Mobile Health (mHealth) Approaches and Lessons for Increased Performance and Retention of Community Health Workers in Low- and Middle-Income Countries: A Review

Abstract

Mobile health (mHealth) describes the use of portable electronic devices with software applications to provide health services and manage patient information. With approximately 5 billion mobile phone users globally, opportunities for mobile technologies to play a formal role in health services, particularly in low- and middle-income countries, are increasingly being recognized. mHealth can also support the performance of health care workers by the dissemination of clinical updates, learning materials, and reminders, particularly in underserved rural locations in low- and middle-income countries where community health workers deliver integrated community case management to children sick with diarrhea, pneumonia, and malaria.
Our aim was to conduct a thematic review of how mHealth projects have approached the intersection of cellular technology and public health in low- and middle-income countries and identify the promising practices and experiences learned, as well as novel and innovative approaches of how mHealth can support community health workers.
In this review, 6 themes of mHealth initiatives were examined using information from peer-reviewed journals, websites, and key reports. Primary mHealth technologies reviewed included mobile phones, personal digital assistants (PDAs) and smartphones, patient monitoring devices, and mobile telemedicine devices. We examined how these tools could be used for education and awareness, data access, and for strengthening health information systems. We also considered how mHealth may support patient monitoring, clinical decision making, and tracking of drugs and supplies. Lessons from mHealth trials and studies were summarized, focusing on low- and middle-income countries and community health workers.
The review revealed that there are very few formal outcome evaluations of mHealth in low-income countries. Although there is vast documentation of project process evaluations, there are few studies demonstrating an impact on clinical outcomes. There is also a lack of mHealth applications and services operating at scale in low- and middle-income countries. The most commonly documented use of mHealth was 1-way text-message and phone reminders to encourage follow-up appointments, healthy behaviors, and data gathering. Innovative mHealth applications for community health workers include the use of mobile phones as job aides, clinical decision support tools, and for data submission and instant feedback on performance.
With partnerships forming between governments, technologists, non-governmental organizations, academia, and industry, there is great potential to improve health services delivery by using mHealth in low- and middle-income countries. As with many other health improvement projects, a key challenge is moving mHealth approaches from pilot projects to national scalable programs while properly engaging health workers and communities in the process. By harnessing the increasing presence of mobile phones among diverse populations, there is promising evidence to suggest that mHealth can be used to deliver increased and enhanced health care services to individuals and communities, while helping to strengthen health systems.

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Original Paper
Mobile Health (mHealth) Approaches and Lessons for Increased
Performance and Retention of Community Health Workers in Low-
and Middle-Income Countries: A Review
Karin Källander
1*
, MSc, PhD; James K Tibenderana
1*
, MB ChB, PhD; Onome J Akpogheneta
2*
, BSC, PhD; Daniel
L Strachan
3*
, BA, MSc; Zelee Hill
3*
, MA, MSc, PhD; Augustinus H A ten Asbroek
4*
, RN, MSc, PhD; Lesong Conteh
4*
,
BSC, MSc, PhD; Betty R Kirkwood
4*
, MA, MSc, DIC, FFPH, FMedSci; Sylvia R Meek
2*
, MA, MSc, PhD
1
Malaria Consortium Africa, Kampala, Uganda
2
Malaria Consortium, London, United Kingdom
3
Institute of Global Health, University College London, London, United Kingdom
4
Faculty of Epidemiology and Population Health, Department of Population Health, London School of Hygiene and Tropical Medicine, London, United
Kingdom
*
all authors contributed equally
Corresponding Author:
Karin Källander, MSc, PhD
Malaria Consortium Africa
P.O Box 8045
Kampala
Uganda
Phone: 256 772744126
Fax: 256 312 300425
Email: k.kallander@malariaconsortium.org
Abstract
Background: Mobile health (mHealth) describes the use of portable electronic devices with software applications to provide
health services and manage patient information. With approximately 5 billion mobile phone users globally, opportunities for
mobile technologies to play a formal role in health services, particularly in low- and middle-income countries, are increasingly
being recognized. mHealth can also support the performance of health care workers by the dissemination of clinical updates,
learning materials, and reminders, particularly in underserved rural locations in low- and middle-income countries where community
health workers deliver integrated community case management to children sick with diarrhea, pneumonia, and malaria.
Objective: Our aim was to conduct a thematic review of how mHealth projects have approached the intersection of cellular
technology and public health in low- and middle-income countries and identify the promising practices and experiences learned,
as well as novel and innovative approaches of how mHealth can support community health workers.
Methods: In this review, 6 themes of mHealth initiatives were examined using information from peer-reviewed journals,
websites, and key reports. Primary mHealth technologies reviewed included mobile phones, personal digital assistants (PDAs)
and smartphones, patient monitoring devices, and mobile telemedicine devices. We examined how these tools could be used for
education and awareness, data access, and for strengthening health information systems. We also considered how mHealth may
support patient monitoring, clinical decision making, and tracking of drugs and supplies. Lessons from mHealth trials and studies
were summarized, focusing on low- and middle-income countries and community health workers.
