m-Health solutions for TB care: A moment to ponder

Dr Diana Wangari, CNS Special Correspondent, Kenya
Dr Evan Lee (R)
In a world where the use of information and communication technology is on a constant rise, the mobile phone, in particular, has permeated to low-income nations where, even in the remotest of areas, it is becoming a form of a necessity. It then seems logical that we utilize this gadget, as much as we can, in seeking health solutions. During the 46th Union World Conference on Lung Health held in Cape Town, results of some of the m-health projects for TB care and control piloted in different countries were shared in a lively session.

Tajikistan is using satellite technology for MDR-TB treatment support. In one such pilot study, social workers were equipped with, and trained to use small GPS trackers to strengthen and guarantee DOTS for MDR-TB patients. The trackers send data via GMS and report to the server on GPS positioning, which coordinators and managers can access. The report contains data on the amount of time spent and shows travel on among geozones. The system allows recording of the dialogue between patient and social worker.

Pakistan’s Indus Hospital collects and maintains data in open source electronic recording and reporting system to help in community based MDR-TB treatment. This ambulatory care model involves patient enablers and is used for analysis and tracing. Aside from the consultations, treatment supporters also provide daily DOTS in the patient’s home. Patients are provided with monthly enablers in the form of food baskets for family and travel costs, with the treatment supporter receiving the same basket as well.

Myanmar is using mobile health to strengthen community based management of MDR-TB. A mobile health application, DOTSync was developed to train and track community volunteers in their daily work. The mobile app goes through simple steps to guide the activity workflow in the home, providing a checklist to review DOTS, health education messages and audio–visual aids for patient communications. Through the sync feature, data is uploaded to the cloud and in remote areas the information is automatically uploaded upon immediate return to an access area.  Thus, DOTS provision is monitored through daily data uploads, enabling timely follow up for missed doses and quality control for community volunteers. The results? Compared to preDOT sync, the identification of presumptive TB/MDR–TB cases was more efficient with a higher sputum positivity rate. Data on treatment outcome for 30 patients supported with DOTsync are promising with a treatment success rate of 93%.

Vietnam has used the application of m-health in monitoring and social franchising activities on TB screening and referral among pharmacies and private clinics in three provinces. The study was done between December 2014 and October 2015 where 1453 rural pharmacy operators were engaged to screen and refer customers with TB symptoms using four main strategies, one of which involved a mobile screening app and sms text messages, reminding pharmacy operators of the benefits of correct referral practices. The findings? 13,730 individuals with TB symptoms were referred, 10,407 were sputum tested and 1,822 cases were detected-- that is 10 cases of smear positive TB detected for every 100 presumptive TB cases referred.

Zambia has utilized electronic health records to improve data capture of TB screening in an HIV setting where all that the patients require is a chip card that contains all their information, including doctor’s reviews and treatment. Apart from these, some pilot studies done in Canada, Nigeria and India were also presented.

The presentations and discussions surrounding the various solutions brought out various factors where one has to wonder (as we applaud the strides made in integrating information and technology to provide m-health solutions), if we have thought through it and asked what next?

Like in case of most innovations, implementation of m-health projects will also present challenges. How many staff members are computer literate particularly in rural settings of low and middle-income countries where the disease burden is highest? Will they therefore have to undergo training to simply learn how to use the very system that is meant to make their work easier? In Zambia, one version of the project has a data clerk enter the data and the other the practitioners do so while reviewing patients. However, only 6.7% of the patients screened were captured under the Smart Care, performing dismally compared to the paper system of data capture.

What could be the motivating factors to use this technology?

In Pakistan for example, food baskets are provided. In Vietnam non monetary incentives, such as phone cards, practical clinic items like wall clock with thermometer and hygrometer, stethoscope, medical blouse or modest cash awards proved successful in motivating pharmacy operators and private providers to continue detecting TB cases as compared to recognition based rewards which were less motivational.

But what happens when this is no longer enough? What about acceptability? How will health professionals, social workers and community at large perceive the programme? In Tajikistan, for example the community health workers regarded it as a system to monitor and control their movement, indicating an element of lack of trust.

Then, come the costs. For most of these projects, the patient would incur no cost but that might not necessarily make it a cost effective model. One needs to explore as to what cost will the provider incur. Perhaps the most important question we ought to ask is if they will be sustainable? Most of these pilot projects are being funded by donors but if the implementing governments do not provide or have the capability to provide significant support, what would happen when donor funding stops? Another point to ponder is that of confidentiality. In an age of data hackers and whistleblowers, how safe will the patients’ private medical information be? Surely we will need rules and regulations on the use of m-health solutions.

Dr Evan Lee, Vice President of Global Health Programmes at Eli Lilly, while speaking to CNS (Citizen News Service) about the various projects they support, said that, “The projects are meant to fill the gaps within the various health systems as identified by the community. Therefore in providing support, even if it is only for a pilot study, it allows for the community to know that it is possible and serves as a motivation that m- health solutions can indeed work.” In as much as we are in agreement that the integration of m-health with TB care and control is an innovative and useful concept, one has to find ways and means to implement such projects on a massive scale. We have to ensure that they are sustainable and be able to deal with the challenges that come along the way.
Dr Diana Wangari, Citizen News Service - CNS
December 14, 2015
(Dr Diana Wangari MD, is providing thematic coverage from the 46th Union World Conference on Lung Health in Cape Town, South Africa, with kind support from Lilly MDR TB Partnership. Follow her on Twitter: @diana1wangari)