healthcare provider acceptability of the service.

A descriptive cross-sectional survey was undertaken at a provincial TB control clinic in BC. A clinician administered a questionnaire focused on demographics, mobile phone ownership and use, and attitudes towards receiving text messages from the clinic. The WelTel intervention was then implemented in a small group of LTBI patients for 12 weeks. On Monday morning, an SMS gateway sent “How are you?” text messages to patients, to which they were to respond either “OK” or “Not OK” within 48 hours. A clinician phoned those who responded ‘Not OK” and those who did not respond. Participants completed baseline and follow-up questionnaires, and semi-structured interviews.

Of 82 participants who completed the survey between September 2011 and December 2011, 68 owned a mobile phone and 58 used text messaging weekly. Participants were receptive to receiving treatment-related communication from the clinic via text messaging (n= 80) but preferred not to have language relating to TB in the message content. Of 16 patients who received the intervention, 14 completed the study. After overcoming initial difficulties, the technological platform was an efficient way to deliver the intervention. The greatest participant-perceived benefits were that it enabled them to report side effects quickly (n=6), reminded them to take their medication (n=4), and imparted a feeling that their healthcare providers cared (n=2). Interview data supported these findings. Barriers included cost (n=3) and network coverage (n=2).

Patients have the means to communicate with their healthcare providers via text-messaging and were receptive to doing so. The intervention was well-received by participants and the healthcare provider; however, research on its effectiveness to improve TB treatment adherence is required.

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Posted on Dec 5, 2013 in Conference | 0 comments

WelTel LTBI: A Randomized Controlled Trial Protocol of a Text-Messaging Intervention to Improve Patient Adherence to Treatment for Latent Tuberculosis Infection

WelTel LTBI: A Randomized Controlled Trial Protocol of a Text-Messaging Intervention to Improve Patient Adherence to Treatment for Latent Tuberculosis Infection

Mia L van der Kop 1,2, Kirsten Smillie 3, Jasmina Memetovic 3, Kevin Elwood 3, Jan Hajek 4, Lehana Thabane 5, Fawziah Marra 4, Kadria Alasaly 3, Darlene Taylor 4, Richard Lester 4

1University of British Columbia Centre for Disease Control, Vancouver, BC, Canada; 2Karolinska Institutet, Stockholm, Sweden; 3British Columbia Centre for Disease Control, Vancouver, BC, Canada; 4University of British Columbia, Vancouver, BC, Canada; 5McMaster University, Hamilton, ON, Canada

Journal MTM 2:4S:4, 2013

DOI: 10.7309/jmtm.2.4S.3


Successful treatment of latent tuberculosis infection (LTBI) is critical to reduce the impact of TB; however, in North America, fewer than half of individuals starting LTBI treatment complete therapy. While existing TB treatment adherence interventions have not yet proven consistently successful, evidence has shown that weekly text messages can improve treatment adherence in HIV. One of these evidence-based interventions is WelTel, a service involving weekly text-message “check-ins” with patients. The aim of this study is to determine the effectiveness of the WelTel intervention on adherence to LTBI treatment.

The objectives of this study are to: 1) determine the effect of the WelTel intervention on completion of LTBI treatment; 2) determine the effect of the WelTel intervention on daily adherence to LTBI treatment; 3) measure patient satisfaction with the WelTel intervention; 4) evaluate the cost-effectiveness of the WelTel intervention.

A multi-site randomized controlled trial will be conducted at three TB control clinics in British Columbia, Canada. Over two years, we expect to enroll 486 individuals diagnosed with LTBI and initiating isoniazid (INH) (300mg daily for nine months). Participants will be randomly allocated to an intervention or control arm (standard care) at a 1:1 ratio. Intervention arm participants will receive a weekly SMS ‘check-in’, “Are you OK?”, to which they will be instructed to respond within 48 hours either “yes” or “no”. A TB clinician will follow-up and triage any problems that are identified. Participants will be followed for one year, with a primary endpoint of treatment completion, defined as having taken at least 80% of prescribed doses within 12 months. Follow-up questionnaires will be used to assess participant satisfaction with the intervention. Cost-effectiveness will be analyzed through decision-analytic modeling. Data will be analyzed according to intention to treat principles. Chi-squared tests will be used for categorical outcomes; and t-tests or Mann-Whitney U tests for continuous outcomes

Ethical approval has been received from the University of British Columbia Clinical Research Ethics Board (H13-01450). The trial is registered with (NCT01549457). Recruitment began in July 2012, and the study is currently enrolling participants.