Results: The review revealed that there are very few formal outcome evaluations of mHealth in low-income countries. Although
there is vast documentation of project process evaluations, there are few studies demonstrating an impact on clinical outcomes.
There is also a lack of mHealth applications and services operating at scale in low- and middle-income countries. The most
commonly documented use of mHealth was 1-way text-message and phone reminders to encourage follow-up appointments,
healthy behaviors, and data gathering. Innovative mHealth applications for community health workers include the use of mobile
phones as job aides, clinical decision support tools, and for data submission and instant feedback on performance.
Conclusions: With partnerships forming between governments, technologists, non-governmental organizations, academia, and
industry, there is great potential to improve health services delivery by using mHealth in low- and middle-income countries. As
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with many other health improvement projects, a key challenge is moving mHealth approaches from pilot projects to national
scalable programs while properly engaging health workers and communities in the process. By harnessing the increasing presence
of mobile phones among diverse populations, there is promising evidence to suggest that mHealth can be used to deliver increased
and enhanced health care services to individuals and communities, while helping to strengthen health systems.
(J Med Internet Res 2013;15(1):e17) doi:10.2196/jmir.2130
KEYWORDS
mHealth; community health worker; Africa
Introduction
Community health workers were a cornerstone of primary health
care as envisaged by the Declaration of Alma-Ata in 1978, yet
the enthusiasm for community health workers started to diminish
by the early 1990s, partly because of the challenges of scaling-up
programs in a sustainable fashion while maintaining their
effectiveness [1]. However, due to slow progress toward the
United Nations’ Millennium Development Goals,
community-based programs delivering care to sick children
have yet again become priorities to curb child mortality in
high-mortality countries [2]. Integrated community case
management (ICCM) of malaria, pneumonia, and diarrhea
delivered by community health workers is such a strategy, which
is now being implemented at scale in several African countries,
including Uganda and Mozambique. The purpose of ICCM is
to improve access to effective treatment for sick children among
hard-to-reach populations with the ultimate goal of reducing
under-5 mortality.
The Innovations at Scale for Community Access and Lasting
Effects (inSCALE) project, a collaboration between Malaria
Consortium, London School of Hygiene and Tropical Medicine,
and University College of London, aims to better understand
community health workers motivation and supervision, and to
find feasible and acceptable solutions to community health
workers’retention and performance, both of which are vital for
successful implementation of ICCM at scale. One such solution
could be to use mobile phones as a tool to increase the status
of community health workers in the community and allow
frequent feedback and support to community health workers
based on data submitted, potentially resulting in improved
quality of care delivered.
With almost 5 billion mobile phone users in the world, health
care providers and researchers are realizing the potential of
using mobile technologies, such as mobile phones, portable
computers, and personal digital assistants (PDAs), for health
services. Mobile health (mHealth), as defined by the World
Health Organization (WHO), is an area of electronic health
(eHealth) that provides health services and information via
mobile technologies such as mobile phones and PDAs. mHealth
can also support the performance of health care workers by the
dissemination of clinical updates, learning materials, and
reminders [3], particularly in underserved rural locations in low-
and middle-income countries where community health workers
deliver ICCM to children sick with diarrhea, pneumonia, and
malaria [3,4].
The aim of this review is to provide a thematic overview of
mHealth project approaches to the intersection of mobile
technology and public health and the application of these
approaches in programs specifically focusing on community
health workers. The potential challenges and opportunities for
integration of such mHealth applications in existing national
systems are discussed.
Methods
A 2-stage process was applied in this review. In the first stage,
a broad search was done to generate a list of domains in which
mHealth has been applied in low- and middle-income countries.
Non-peer-reviewed sources of information, including Web-based
mHealth portals, mHealth review documents [4-7], and reports
that specifically map out mHealth initiatives in Uganda and
Mozambique [8,9] were used (Table 1). The search in this stage
did not aim to generate a comprehensive list of all mHealth
projects conducted in low- and middle-income countries; the
purpose was to generate different mHealth domains and give
examples of projects that have addressed the domains identified.
Table 1. Sources used to identify mHealth projects.
NameSource
The Communication Initiative Network [10]mHealth portals
KIT Royal Tropical Institute [11]
Mechael et al [5]Review documents
Vital Wave Consulting [6]
Vital Wave Consulting [7]
Macueve [8]Country reports
Mwagale and Kakaire [9]
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In the second review stage, a narrower and more systematic
search was done to identify projects that applied mHealth for
community health workers in low- and middle-income countries.
In addition to the sources provided in Table 1, peer-reviewed
papers were identified from searches on PubMed and Google
Scholar by using the following search terms: mHealth, mobile
health, developing, and low income. Projects conducted in
countries with low, lower-middle, or upper-middle incomes (as
per World Bank definition) qualified for inclusion if they
mentioned that at least 1 of their user groups included
community health workers. Although the main reviews for both
stages 1 and 2 were conducted by the first author (KK) between
June and September 2010, the review in stage 2 was updated
in April 2012 by using the same search terms as used previously.
