Exploring the patterns of use and the feasibility of using cellular phones for clinic appointment reminders and adherence messages in an antiretroviral treatment clinic, Durban, South Africa

In preparation for a proposed intervention at an antiretroviral therapy (ART) clinic in Durban, South Africa, we explored the dynamics and patterns of cellular phone use among this population, in order to ascertain whether clinic contact via patients' cellular phones was a feasible and acceptable modality for appointment reminders and adherence messages. Adults, who were more than 18 years old, ambulatory, and who presented for treatment at the clinic between October-December 2007, were consecutively recruited until the sample size was reached (n?=?300). A structured questionnaire was administered, including questions surrounding sociodemographics, cellular phone availability, patterns of use, and acceptability of clinic contact for the purpose of clinic appointment reminders and adherence support. Most respondents (n?=?242; 81%) reported current ownership of a cellular phone with 95% utilizing a prepaid airtime service. Those participants who currently owned a cellular phone reported high cellular phone turnover due to theft or loss (n?=?94, 39%) and/or damage (n?=?68, 28%). More females than men switched their cell phones off during the day (p?=?0.002) and were more likely to not take calls in certain social milieus (p?≤?0.0001). Females were more likely to share their cell phone with others (p?=?0.002) or leave it in a place where someone could access it (p?=?0.005). Most respondents were willing to have clinic contact via their cellular phones, either verbally (99%) or via text messages (96%). The use of cellular phones for intervention purposes is feasible and should be further investigated. The findings highlight the value of gender-based analyses in informing interventions.     

A meta‐analysis of overall effects of weight loss interventions delivered via mobile phones and effect size differences according to delivery mode,personal contact,and intervention intensity and duration

Weight loss interventions are delivered through various mediums including, increasingly, mobile phones. This systematic review and meta‐analysis assesses whether interventions delivered via mobile phones reduce body weight and which intervention characteristics are associated with efficacy. The study included randomised controlled trials assessing the efficacy of weight loss interventions delivered via mobile phones. A meta‐analysis to test intervention efficacy was performed, and subgroup analyses were conducted to determine whether interventions' delivery mode(s), inclusion of personal contact, duration and interaction frequency improve efficacy. Pooled body weight reduction (d = ?0.23; 95% confidence interval = ?0.38, ?0.08) was significant. Interventions delivered via other modes in addition to the mobile phone were associated with weight reduction. Personal contact and more frequent interactions in interventions were also associated with greater weight reduction. In conclusion, the current body of evidence shows that interventions delivered via mobile phones produce a modest reduction in body weight when combined with other delivery modes. Delivering interventions with frequent and personal interactions may in particular benefit weight loss results.     

Using Mobile Phones to Improve Clinic Attendance Amongst an Antiretroviral Treatment Cohort in Rural Uganda: A Cross-sectional and Prospective Study

We aimed to assess the patterns and dynamics of mobile phone usage amongst an antiretroviral treatment (ART) cohort in rural Uganda and ascertain its feasibility for improving clinic attendance. A cross-sectional study of clients on ART exploring their access to mobile phones and patterns of use was employed. Clinic attendances for antiretroviral drug refills were then monitored prospectively over 28 weeks in 176 patients identified in the cross-sectional survey who had access to mobile phones and had given consent to be contacted. Patients were contacted via voice calls or text messages to remind them about their missed clinic appointments. Of the 276 patients surveyed, 177 (64%) had access to mobile phones with all but one were willing to be contacted for missed visits reminders. Of the 560 total scheduled clinic appointments, 62 (11%) were missed visits. In 79% of episodes in which visits were missed, patients presented for treatment within a mean duration of 2.2 days (SD = 1.2 days) after mobile phone recall. Access to mobile phones was high in this setting. Privacy and confidentiality issues were not considered deterrents. Mobile phones have a potential for use in resource-constrained settings to substantially improve the clinical management of HIV/AIDS.     