The WelTel LTBI trial will contribute important information on the effectiveness of the WelTel text-messaging intervention to improve treatment adherence among patients with LTBI. Trial results and a cost-effectiveness evaluation will inform how WelTel might contribute to the long-term success of TB control and elimination efforts.

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Posted on Dec 5, 2013 in Conference | 0 comments

Improving recognition of severe illness and patient pathways in primary health services using mHealth technology in urban Blantyre, Malawi

Thomasena O’Byrne 1, Deborah Nyirenda 3, Rachel Perrin 2, Sara Marshall 2, Marije Geldof 7, Sarah Bar-Zeev 5, Norman Lufesi 6, Eltas Nyirenda 6, Queen Dube 3,4, Naor Bar-Zeev 3, Linda Glennie 2, Elizabeth Molyneux 4, Robert Heyderman 3,5, Nicola Desmond 3,5

1Action Meningitis, Meningitis Research Foundation, Malawi; 2Meningitis Research Foundation, UK; 3Malawi Liverpool Wellcome Trust Clinical Research Programme, Malawi; 4College of Medicine, Malawi; 5Liverpool School of Tropical Medicine, UK; 6Ministry of Health, Malawi; 7D-Tree International, Malawi

Journal MTM 2:4S:2–3, 2013

DOI: 10.7309/jmtm.2.4S.2


Hospital-based studies suggest that late presentation at tertiary level is a driving factor for mortality from severe febrile illness in resource-poor contexts. Recent research into health seeking pathways in Malawi identified primary level barriers linked to service provision and misdiagnoses. In Malawi an Emergency Triage, Assessment and Treatment (ETAT) package, approved by the World Health Organisation (WHO) has been introduced at tertiary level and is being rolled out to district and primary clinics. mHealth technologies are likely to sustain quality in implementing clinical protocols, particularly when community-based health providers with limited formal training are increasingly working to offset primary level staff shortages.

We aimed to develop and evaluate feasibility and acceptability of a prototype primary care level intervention to improve triage, assessment and referral of children with severe illness in Blantyre and to investigate whether this facilitates systematic and timely recognition and response to severe illness.

All paediatric cases within five primary clinics in urban Blantyre were triaged and assigned Red for Emergency, Amber for Priority and Green for Queue using the mHealth triage algorithm. Phones were assigned to triage, to clinicians and the A&E department within the local tertiary, referral hospital (Queen Elizabeth Central Hospital (QECH)) for monitoring patient referrals.

We conducted a rigorous evaluation using a combination of quantitative and qualitative approaches, both pre- and post and, using the phone as a monitoring tool, in parallel to the intervention.

Seventy-four healthcare staff were trained across five urban primary clinics. A total of 41,358 patients were assessed using the mHealth triage algorithm from December 2012 to May 2013, of whom 1.56% were referred to QECH. Rates of concordance between triage and clinician assessment showed a good level of agreement above chance (Kappa value = 0.71). Pre- and post-Patient Journey Modelling tools identified positive changes in patient flows. Overall patient and health worker satisfaction was high with indirect impact on quality of clinical assessment amongst health workers based at intervention clinics but not directly involved in the intervention.

This study has shown that mHealth technologies have the potential to improve primary level health services in resource-poor contexts with high patient numbers and overburdened health staff. Working in collaboration with the Ministry of Health the data we present will inform the development of a cluster-randomised trial to rigorously evaluate the role of mHealth in the implementation of ETAT. This will aid policy decisions around ETAT implementation at primary health level.

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