Project descriptions published after these dates are not included
in this review.
The information from stage 1 was structured by the first author
(KK) who classified the projects into predefined themes. Various
numbers of themes have been used previously within the
mHealth ecosystem, ranging from 4 different categories in a
review by Blynn [12], 5 in a paper by Mechael et al [5], and 6
in a report by Vital Wave Consulting [6]. To give a more
diversified description of the projects reviewed, we adopted the
6-theme classification used by Vital Wave Consulting (Table
2).
Table 2. The six themes in mHealth.
Description
Theme
a
Primarily 1-way communication programs to mobile subscribers via SMS/text messaging in support of public health,
behavior-change campaigns.
Education and awareness
Applications designed to use mobile phones, PDAs, or laptops to enter and access patient data. Some projects may
also be used by patients to access their own records.
Data access
One- or 2-way communications to the patient to monitor health conditions, maintain caregiver appointments, or ensure
strict medication regimen adherence. Some applications may also include inpatient and outpatient monitoring sensors
for monitoring of multiple conditions (such as diabetes, vital signs, or cardiac).
Monitoring and compliance
Applications using mobile devices to send and receive data of disease incidence, outbreaks, geographic spread of
public health emergencies, often in association with Global Positioning System (GPS) systems and backend applications
for visualization.
Disease and emergency
tracking
Applications developed for “back office” or central health care information technology systems allowing for access
by and integration with mHealth application. Such applications often tie-in to regional, national, or global systems.
Health information systems
Applications developed to provide support for diagnostic and treatment activities of remote caregivers through Internet
access to medical information databases or to medical staff.
Diagnosis and consultation
a
Adopted from Vital Wave Consulting [6].
Key mHealth technologies reviewed included mobile phones,
PDAs and smartphones, patient monitoring devices, and mobile
telemedicine devices. The ways these tools can be used for
education and awareness, data access, and for strengthening
health information systems were explored. We also considered
how mHealth may support patient monitoring, clinical decision
making, and tracking of drugs, supplies, and emergencies.
For information gathered in stage 2 of the review process, the
results were analyzed, classified into a theme, and described in
more detail by using a predesigned data collection table
(available on request from first author). The results were
presented to the coauthors in an 8-person research team meeting
and the classification was discussed until consensus was
achieved.
Results
Common mHealth Solutions
The main capabilities provided by mHealth applications are
voice, text, and data access with information going 1 way, 2
ways, or multiple ways (Table 3). These applications included
phone calls (personal or automated robocalls with or without
toll-free numbers), text messages (including personal text
reminders or mass texting for community mobilization), data
transfer for health record tracking or clinical decision support,
and mobile telemedicine devices for patient monitoring or
diagnosis.
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Table 3. Example of mHealth applications utilizing 1-way, 2-way, or multiway communication.
Example mHealth applicationCommunication type
SMS/rapid SMS1-way
Sending data
Push messages
“Please call me” message
Sending data and receiving feedback2-way
Quizzes/games
Hotlines/textlines
Remote consultation/training
Frontline SMSMultiway
Facebook
Twitter
One-Way, Two-Way, or Multiway Applications
Communication between a sender and receiver can occur in
more than 1 direction and within varying group sizes. One-way
communication is similar to mass media that distributes
information in 1 direction. mHealth innovations have typically
been designed as 1-way communications in which projects use
“push” technology to deliver information to subscribers’phones
by using messages tailored to personal needs. Most commonly
identified push designs include bulk short message service
(SMS) or robocalls to large audiences.
Two-way communication is interactive and more similar to
interpersonal communication. For users, interactivity may
require greater effort and generate greater interest. Interactive
quizzes, information menus, data collection and tailored
responses, hotlines, and interactive voice responses are examples
of 2-way communication [5]. Although most 2-way
communication does not occur in real time, some applications,
such as closed user groups or voice over IP (VoIP) for remote
health consultations and health worker training, do use real-time
communication [6].
Multiway communication can vary the number of senders and
receivers, including 1-to-many, many-to-1, and many-to-many
communication. Many-to-many communications include social
media applications, such as Facebook or Twitter, that can be
accessed from most Internet-enabled mobile phones. Most
mHealth projects used a combination of 1-way and 2-way
communication methods pertinent to several themed categories
in Table 2, whereas only a few projects could be identified that
used social media.
Education and Awareness
The Cellphones4HIV project in South Africa described by de
Tolly and Alexander [13] sends out messages on antiretroviral
treatment adherence using Unstructured Supplementary Service
Data (USSD) (ie, the system used to load airtime), Mxit (a Java
application that allows general packet radio service [GPRS] or
3G-based instant messaging) and voicemail messages pushed
into the user’s voicemail inbox with notification by SMS. Push
designs were found to have differing capabilities, limitations,
and requirements, but may be combined, adapted, or further
expanded as technology evolves.
