* StAR. Developing technologies for the developing world. a mobile phone based health-care infrastructure. Andrew Farmer November 2013

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Developing technologies for the

developing world

Andrew Farmer

November 2013

*

StAR

a mobile phone based health-care

infrastructure

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The team

• Coordinating Centre Oxford: IBME staff, Lionel Tarassenko; PCTU staff: Andrew Farmer.

• Coordinating Centre Cape Town: Kirsten Bobrow (Study

Coordinator) Carmen Delport, Carmelita Sylvester, Susan Botha, Chantel Stuart.

• Intervention Development: David Springer, Thomas Brennan, Nomazizi Cishe, Ntobeko N’wagi.

• Research Staff: Liezel Fisher, Melissa Paulse, Nicolette

Gertse,Theresa Louw, Ntombi Ngabom, Nomfuneko Konzapi, Desmond Raqa, Nombulelo Ralarala, Luyanda Sebe.

• Clinic Staff: Mosedi Namane, Luntu Mbanga.

• Trial Management Committee: Bryan Rayner, Dinky Levitt (local PI), Krysela Steyn (AF and KB)

• Trial Steering Committee: Carl Lombard, Karen Sliwa, Tracey Naledi, Bob Mash (AF, LT and KB)

• Social and policy work: AF, Rebecca Surender, KB, Alexander Finlayson

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Technologies for global health

• A need for frugal

technology1

• New technology needs to be combined with

innovation in process1

• Implementation and evaluation is required

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Technology in primary care

• Strengthen the district-based primary health system…1

• Limited interoperability across health care information technology

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The burden of hypertensive disease

• 7.6 million premature deaths from blood

pressure related disease with 80% of the burden in low and middle income settings.1

• Effective blood pressure lowering with medication reduces cardiovascular

disease burden.2

1_{Lawes et al.}_Lancet_2008;_{371 ;1513}_. 2_{Law et al..}_BMJ_2009;₃₃₈_:b1665–5.

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Failure to take medication

1 _{Chowdhury et al}_._{EurHeart J}_{2013. doi:10.1093/eurheartj/eht295} • In Europe, 9% of

cardiovascular events can be attributed to poor adherence

with vascular medications.1

• Poor adherence results from problems at both the

individual and the system level

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Potential for mobile phone based health care

technologies

• Infrastructure for access to mobile phones is

available to 90% of the world’s population.

• 70% of urban South

African’s have access to a mobile phone.

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Integrated information technology

• Mobile device-based electronic

data collection at the point of care • Use of open-source software

platforms in conjunction with off-the-shelf hardware

• Use of open source technologies maximizes interoperability and takes maximum advantage of what is already in place

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Information technology to integrate care

• Clinical record integrating patient data and linked clinic devices

• Secure linkage of clinical record with clinical, demographic, and appointment databases

• Data used to enable timely educational messages and reminders for collecting medication

• Interaction with clinic by user generated SMS text • Real-time patient management system for tracking

appointments and collection of medication

• Integrated facility for evaluation: trial management system.

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Delivering care at low-cost and scale

• Sana Mobile used for clinical data collection and transmission. • OpenMRS is the

electronic medical record and health system

management platform

• Individual SMS-texts tailored for language, delivery time, and

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Why use SMS-text messages?

• Timely and relevant messages are likely to change and maintain desired behaviours

• SMS (text) based reminders and motivational

interventions have been successful for a range of

health conditions,1_{including adherence support.}2

• Tailored text messages have the potential to

reinforce health messages, provide reminders to attend clinic, and obtain and take medication

1 _{de Jongh et al}_{. Cochrane Database of Systematic Reviews}_{. 2013:1–52.} 2 _{Vervloet et al.}_{BMC Health Serv Res}_2011;11:5.

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StAR

Locally appropriate messages

Pls remember your next CLUB DATE is 10:00 on 21/02/12.

Thnx,Sr Tana (CLUBSR@VAN)

A pill box can help you to remember when to take you high blood pills. Ask at WINDOW 11 where

you can buy one. ThnxDrNamane

(DR@VAN)

Set an alarm (on your phone or clock) to help you remember

when to take your high blood pills. ThnxDrNamane(DR@

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StAR

Objective: To test whether a short Messaging Service (SMS) text-message based platform to support patients with hypertension improves blood pressure control at 12 months follow-up compared to usual clinical care

Design: Randomised controlled trial

People: Men and women hypertension aged 21 years or

older

Main study outcomes: changes in blood pressure,

proportion of planned medication collected from the clinic

Implementation and evaluation

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StAR

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StAR

Excluded and not willing to participate SCREENING FOR ELIGIBILITY

E NRO L L M E NT A LLO C A TI O N BA S E L INE FO LLO W U P BASELINE MEASUREMENT RANDOMISATION n=1372 Enhanced usual care Intervention (information only) Intervention (interactive SMS texting) Systolic blood pressure at 12 months Systolic blood pressure at 12 months Systolic blood pressure at 12 months Loss to follow up Loss to follow up Loss to follow up

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Integrating clinical care and a trial

evaluation

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Follow-on implementation work

• In-depth interview study of the impact of the StAR clinical platform now funded

• Study will explore the implications of wider use of the technology for the future provision of clinical care in a low-income setting

• Aims to inform wider application of mobile phone-based health care infrastructure and its potential for reducing

barriers for access to effective and affordable health care • Government of the Western Cape is a key stakeholder

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Significance of the work

• We are delivering timely and targeted text messages to a 1370 clinic registered patients with a long-term condition, using an integrated low-cost software platform, available clinical data, and through devices already owned by

patients

• Technology development was guided by clinical staff and patients to ensure a close fit with current practice

• Development of the text-messages and process changes for clinical care took place in close consultation with the engineering team

• This approach to integration in health care of records, behavioural support and evaluation is already being scaled up in a number of areas; the next step is to demonstrate potential for area wide use

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Issues for implementation

• There are more than 3 million people living with hypertension in South Africa…

• Hypertension is only one of a number of long-term conditions

• Many people have more than one long-term condition • Lessons for wide-scale adoption

• Large-scale implementation study to provide lessons for continuing adoption

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Developing relevant text-messages

Refining and optimising intervention • Feedback session with medical experts

and chronic care providers

• SMS-texts revised and new content added

Intervention testing

• Initial group of SMS text-messages developed together with local health care

professionals, local health resources (e.g. leaflets) • Eight interactive focus groups

with patients to assess an initial bank of SMS-texts

Draft Intervention

• Communication with clinic • Prompts and reminders • Providing tips and hints • Support problem solving • Support self-efficacy Problem

• Problem: failure to collect refills • Intervention to deliver timely

reminders and develop clinic engagement

• Potential for using SMS texts explored with multidisciplinary group

Exploratory trial Intervention testing • Five week interactive

testing with participant informant group using trial SMS-delivery system

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