Cell phones: tightening the communication gap in resource-limited antiretroviral programmes?
Richard Todd Lester, Lawrence J. Gelmon, Francis Allan Plummer · AIDS · 2006
Stepping up telecommunications technology in resource-limited healthcare settings has been included as a World Health Organization/UNAIDS priority [1]. Wireless communications in the form of mobile (cellular) phones have obvious advantages to land-based telecommunications in these regions by bypassing traditionally meager, limited or costly infrastructures. They are already influencing personal and business communications on a wide scale in developing regions [2]. Do they also have a timely potential for use in healthcare? The answer seems obvious, but very little systematic research has been published on this topic in the medical literature [3]. Globally, sub-Saharan Africa is faced with the greatest burden of HIV infection, where more than 8 million people could benefit from antiretroviral therapy (ART) [4]. Although resources are finally pouring into some regions, a major limiting factor to broad ART access is healthcare infrastructural capacity, more so than the availability of drugs [5]. These same regions have the highest rate of mobile phone uptake in the world and network coverage areas are continually expanding [6]. The best approach, however, to integrating these two developmental paradigms is unknown. To meet the vast challenge of global access to ART, efficient and sustainable communications systems must be constructed to meet patient counselling, monitoring, and long-term follow-up goals. Telecommunications have been a standard part of clinic management in western settings since modern medicine was born. However, to many populations in less developed regions the experience is new, or more likely, has not yet been coordinated. As a proof of concept, we assessed mobile phone access and usage pertaining to healthcare at two primary HIV care clinics in the economically poor Pumwani area of Nairobi, Kenya [7]. One clinic is a maternal and child health clinic [8], and the other is a female commercial sex-worker clinic [9]. Of 111 patients who participated in the survey, self-reported income was less than US$5 equivalent per day for 80% and less than US$1 equivalent per day for 22% of respondents. Fifty-three per cent of respondents could read and write in either English or Kiswahili enough to use short message services (SMS; texting). Despite generally broad access to mobile phones, they were rarely used for healthcare purposes (Fig. 1). Eighty-nine per cent had access to a phone but only 12% had ever called or been called by healthcare staff. With the exception of one respondent, all of the telephone access was via cell phones, a clear indication of the novelty of telecommunications in this population, as cell phones have only been available or affordable for a relatively short time.Fig. 1: The gap between general phone access and phone usage in healthcare by patients attending the Nairobi clinics.Accordingly, consideration of confidentiality issues will be of the utmost importance in any strategy to use cell phones in healthcare. Preferring to talk with clinic staff in person and issues regarding stigma or confidentiality were important barriers identified by patients. Nonetheless, in this group, 54% said they would be comfortable receiving HIV-related information by telephone, an indication that a level of trust already exists. Other barriers pertained more to logistical issues, rather than health-related concerns. Sex, cultural, and other business and economic biases are also likely to affect patient's mobile phone ownership as well as attitudes and access. The advantages of mobile telecommunications in healthcare have been considered elsewhere, mostly in developed settings. Clinic attendance by patients has been shown to improve with SMS text reminders [10]. A targeted mobile phone intervention was highly effective in promoting smoking cessation among a marginalized HIV-infected population in Texas, USA [11]. In South Africa, mobile phone reminders have been proposed to improve tuberculosis drug adherence [12], and regular telephone reminders to take antiretroviral medications have shown some improvement in self-reported adherence among patients in the United States, Italy, and Puerto Rico [13]. Cell phones have been given to healthcare field workers for data reporting in South Africa [14] as have handheld computers in other regions [15]. We are currently examining ART adherence and monitoring practices via patient-based mobile phones in Kenya. The ability to use mobile phones is already widespread and their use in healthcare appears largely acceptable. The relevance of this revolution in telecommunications appears most timely to the global up-scaling of treatment programmes for HIV/AIDS, and other health systems will overlap. Improving patient follow-up, drug adherence, reporting of side-effects and the overall efficiency of healthcare delivery are possibilities. The integration and evaluation of these strategies with global healthcare development goals should be pursued proactively. Sponsorship: The funding of study cohorts was provided by the Canadian Institutes of Health Research (HGC-13301). R.T.L. has an unrestricted research award through AMMI-Bristol-Myers-Squibb (Canada) and the University of Manitoba hosted CIHR/ICID National Training Program in Infectious Diseases. Ethics approval for collection of the primary clinical and social data in Pumwani cohorts has been granted by the University of Manitoba and University of Nairobi ethics review boards.