Projects for remote health information dissemination, like
Project Masiluleke [14] and Text-to-Change (TTC) [15], have
reached large audiences with information on HIV prevention
and treatment using ”please call me” (PCM) messages and bulk
SMS. PCM messages have been widely used in mHealth projects
in Africa because they are free for senders and can be sent from
phones that have no credit. Project Masiluleke in South Africa
sent 1 million PCM messages per day for 1 year, offering contact
information for local HIV and tuberculosis call centers
[14].Within 5 months, calls to South Africa’s National AIDS
helpline quadrupled [16]. In Uganda, TCC used a bulk SMS
platform to create dialog and increase awareness of HIV in order
to reduce related stigma and discrimination, and motivate people
to seek HIV testing and treatment [15]. TTC also sent out
quizzes and information about HIV prevention and testing,
awarding those who pass the quiz with airtime. Of 15,000
subscribers contacted by TTC, 2500 responded to each question.
In FHI360-SATELLIFE’s Uganda Health Information Network
(UHIN) project, continuing medical education targeted to health
workers was broadcast 3 times per week via PDAs regarding
diagnosis, treatment, and prevention of major health problems
[17]. In addition, they received daily news from mainstream
media. Other projects used SMS for behavior-change
communication. The Text2Teach project gave Philippine
teachers a mobile phone texting platform to receive videos via
satellite over school-based televisions and mobile technology
involving parents [18]. Behavior-change communication can
be used in various applications, from family planning and
teenage pregnancy to disease awareness and prevention to advice
on agricultural and farming techniques.
Social networks, such as Facebook, Twitter, or Hi5, are used
by hundreds of millions of people to communicate about a huge
range of topics, including health. The WHO used Twitter during
the influenza A (H1N1) pandemic and, at time of writing, had
more than 11,700 followers from all over the world [19]. In
Mozambique, the nonprofit organization DKT International
launched a social franchising program, branded as Intimo, that
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uses social media to increase access to its clinics. Its Facebook
page reaches over 6600 Mozambicans (85% between the ages
of 18 and 34 years) with information on family planning and
reproductive health [20]. In Indonesia, the Fiesta condom brand
has used Facebook, Twitter, and YouTube to talk about safe
sex and condom use [21].
Community Health Worker Program Innovations for
Education and Awareness
Through SMS with community members and community health
workers, mHealth has opportunities to communicate health
messages directly and simultaneously [22]. The SMS campaigns
for health education, promotion, and awareness typically used
SMS to disseminate information and prevention messaging or
direct patients to services. Mobile phones also present
opportunities for community health workers to communicate
directly with one another and provide peer support [4]. To
provide additional support to community health workers during
home visits, the Tanzanian Mobile Video for Community Health
Workers project used the CommCare tool to provide health
education videos played on mobile phones [23].
Stakeholders suggested expanding 1-way to 2-way
communications, including introducing a referral alert process
in which community health workers call health facilities before
the patients’ arrival [4]. Establishing call-in services for each
health facility could also allow community health workers to
receive updated information on drug stocks, attendance records,
and other relevant information. In addition, appointment
confirmation texts for referred patients with time, date, and
appointment location could be effective, as well as SMS alerts
to community health workers about appointments attended by
referred patients. Texts or SMS could also be used by health
facility workers and community health workers to keep each
other informed of recent developments and upcoming events,
including SMS to community health workers on their birthday
for motivation [4].
The concern that national privacy laws can hinder projects from
accessing the target beneficiaries’personal phone numbers was
raised. One stakeholder mentioned a project in which a
collection of mobile phone numbers for health workers to send
push messages had to be stopped after concerns were raised
about the assumption that all health providers had given their
permission to allow projects to reach them on their telephones
(J Tibenderana, personal communication, September 2010).
Data Access
Innovations in mHealth can conceivably change how data are
used in health programs, leading to faster, decentralized decision
making and reallocation of resources due to faster data analysis
[22]. Handheld computers, PDAs, or laptops for data collection
and reporting can use 1- or 2-way communication systems.
RapidSMS has established a 2-way flow of communication that
empowers stakeholders with a dynamic tool for fast, efficient,
and accurate data collection, analysis, and communication [24].
In addition, SMS-based data for health care workers can identify,
diagnose, and track patients by using streamlined technology
that is automatically updated in a central system.
Twelve Ugandan projects used mobile technology for data
collection and reporting [9]. Most were designed as 1-way
communication systems to improve data collection or
management in surveys, routine care, and vaccine trials.