A Pilot Randomized Controlled Trial of an Integrated In-person and Mobile Phone Delivered Counseling and Text Messaging Intervention to Reduce HIV Transmission Risk among Male Sex Workers in Chennai,India

Men who have sex with men (MSM) are at increased risk for HIV infection in India, particularly those who engage in transactional sex with other men (i.e., male sex workers; MSW). Despite the need, HIV prevention efforts for Indian MSW are lacking. As in other settings, MSW in India increasingly rely on the use of mobile phones for sex work solicitation. Integrating mobile phone technology into an HIV prevention intervention for Indian MSW may mitigate some of the challenges associated with face-to face approaches, such as implementation, lack of anonymity, and time consumption, while at the same time proving to be both feasible and useful. This is a pilot randomized controlled trial to examine participant acceptability, feasibility of study procedures, and preliminary efficacy for reducing sexual risk for HIV. MSW (N = 100) were equally randomized to: (1) a behavioral HIV prevention intervention integrating in-person and mobile phone delivered HIV risk reduction counseling, and daily, personalized text or voice messages as motivating “cognitive restructuring” cues for reducing condomless anal sex (CAS); or (2) a standard of care (SOC) comparison condition. Both groups received HIV counseling and testing at baseline and 6-months, and completed ACASI-based, behavioral and psychosocial assessments at baseline, 3, and 6 months. Mixed-effects regression procedures specifying a Poisson distribution and log link with a random intercept and slope for month of follow-up was estimated to assess the intervention effect on the primary outcomes: (1) CAS acts with male clients who paid them for sex, and (2) CAS acts with male non-paying sexual partners—both outcomes assessed over the past month. The intervention was both feasible (98% retention at 6-months) and acceptable (>96% of all intervention sessions attended); all intervention participants rated the intervention as “acceptable” or “very acceptable.” A reduction in the reported number of CAS acts with male clients who paid them for sex in the past month was seen in both study conditions. MSW in the intervention condition reported a faster rate of decline in the number of CAS acts with male clients in the past month from the baseline to both the 3-month (B = ?1.20; 95% CI ?1.68, ?0.73; p < 0.0001) and 6-month (B = ?2.44; 95% CI ?3.35, ?1.53; p < 0.00001) assessment visits compared to the SOC condition. Post-hoc contrasts indicated that, at 3 months, participants in the intervention condition reported 1.43 (SD = 0.29) CAS acts with male clients in the past month compared to 4.85 (SD = 0.87) in the control condition (p = 0.0003). Furthermore, at 6 months, the intervention condition participants reported 0.24 (SD = 0.09) CAS acts with male clients in the past month compared to 2.79 (SD = 0.79) in the control condition (p < 0.0001). Findings are encouraging and provide evidence of feasibility and acceptability, and demonstrate initial efficacy (for reducing sexual risk for HIV) of a behavioral HIV prevention intervention for Indian MSW that combines daily, personalized text or voice messages with mobile phone-delivered sexual risk reduction counseling and skills building. Future testing of the intervention in a fully powered randomized controlled efficacy trial is warranted.     

India calling: harnessing the promise of mobile phones for HIV healthcare

The technology that has been able to straddle the digital divide most effectively in resource-constrained settings has been the mobile phone. The tremendous growth seen in Africa and Asia in mobile phone use over the last half decade has spurred plans to integrate mobile phones with healthcare delivery globally. A major challenge in HIV healthcare is sustaining good adherence to antiretroviral treatment. This report focuses on specific applications of mobile phones in the area of HIV healthcare delivery. It highlights the widespread use of mobile phones in developing areas of the world, those which have a heavy burden of HIV and infectious diseases. There is scope for exploiting existing mobile phone technology and infrastructure for healthcare enhancement in resource-constrained settings.     

