TXT 4 Health

A review of the evidence

Dr. Thyra de Jongh, MSc DIC PhDthyra.dejongh@gmail.comCentre for Health ManagementImperial College Business School, London

Mobile Phone Coverage

MDG8: “In cooperation with the private sector, make available the benefits of new technologies, especially information and communications”

Estimates. Source: ITU World Telecommunication/ICT Indicators database

Mobile Phones in the developing world

Short Message Service (SMS)

• 160 characters • Accidental success• Textese (cu l8r, g2g)• Variety of applications

In UK: in 2008 78.9 billion texts sent*= 3.6 texts per person per day= 2,500 texts /second !

* Mobile Data Association, http://www.text.it/

Low

Yes

Moderate

High

Immediate or stored

LowModerateLowModerateHighCost

YesN/AN/ANoN/ADelivery confirmation

ModerateLowLowModerateLowLikelihood of mis-interpretation

HighHighModerateHighHighPrivacy / Confidentiality

Immediate or stored

ImmediateImmediateSlowSlowImmediacy

Why SMS?

fast, relatively safe, and cheap

Potential benefits of SMS in healthcare delivery

3 types of benefits:

• Efficiency gains

• Benefits to patients: - Improved health outcomes- Improved quality of service

• Public health benefits

A review of the characteristics and benefits of SMS in delivering healthcare, R. Atun and S.R. Sittampalam,Vodafone Policy Paper Series, (2006):4.

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Efficiency gains through SMS

• Appointment remindersUK, USA, Norway, Sweden, the Netherlands, Spain, China, Malaysia

Provider P Patient

• Communication between healthcare workersExpert consultation, coordination of care

Provider Provider⇄

Benefits to patients from SMS

•Improving adherence to medication and health adviceTB, HIV/AIDS, hypertension, asthma

Provider P Patient

•Monitoring illness and medical interventionsAsthma, diabetes, hypertension

Provider Patient⇄

•Psychological supportSmoking cessation, mental health, eating disorders

Provider Patient⇄

Public health benefits from SMS

•Communicating health informationHIV, malaria, vaccinations, SARS, sex education

Provider P Public (‘one-to-many’)Provider Person (‘one-to-one’)⇄

•Contact tracing and partner notificationSTIs, TB, HIV/AIDS

Provider P Patient

• Non-adherence ➠ relapse & drug resistanceForgetting, ‘feeling better’, side-effects, etc.

• Directly Observed TherapyShortage of health workers, travel distances, cost, stigma

• Possible roles for mobile phones:Education, medication reminders, progress monitoring, communication of diagnostic results

• South Africa pilot projects:- Diagnostic results sent by SMS from lab to local clinic

- Cell Phone Prompted Self-Administered Therapy

SMS in TB control: potential applications

• Modelling the impact of SMS use in TB control in England

• Scenario modelling of incremental cost-effectivenessRoutine care: non-compliance rate 20%Simulated improvements in adherence: 5% to 100%

• For 1,000 patients potential cost savings to NHS range from ₤117,000 to over ₤3.8 million

• Gains in years of life saved; reduction in rates of MDR-TB

SMS in TB control: potential cost-savings

The potential of SMS applications for the control of tuberculosis, R. Atun et al., Vodafone Policy Paper Series, (2006):4.

SMS in management of Type 1 Diabetes Mellitus

• Insulin-dependent; early-onset

• Daily monitoring blood glucose + insulin injections; healthy lifestyle

• SweetTalk to enhance self-efficacy through automated delivery of tailored messages and newsletters

❏ Dont 4get 2 inject! ❏ Boost ur daily activity-play ur favourite music and dnz!

• RCT finds SweetTalk cost-effectively supports Intensive Insulin Therapy in young people

Use of mobile technologies to enhance control of Type 1 diabetes in young people: economic evaluation, V. Franklin et al., Vodafone Policy Paper Series, (2006):4.

• Effects on equityIncomplete coverageMorbidity patterns vs. mobile phone ownership

• Confidentiality and privacy• Misunderstanding or misinterpretation• Difficulty reading SMS & illiteracy• Data entry errors• Inadequate personal follow-up• Cost• Desensitization

Drawbacks and risks of SMS in health care

• Lot of anecdotal evidence and pilot studies but need for systematic review of rigorous trials

• Registered Cochrane reviews on use of SMS in 4 distinct applications:

Facilitating self-management of long-term illness Preventive healthcare Communicating results of medical investigations Reminders for attendance at scheduled healthcare

appointments

The need for evidence

Cochrane Database of Systematic Reviews (2008), Issue 4.

• RCTs, Quasi-RCTs, CBAs, ITSs

• SMS based communication between providers and patients or vice versa

• Health outcomes; patient & provider evaluations; cost and cost-effectiveness; potential adverse effects

• Peer reviewed literature, trials, dissertations

• Combined search and selection strategy for all 4 reviews

Review design

• Many applications for SMS in healthcare delivery

• Paucity of rigorously conducted studies

• Limited evidence from studies in low resource settings

• Limited evidence on long-term effectiveness

• Need for investigations into user perceptions and satisfaction to feed into further development of interventions

Conclusions

Dr. Ipek Gurol-UrganciLondon School of Hygiene and Tropical Medicine, UK

Dr. Josip CarFaculty of Medicine, Imperial College London, UK

Dr. Vlasta Vodopivec JamšekDepartment of Family Medicine, University of Ljubljana, Slovenia

Prof. Dr. Rifat AtunImperial College Business School, London, UKThe Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland

Centre for Health Management, Imperial College Business SchoolVodafone

Acknowledgements

• The role of mobile phones in increasing accessibility and efficiency in healthcare, The Vodafone Policy Paper Series, Number 4, March 2006: http://www.vodafone.com/etc/medialib/public_policy_series.Par.38545.File.dat/public_policy_series_4.pdf.

• Mobile phone messaging telemedicine for facilitating self management of long-term illnesses.de Jongh T, Gurol-Urganci I, Vodopivec-Jamšek V, Car J, Atun R. Cochrane Database of Systematic Reviews (2008), Issue 4.

• Mobile phone messaging reminders for attendance at scheduled healthcare appointments. Car J, Gurol-Urganci I, de Jongh T, Vodopivec-Jamšek V, Atun R. Cochrane Database of Systematic Reviews (2008), Issue 4.

• Mobile phone messaging for preventive health care.Vodopivec-Jamšek V, de Jongh T, Gurol-Urganci I, Atun R, Car J. Cochrane Database of Systematic Reviews (2008), Issue 4.

• Mobile phone messaging for communicating results of medical investigations.Gurol-Urganci I, de Jongh T, Vodopivec-Jamšek V, Car J, Atun R. Cochrane Database of Systematic Reviews (2008), Issue 4.

References