Community Health Worker Program Innovations for
Data Access
Although there is little evidence of the effectiveness of
community health workers collecting and self-reporting data
from patient records, mobile phones have been suggested as a
useful tool for rural health workers’ reporting of data as it is
suggested it improves accuracy, reduces time and cost, and
improves data quality [19]. A cost-effectiveness study showed
that using PDAs for data collection delivered 24% savings per
unit of spending over traditional manual data collection and
transmission approaches [25]. However, use of PDAs in a
Rwandan ICCM program exacerbated, rather than lessened,
volunteer workload [4]; mobile phone-assisted data collection
became onerous and was felt to have distanced community
health workers from the human side of their role, turning them
into “data collection robots.”
Blaschke et al [26] and the Millennium Villages Project [27]
describe the use of ChildCount+ that uses mobile technologies
for improving data use and reporting among community health
workers in several African countries, including Malawi and
Uganda. This platform, developed by the Millennium Villages
Project, aimed to improve maternal and child survival by
supporting delivery of community-based management of acute
malnutrition, malaria, and diarrhea. Three months after initiation,
95% of 9561 children under 5 years in the Malawian cluster
had been registered using mobile technology, and only
approximately 10% of incoming messages to the system were
rejected due to improper formatting [26]. The RapidSMS
platform used led to significant reduction in data transmission
delay compared to Malawi’s current paper-based system.
Monitoring and Compliance
Text messaging via mobile phones has garnered increasing
attention as a means of reminding patients of appointments in
the United Kingdom, United States, Norway, and Sweden. This
resulted in a lowering of nonattendance to scheduled
appointments, yielding significant savings in health costs for
facilities and practitioners [28]. In this case, the benefit is
cost-related rather than health outcome-related.
In addition, SMS has also been used as a way of monitoring
patients’ medication compliance. However, literature on
treatment compliance has focused primarily on management of
chronic diseases, such as diabetes, smoking cessation, and breast
cancer, in high-income countries and few examples exist from
low- and middle-income countries [5]. A South African trial
showed tuberculosis patients with increased compliance rates,
and a Thai study showed that 90% of tuberculosis patients
receiving daily SMS medication reminders adhered to treatment
[7,12]. A Kenyan efficacy study provided 428 HIV patients
with mobile phones and randomized patients to receive daily,
weekly, or no SMS reminders. Treatment adherence was
improved for patients receiving weekly, but not daily, SMS and
treatment interruptions were less likely [29]. Adding words of
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encouragement to an SMS did not prove more effective and
confidentiality was a concern.
To improve medicine compliance and adherence to antiretroviral
drugs in Uganda, a medical container called Wisepill was used
to transmit a cellular signal whenever opened, send weekly SMS
at preset times, and provide interactive voice response [30]. A
similar project, SIMpill, monitored adherence to tuberculosis
drugs in South Africa [31]. Few randomized controlled trials
studying treatment compliance were found, and statistically
significant results were limited by sample size; mixed results
have been found in other studies [32]. A strong focus on
feasibility and usability was evident, with little connection to
health outcomes [5].
Other mHealth applications can be used to improve compliance
to guidelines by health workers. A proof-of-concept randomized
controlled Kenyan trial on adherence to malaria treatment
guidelines used 10 carefully designed SMSs with drug delivery
instructions and an unrelated motivational message to aid rural
health facility workers [33]. Both immediate and 6-month
analyses showed improved malaria case management. The trial
is undergoing cost-effectiveness analysis and qualitative analysis
to examine possible added burdens on health workers.
Community Health Worker Program Innovations for
Monitoring Compliance
A randomized controlled trial delivered SMS to
community-based peer health workers in rural Uganda
supporting antiretroviral treatment for HIV patients [34]. No
virological differences in patient outcome over 26 months were
observed, but limited qualitative data showed improvements in
patient care, logistics, and broad support from health workers
and patients. Improvements in peer health worker morale and
confidence were reported; peer health worker-patient
relationships improved, shifting burdens from staff-patient
relationships. As compared to voice calls, reservations about
the lack of immediate response via SMS were noted, privacy
concerns were raised, and phone maintenance and charging
were also problematic.
Disease and Emergency Tracking
Several countries have used mHealth innovations for not only
disease tracking, but also for supply tracking. The Foundation
for Innovative New Diagnostics (FIND) deployed RapidSMS
in 2 districts in Uganda and worked with health centers to submit
and map weekly epidemiological records, malaria case
management, and malaria medicine stock reports [35]. The
platform EpiSurveyor has also been widely used for emergency
response and tracking supplies. It allows users to download,
fill, and send forms to central databases for real-time analysis
[36].
Mobile phones and Web-based technologies have also been
used for early warning of disease outbreaks. The Acute
Encephalitis Syndrome Surveillance Information System
(AESSIMS) project in India aimed to improve immunization
services for Japanese B encephalitis, diphtheria, hepatitis B,
measles, pertussis, tetanus, and polio by tracking diseases in
real time [37].
Reports have described mobile technology use during natural
disasters, including the earthquakes in China in 2008 and Haiti
in 2010 [38,39]. Mobile phones were primarily used for tracking
population movements, infectious disease reporting, and
coordinating search and rescue missions. Studies investigating
mobile phone use for telemedicine during emergencies found
them effective for relatively fast and accurate in-transit patient
treatment, sending images for diagnosis, and using video
capabilities.