Communication technology use and mHealth acceptance among HIV-infected men who have sex with men in Peru: implications for HIV prevention and treatment

The HIV epidemic in Peru is concentrated among men who have sex with men (MSM). Given that MSM have been documented as early adopters of emerging technology, we examined communication technology access and utilization, and mobile health (mHealth) acceptance among Peruvian MSM and transgender women (TGW) in order to gauge opportunities for mHealth-enabled HIV interventions. A convenience sample of 359 HIV-infected MSM and TGW recruited from three sites in Lima, Peru completed standardized assessments of alcohol use disorders (AUDs), risky sexual behavior, and antiretroviral therapy (ART) adherence along with self-constructed measures of communication technology access and utilization, and mHealth acceptance. Most participants (86%) had daily access to any cell phone, including smartphones (30%). The most frequent communication activities were receiving and making calls, and receiving and sending text messages using cell phones. On a 5-point Likert scale, participants expressed interest in using mHealth for medication reminders (M = 3.21, SD = 1.32) and engaging in anonymous online interactions with health professionals to discuss HIV-related issues (M = 3.56, SD = 1.33). Importantly, no significant differences were found in communication technology use and mHealth acceptance among participants with AUDs, depression, and suboptimal ART adherence, all of which are associated with poor HIV treatment outcomes. Findings show support for implementing mHealth-based intervention strategies using cell phones to assess and reduce HIV-risk behaviors among HIV-infected MSM and TGW.     

Mobile technology use and desired technology-based intervention characteristics among HIV+ Black men who have sex with men

HIV positive Black men who have sex with men (MSM) are retained in HIV medical care at suboptimal rates. Interventions targeted to Black MSM are needed to help to improve their retention in care. The purposes of this study were to investigate the use of mobile technology among HIV+ Black MSM and to explore participants’ thoughts about the use of mobile technology for HIV retention in care interventions. Twenty-two HIV+ Black MSM completed a technology use survey and participated in a qualitative interview regarding technology-based interventions. The majority of participants (95%) had access to a cell phone, and used their phones frequently (median 3 hours/day). Men preferred interventions that would allow for anonymous participation and that would provide individually tailored support. Mobile technology is a promising approach to intervention delivery for both younger and older HIV+ Black MSM. These interventions should incorporate features that are desirable to men (i.e., anonymous participation and individual tailoring).     

Impact of a mHealth Intervention for Peer Health Workers on AIDS Care in Rural Uganda: A Mixed Methods Evaluation of a Cluster-Randomized Trial

Mobile phone access in low and middle-income countries is rapidly expanding and offers an opportunity to leverage limited human resources for health. We conducted a mixed methods evaluation of a cluster-randomized trial exploratory substudy on the impact of a mHealth (mobile phone) support intervention used by community-based peer health workers (PHW) on AIDS care in rural Uganda. 29 PHWs at 10 clinics were randomized by clinic to receive the intervention or not. PHWs used phones to call and text higher level providers with patient-specific clinical information. 970 patients cared for by the PHWs were followed over a 26 month period. No significant differences were found in patients’ risk of virologic failure. Qualitative analyses found improvements in patient care and logistics and broad support for the mHealth intervention among patients, clinic staff, and PHWs. Key challenges identified included variable patient phone access, privacy concerns, and phone maintenance.     

Designing a Mobile Phone-Based Intervention to Promote Adherence to Antiretroviral Therapy in South India

Integration of mobile phone technology into HIV care holds potential, particularly in resource-constrained settings. Clinic attendees in urban and rural South India were surveyed to ascertain usage of mobile phones and perceptions of their use as an adherence aid. Mobile phone ownership was high at 73%; 26% reported shared ownership. A high proportion (66%) reported using phones to call their healthcare provider. There was interest in weekly telephonic automated voice reminders to facilitate adherence. Loss of privacy was not considered a deterrent. The study presents important considerations in the design of a mobile phone-based adherence intervention in India.     

Time to use text reminders in genitourinary medicine clinics

Faced with a national 48-hour waiting time target and high non-attendance rates for booked appointments, our sexual health service sought patient preferences for appointment reminders. Questionnaires were distributed to 350 consecutive genitourinary medicine clinic attendees. Eighty-eight percent of respondents approved of appointment reminders, with text messaging being the preferred option. Automated voicemail reminders to mobile phones were acceptable to 84%. Patients would generally choose a voicemail reminder to their mobile phone as opposed to home or work phone, and this preference was more pronounced in younger patients (P = 0.03). The majority of patients considered reminders two or three days in advance sufficient notice, with 98% owning a mobile phone. Text or voicemail reminders may significantly reduce non-attendance rates and their associated costs, improve accessibility and reduce waiting times.     

Mobile Health and Diabetes: Development and Feasibility of a Text Messaging and Interactive Voice Response Intervention for Low-Income,Diverse Adults with Type 2 Diabetes Mellitus

Low-income, racial/ethnic minorities are often nonadherent to diabetes medications, have uncontrolled glycemia, and have high rates of diabetes-related morbidity. Cell phones provide a viable modality to support medication adherence, but few cell phone-based interventions have been designed for low-income persons, a population with more feature phone penetration than smartphone penetration. In an effort to reach the broadest range of patients, we leveraged the voice and text messaging capabilities shared by all cell phones to design the MEssaging for Diabetes intervention. We specifically advanced and adapted an existing tailored text messaging system to include interactive voice response functionality and support the medication adherence barriers of low-income, diverse adults with type 2 diabetes mellitus. We report on the design process and feasibility testing results (i.e., technical use patterns and subjective user experiences) from patients from the target population who used the intervention in one of three user-centered design iterations. The types of challenges encountered in design were related to providing text message content with valued information and support that engages patients. The design process also highlighted the value of obtaining mixed methods data to provide insight into legitimate versus illegitimate missing data, patterns of use, and subjective user experiences. The iterative testing process and results outlined here provide a potential template for other teams seeking to design technology-based self-care support solutions for comparable patient populations.     

Mobile health for early retention in HIV care: a qualitative study in Kenya (WelTel Retain)

Many people newly diagnosed with HIV are lost to follow-up before timely initiation of antiretroviral therapy (ART). A randomised controlled trial (RCT), WelTel Kenya1, demonstrated the effectiveness of the WelTel text messaging intervention to improve clinical outcomes among patients initiating ART. In preparation for WelTel Retain, an RCT that will evaluate the effect of the intervention to retain patients in care immediately following HIV diagnosis, we conducted an informative qualitative study with people living with HIV (n = 15) and healthcare providers (HCP) (n = 5) in October 2012. Study objectives included exploring the experiences of people living with HIV who have attempted to engage in HIV care, the use of cell phones in everyday life, and perceptions of communicating via text message with HCP. Participants were recruited through convenience sampling. Semi-structured, qualitative interviews were conducted and recorded, transcribed verbatim and analysed using NVivo software. Analysis was guided by the Theory of Reasoned Action and the Technology Acceptance Model. Results indicate that while individuals have many motivators for engaging in care after diagnosis, structural and individual barriers including poverty, depression and fear of stigma prevent them from doing so. All participants had access to a mobile phone, and most were comfortable communicating through text messages, or were willing to learn. Both people living with HIV and HCP felt that increased communication via the text messaging intervention has the potential to enable early identification of problems, leading to timely problem solving that may improve retention and engagement in care during the first year after diagnosis.     

Supporting patient adherence to antiretrovirals using mobile phone reminders: patient responses from South India

There has been exponential growth in the use of mobile phones in India over the last few years, and their potential benefits as a healthcare tool has raised tremendous interest. We used mobile phone reminders to help support adherence to antiretroviral therapy (ART) among HIV patients at an infectious disease clinic in a tertiary hospital in Bangalore. Between March and June 2010, 139 adult HIV patients taking regular ART for at least a month received weekly reminders to support adherence. These reminders consisted of a weekly interactive call and a non-interactive neutral pictorial short message service (SMS). After four weeks of the intervention, participants were interviewed to study perceptions on preference, usefulness, potential stigma and privacy concerns associated with this intervention. Majority of the participants were urban (89%), and had at least a secondary education (85%). A total of 744 calls were made, 545 (76%) of which were received by the participants. In addition, all participants received the weekly pictorial SMS reminder. A month later, 90% of participants reported the intervention as being helpful as medication reminders, and did not feel their privacy was intruded. Participants (87%) reported that they preferred the call as reminders, just 11% favoured SMS reminders alone. Only 59% of participants viewed all the SMSs that were delivered, while 15% never viewed any at all. Participants also denied any discomfort or stigma despite 20% and 13%, respectively, reporting that another person had inadvertently received their reminder call or SMS. Mobile phone interventions are an acceptable way of supporting adherence in this setting. Voice calls rather than SMSs alone seem to be preferred as reminders. Further research to study the influence of this intervention on adherence and health maintenance is warranted.     