Community Health Worker Program Innovations for
Disease and Emergency Warning Systems
As part of Cambodia’s malaria elimination strategy, the National
Center for Parasitology, Entomology and Malaria Control
(CNM), with technical support from Malaria Consortium and
WHO, village malaria workers are trained to send SMSs to
report malaria cases in real time [40]. These SMS messages
also support the paper reporting that feeds into the health
information system from the health centers. The project had
low start-up costs, estimated at US $100 for each village malaria
worker, which includes a mobile phone, subscriber identity
module (SIM) card, solar charger, and training. Because of the
effective cooperation with the private sector, all SMS messaging
is free resulting in essentially zero maintenance costs [41].
In areas where outbreaks of disease occur, community health
workers could use mHealth to track medicine stocks (eg, FIND)
and report observed cases with daily case statistics delivered
using FrontlineSMS [40]. Community health workers can also
minimize the impact of outbreaks by disseminating educational
information about disease prevention and handling. In the
Healthy Child Uganda project, community health workers used
mobile phones to send emergency alerts and requisition supplies
to support ICCM activities in treating pneumonia, diarrhea, and
malaria [42].
Health Information Systems
Health administration systems are used for epidemiological
research, tracking of indicators for monitoring and evaluation,
and financial and cost reporting for supply management [6].
Mozambique used PDAs to support collection of data from
health records [43]. The stand-alone system, known as “módulo
básico,” has now been implemented in all provinces and districts
in the country [44].
Several African countries, including Mozambique and Uganda,
have tested 2-way access to district health information by using
mobile phone networks and low-cost PDAs for data
dissemination, collection and reporting, and email exchange
[17,45]. The Mozambique Health Information Network (MHIN)
set up data transfer via PDAs using wireless access points and
a server located at the Ministry of Health in Mozambique.
District health offices received data from health centers and
used the network to monitor drug stocks and guide orders. Up
to 50% improvement in data quality was observed. The MHIN
services are expanding to additional districts and cost-benefit
analyses comparing MHIN- and paper-based approaches are
planned [45].
The same team who worked on MHIN also set up UHIN in
Uganda [17]. Health workers used PDAs to collect and upload
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data and emails via infrared, Bluetooth, or Wi-Fi at rural health
facilities. The access point sent data and messages via mobile
networks to the server, which routed them to the correct
recipients and sent return messages with data and health
information.
The public-private SMS for Life project in Tanzania used mobile
phones and electronic mapping technology to generate and
deliver weekly information to health centers on malaria
medicines [46]. The project proved successful, and medicine
stock-out rates were significantly reduced within 21 days.
Sustainability of countrywide mHealth programs relies on
incorporation with the national health care program of the
country, yet few African countries have developed national
eHealth or mHealth policies, strategies, or guidelines [5]. Much
of this is because of the limited knowledge of what works, how
it works, and how much it costs. An exception is Ethiopia, where
a national policy for eHealth is about to be launched [47].
Community Health Worker Program Innovations for
Health Information Systems
Few studies have examined health information and
administration systems that include community health workers.
The ICT4MPOWER project is a 3-year proof-of-concept project
in Uganda aiming to increase health system effectiveness and
empower community health workers in rural areas by aiding
referrals and patient follow-up, while ensuring transfer of skills
and knowledge to health workers [48]. The Tanzanian
CommCare project provided a community health mobile
platform, enabling community health workers to provide more
efficient care and to receive better supervision [49]. Such
projects indicate the great potential to link community health
workers with health administration systems by using mobile
technologies that would add value to government health policy,
providing integrated health data and a dynamic picture of
national health care provision.
Diagnosis and Consultation
Use of electronic technologies to provide support for diagnosis,
consultation, and treatment activities conducted by remote
caregivers is increasingly common. Mobile phones can be used
as respiratory or pulse rate counters, gestational age date
calculators, drug dose calculators, drip rate calculators, and drug
reminder alarms when installed in mobile phones and linked to
a sensor [50]. Another example of a diagnostic tool is CellScope,
which uses a modified mobile phone for blood, urine, or other
sample loading for malaria, HIV, and tuberculosis diagnosis
[51]. None of these applications requires any transfer of data;
hence, running costs are close to zero.
A pilot study of Electronic Integrated Management of Childhood
Illnesses (eIMCI) in rural Tanzania, tested whether PDAs could
improve diagnosis of children using IMCI protocols. The project
was found to be feasible and acceptable to health workers in
providing mobile decision support [52]. In addition, 6 Ugandan
projects used mobile phones to send medical test results through
SMS or email to patients and health workers; others used
wireless devices to provide clinical training and patient care
support services [9].