Mobile Phone-Based Antiretroviral Adherence Support in Vietnam: Feasibility, Patient’s Preference, and Willingness-to-Pay

Feasibility of using mobile phone for antiretroviral treatment adherence support was assessed in a multi-site survey. Of 1,016 respondents, 84.5?% used mobile phones; 78.6?% found it effective for adherence aid, 44.8?% had privacy concerns, and 63.5?% expressed willingness-to-use the service. Willingness-to-pay was US$ 2.5/month. Text messaging (41.8?%) and direct calls by health workers (35.4?%) were preferred. Expressed preference for specific support service included direct counseling with physician (43.1?%), automated reminder for pills taking (29.1?%), regular information messages (21.3?%), and booking of clinic visits (16.5?%). These findings inform the design of adherence interventions using mobile phone in the Vietnamese setting.     

Real-Time Assessments of the Strength of Program Implementation for Community Case Management of Childhood Illness: Validation of a Mobile Phone-Based Method in Malawi

Health surveillance assistants (HSAs) in Malawi have provided community case management (CCM) since 2008; however, program monitoring remains challenging. Mobile technology holds the potential to improve data, but rigorous assessments are few. This study tested the validity of collecting CCM implementation strength indicators through mobile phone interviews with HSAs. This validation study compared mobile phone interviews with information obtained through inspection visits. Sensitivity and specificity were measured to determine validity. Using mobile phones to interview HSAs on CCM implementation strength indicators produces accurate information. For deployment, training, and medicine stocks, the specificity and sensitivity of the results were excellent (> 90%). The sensitivity and specificity of this method for drug stock-outs, supervision, and mentoring were lower but with a few exceptions, still above 80%. This study provided a rigorous assessment of the accuracy of implementation strength data collected through mobile technologies and is an important step forward for evaluation of public health programs.     

Monitoring Study Participants and Implementation with Phone Calls to Support Hypertension Control During the COVID-19 Pandemic: The Case of a Multicomponent Intervention Trial in Guatemala

Background:The COVID-19 pandemic presents a challenge to health care for patients with chronic diseases, especially hypertension, because of the important association and increased risk of these patients with a severe presentation of COVID-19 disease. The Guatemalan Ministry of Health has been implementing a multi-component program aimed at improving hypertension control in rural communities since 2019 as a part of an intervention research cluster randomized trial. When the first cases of COVID-19 were reported (March 13, 2020) in Guatemala, our study paused all study field activities, and began monitoring participants through phone calls. The objective of this paper is to describe the approach used to monitor study participants during the COVID-19 pandemic and compare data obtained during phone calls for intervention and control group participants.Methods:We developed a cross-sectional study within the HyTREC (Hypertension Outcomes for T4 Research within Lower Middle-Income Countries) project ‘Multicomponent Intervention to Improve Hypertension Control in Central America: Guatemala’ in which phone calls were made to participants from both intervention and control groups to monitor measures important to the study: delivery of antihypertensive medications in both groups, receipt of coaching sessions and use of a home blood pressure monitor by intervention group participants, as well as reasons that they were not implemented.Results:Regarding the delivery of antihypertensive drugs by the MoH to participants, those in the intervention group had a higher level of medication delivery (73%) than the control group (51%), p<0.001. Of the total participants in the intervention group, 62% had received at least one health coaching session in the previous three months and 81% used a digital home blood pressure monitor at least twice a week. Intervention activities were lower than expected due to restricted public transportation on top of decreased availability of health providers.Conclusion:In Guatemala, specifically in rural settings, access to antihypertensive medications and health services during pandemic times was impaired and less than expected, even after accounting for the program’s implementation activities and actions.     