Community Health Worker Program Innovations for
Diagnosis and Consultation
RapidSMS can be used in various ways, including supporting
community health worker-patient interactions [24]. Mobile
phones used as job aides could allow community health workers,
via SMS or data transfer, to send patient information and receive
instructions on how to proceed [27]. This could demonstrate
program effectiveness to community health workers, potentially
motivating continued work and better service [4]. In Colombia,
the CellPhone GuideView system broke down complex
diagnostic and treatment procedures into simple steps for
community health workers using an authoring tool in which
text, pictures, audio, and video were embedded to aid
comprehension and ease of use [50,53]. Community health
workers were then able to transmit images, data, and audio to
remote experts for further advice.
Discussion
The review revealed that there are very few formal outcome
evaluations of mHealth in low-income countries. Although there
is vast documentation of project process and uptake, most were
evaluations of small-scale pilot studies that were not designed
to demonstrate an impact on behavior change or health. There
is also a lack of mHealth applications and services operating at
scale in low- and middle-income countries. The most commonly
documented use of mHealth was 1-way text-message and phone
reminders to encourage follow-up appointments, healthy
behaviors, and data gathering. Two-way communication
applications focused primarily on data transmission with
automated feedback response, and few projects were
implementing real-time communication. Although some claim
that social media can be an effective tool for engaging patients
online [54], others argue that health institutions need to develop
clear policies about the use of social media in patient care
environments to ensure patient safety [55]. However, the
majority of multiway and social media projects identified in
this review were patient/user driven, such as Facebook or
Twitter, with little or no involvement of treating physicians or
nurses.
A limited number of mHealth projects were found which
specifically targeted community health workers. Of the few
projects identified, most used a combination of simple mobile
phone applications for data submission, job aids to improve
diagnostics, and for sending and receiving SMS messages and
reminders. None of these projects had evaluated the impact of
these tools on community health workers quality of care
provided. Most projects used applications that communicated
by using 1-way or 2-way SMS, whereas GPRS-enabled
applications were rare. Although several projects tested
applications that aimed to improve accuracy in community
health worker data submission and clinical decision-making
skills using electronic job aids [26,27,49], international
stakeholders cautioned that these may result in community
health workers focusing more on the technology than on the
patient [4].
The key considerations for successful use of or expansion of
mHealth innovations include collaboration, financing, literacy
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and cultural, partnerships, and technical considerations (Table
4). As a young field, mHealth is well positioned to benefit from
best practices and available technology documented in various
project reports. Sustainability and scalability are still the main
challenges to the strategic deployment of mHealth applications,
partly reflecting the gap between what application developers
are doing on the ground and what the governments see as
priorities and initiatives they need to step in and support [2].
Establishing true partnerships with users and policy makers
throughout the design and implementation processes is critical
for success and collaboration with operators could ensure
technical support, make scale-up possible, and reduce costs to
drive mHealth demand and innovation [4,5]. This is illustrated
by examples from Ghana and Cambodia, where physicians
registered with the Ghana Medical Association have access to
unlimited calls through the mobile service operator, OneTouch
[3], and where village malaria workers in Cambodia report
malaria cases by using free SMS with Mobitel [40].
Table 4. Key considerations for successful use and expansion of mHealth innovations.
DescriptionAreas of consideration
Collaborative projects allow simpler widespread implementationCollaboration
Collaboration with operators could ensure technical support and make program scaling possible
Collaboration more likely when all partners display strong affinity to the goal
Collaborations can provide resources and support for project costsCosts and sustainable financing
Organizations more likely to commit resources for piloting new initiatives when projects
lasted for limited timeframe, when partners maintain control over deliverables, and when
funds do not need approval and transference to third party
Average SMS cost does not exceed US $0.05
Lost phones and hardware can be mitigated by providing cheaper phones and ensuring
equipment bears the program logo
Illiteracy is an important consideration for text-based innovations in low- and middle-income
countries
Literacy and cultural specificity
Accessibility to target users/patients must consider cultural sensitivities
Partnership with users can enhance design and implementation of projectsHealth worker partnership, engagement, training, and
compliance
Using iterative cycles with target users when developing a software can stimulate ownership
and enhance project engagement
Data feedback reports should be distributed to users submitting data regularly (perhaps initially
once per week)
Use brief and personal SMS messages, allow opt out, allow language choice (with careful
translation), and validate content with target users
Use user-friendly and project-appropriate equipmentTechnical considerations
Maintain 160 character length for SMS
Take care with abbreviations, slang, and tone in SMS messages
Ensure enough time for procuring and establishing necessary equipment and phone lines
First resolve lack of telephone and Internet connectivity among target health care providers
Use of existing technology, such as “please call me” messages, rather than introduction of
new technologies
Implement clear data usage and storage guidelines with data quality checks and backups made
frequently
The national ownership of mHealth applications cannot be
overemphasized. Some good examples of country ownership
exist, such as state programs in Ghana and Nigeria, which
address maternal and neonatal health using mobile phones [56].