Challenges in Using Mobile Phones for Collection of Antiretroviral Therapy Adherence Data in a Resource-Limited Setting

Frequent antiretroviral therapy adherence monitoring could detect incomplete adherence before viral rebound develops and thus potentially prevent treatment failure. Mobile phone technologies make frequent, brief adherence interviews possible in resource-limited settings; however, feasibility and acceptability are unknown. Interactive voice response (IVR) and short message service (SMS) text messaging were used to collect adherence data from 19 caregivers of HIV-infected children in Uganda. IVR calls or SMS quantifying missed doses were sent in the local language once weekly for 3–4 weeks. Qualitative interviews were conducted to assess participant impressions of the technologies. Participant interest and participation rates were high; however, weekly completion rates for adherence queries were low (0–33%), most commonly due to misunderstanding of personal identification numbers. Despite near ubiquity of mobile phone technology in resource-limited settings, individual level collection of healthcare data presents challenges. Further research is needed for effective training and incentive methods.     

Examining the Acceptability of mHealth Technology in HIV Prevention Among High-Risk Drug Users in Treatment

Despite promising trends of the efficacy of mobile health (mHealth) based strategies to a broad range of health conditions, very few if any studies have been done in terms of the examining the use of mHealth in HIV prevention efforts among people who use drugs in treatment. Thus, the goal of this study was to gain insight into the real-world acceptance of mHealth approaches among high-risk people who use drugs in treatment. A convenience sample of 400 HIV-negative drug users, who reported drug- and/or sex-related risk behaviors, were recruited from a methadone clinic in New Haven, Connecticut. Participants completed standardized assessments of drug- and sex-related risk behaviors, neurocognitive impairment (NCI), and measures of communication technology access and utilization, and mHealth acceptance. We found a high prevalence of current ownership and use of mobile technologies, such as cell phone (91.5%) including smartphone (63.5%). Participants used mobile technologies to communicate mostly through phone calls (M = 4.25, SD = 1.24), followed by text messages (M = 4.21, SD = 1.29). Participants expressed interest in using mHealth for medication reminders (72.3%), receive information about HIV (65.8%), and to assess drug-related (72.3%) and sex-related behaviors (64.8%). Furthermore, participants who were neurocognitively impaired were more likely to use cell phone without internet and show considerable interest in using mHealth as compared to those without NCI. The findings from this study provide empirical evidence that mHealth-based programs, specifically cell phone text messaging-based health programs, may be acceptable to this high-risk population.     

Video Reminders as Cognitive Prosthetics for People with Dementia

This research aims to evaluate a mobile phone-based video reminder system (MPVS) for people with dementia, with respect to its design and utility, in addition to its ability to satisfy user needs. Carers for those using the system use a bespoke desktop-based system to record and schedule reminders for delivery through the MPVS system. Nine participants were set eight activities of daily living (ADL) tasks and asked to repeat these tasks over a number of days within an ABA-evaluation protocol. In the A phase, ADLs were undertaken using standard reminding techniques; in the B phase, the MPVS system was used; following this, a second A phase was evaluated. ADL completion / compliance was rated and recorded by the carer. Carers and participants were interviewed prior to and following the evaluation to gauge their perceived needs and how these are met, in addition to the potential utility of the technology. The generalizability of the outcome of this evaluation is limited due to the low number of participants; however, the participants reported that the MPVS system assisted them to organize their routine, and the phone used to deliver the video messages was of a good size with adequate screen and audio clarity. The carers saw the potential utility of the technology, and although some had to learn how to use the desktop recording system, the wizard-led interface made it much easier to use for people with minimal computer experience.