The challenge is to have health ministers and officials at the
same table as mobile service providers, doctors, technologists,
and financiers. Coordination among these stakeholders and
agreement of incentive structures and responsibilities for
meaningful collaboration is needed to better inform public and
private investments and the deployment of commercially viable
solutions [5].
The mHealth interventions often used SMS to provide
information, motivate individuals, and encourage
self-management or promote disease prevention. However,
illiteracy is an issue for text-based prevention interventions [5].
Culturally specific provision of health information is important
because poorly designed campaigns can have negative
unintended effects; good understanding of cultural context and
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strategies to overcome language and literacy barriers are needed.
As with other mHealth applications, there is a significant gap
in evidence on behavioral, social, economic, and health
outcomes of using mobile phones and SMS for improving health
in low- and middle-income countries, as demonstrated in a
systematic review of the literature [57].
Funding in low- and middle-income countries is not adequate
to support complex telemedicine in emergency situations.
Infrastructural limitations, such as network capacity, also
constrain the effectiveness of emergency monitoring and
tracking [5]. However, routine data from all active SIM cards
could be used in disaster-affected areas for near real-time
monitoring of population movements during disease outbreaks
[39]. Another significant barrier to implementation of mHealth
systems is in relation to health worker resistance to new
technology and broader discussion and research about health
worker benefits, and incentives for use and compliance is
required [5,6,22]. This would include ensuring adequate training
also remains a critical component for large-scale implementation
[5].
Addressing security and privacy issues in mHealth has also
proven challenging. Guidelines on the rights to data, usage, and
storage must be outlined and implemented, with sufficient
qualitative data to explain potential findings collected alongside
close program monitoring. For mHealth success, cooperation
between local communities and regional and national health
information systems is essential [3,58,59]. It is also unclear
from the review whether SMS projects for health workers need
to comply with any national privacy laws because collecting
health workers’ private phone numbers to push messages is
assuming that they have all given their permission to have the
project reach them on their phones.
Limitations related to the landscape analysis should be
considered when interpreting the results. The review focused
only on 6 major thematic areas for mHealth and it is possible
that some mHealth applications and tools have been excluded.
Given the bulk of projects piloting mHealth applications in low-
and middle-income countries, the first stage of the review only
describes a sample of projects and applications tested under
each thematic area. However, the second stage of the review,
ie, that of mHealth projects targeting community health workers,
was deemed systematic and comprehensive. The sources of the
information reviewed were primarily obtained from project
websites because few peer-reviewed evaluations were identified,
potentially resulting in overreporting of positive results and
underreporting of challenges or failures.
With partnerships forming between governments, technologists,
non-governmental organizations, academia, and industry, there
is great potential to improve health services delivery using
mHealth in low- and middle-income countries. As with many
other health improvement projects, a key challenge is moving
mHealth approaches from pilot projects to national scalable
programs while properly engaging health workers and
communities in the process. By harnessing the increasing
presence of mobile phones among diverse populations, there is
promising evidence to suggest that mHealth can be used to
deliver increased and enhanced health care services to
individuals and communities, while helping to strengthen health
systems.
Acknowledgments
We are grateful to the Bill & Melinda Gates Foundation for sponsoring this research under the Innovations at Scale for Community
Access and Lasting Effects (inSCALE) project.
Conflicts of Interest
None declared.
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Abbreviations
AESSIMS: Acute Encephalitis Syndrome Surveillance Information System
FIND: Foundation for Innovative New Diagnostics
GPRS: general packet radio service
GPS: Global Positioning System
ICCM: integrated community case management
MHIN: Mozambique Health Information Network
PCM: please call me
PDA: personal digital assistant
SIM: subscriber identity module
SMS: short message service
TTC: Text-to-Change
UHIN: Uganda Health Information Network
USSD: Unstructured Supplementary Service Data
VoIP: voice over IP
WHO: World Health Organization
Edited by G Eysenbach; submitted 07.04.12; peer-reviewed by E Afari-kumah, A Fuad, S Langrial; comments to author 21.05.12;
revised version received 19.10.12; accepted 08.11.12; published 25.01.13
Please cite as:
Källander K, Tibenderana JK, Akpogheneta OJ, Strachan DL, Hill Z, ten Asbroek AHA, Conteh L, Kirkwood BR, Meek SR
Mobile Health (mHealth) Approaches and Lessons for Increased Performance and Retention of Community Health Workers in Low-
and Middle-Income Countries: A Review
J Med Internet Res 2013;15(1):e17
URL: http://www.jmir.org/2013/1/e17/
doi:10.2196/jmir.2130
PMID:
©Karin Källander, James K Tibenderana, Onome J Akpogheneta, Daniel L Strachan, Zelee Hill, Augustinus H A ten Asbroek,
Lesong Conteh, Betty R Kirkwood, Sylvia R Meek. Originally published in the Journal of Medical Internet Research
(http://www.jmir.org), 25.01.2013. This is an open-access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any
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