Evidence

mHealth applications show great promise in improving health services and outcomes. However, there is a lack of evidence about the actual wide-scale health impacts of mHealth projects. The limited scale and scope of evaluation in mHealth projects is partly due to the newness of the technology but also to the desire to have results quickly. A robust evidence base about the effectiveness of mobile health technology is important not only for cost-effectiveness and scale-up purposes, but also to share information about what works and what doesn’t work.

The "Evidence" section of the mHealth Toolkit includes links to abstracts of journal articles that share results of robust randomized trials of a number of mHealth projects. To suggest additional resources, please contact the mHealth Toolkit team at toolkits@k4health.org. 

 

Investigation into the Use of Short Message Services to Expand Uptake of Human Immunodeficiency Virus Testing, and Whether Content and Dosage Impact.
2012 | Telemedicine Journal & eHealth | 6 pp
 Objective: South Africa has one of the highest human immunodeficiency virus (HIV) prevalence rates in the world, but despite the well-established benefits of HIV counseling and testing (HCT), there is low uptake of HCT. The study aimed to investigate the effectiveness of using short message services (SMSs) to encourage HCT while interrogating the impact of altering SMS content and dosage (the number of SMSs). Materials and Methods: About 2,533 participants were recruited via an SMS sent to 24,000 mobiles randomly sampled from a pre-existing database.
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Short Message Service (SMS) Applications for Disease Prevention in Developing Countries
2012 | Journal of Medical Internet Research | Pages: 20
DOI
Abstract Background: The last decade has witnessed unprecedented growth in the number of mobile phones in the developing world, thus linking millions of previously unconnected people.
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A workshop report on HIV mHealth synergy and strategy meeting to review emerging evidence-based mHealth interventions and develop a framework for scale-up of these interventions.
2011 | PanAfrican Medical Journal | 7 pp
Link to PDF
 This document examines the outcomes of the May 2011 two-day workshop for mHealth stakeholders. Discussion included the low adherence to anti-retroviral therapy (ART) and the potential use of mHealth to improve adherence and retention and evidence-based mHealth research in the area of HIV care and treatment as well as in other areas. Participants from twenty-five organizations in five countries attended and developed a framework to guide regional mhealth initiatives.
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Adherence to antiretroviral treatment in HIV-positive patients in the Cameroon context: promoting the use of medication reminder methods.
2011 | JAIDS Journal of Acquired Immune Deficiency Syndromes | S40-3 (4 pp)
Link to article
OBJECTIVES: Antiretroviral treatment (ART) scale-up in sub-Saharan Africa has made it possible to investigate the maintenance of adherence to HIV medications. We describe here adherence to ART and identify its correlates in the Cameroonian context. DESIGN: Prospective cohort study in 9 rural district hospitals. METHODS: A mixed logistic regression model was used to identify factors associated with adherence to ART in 401 patients with data prospectively collected on adherence.
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Call to Action on Global eHealth Evaluation
2011 | The Bellagio eHealth Evaluation Group | Pages: 5
GHDonline Link |
Report
Large numbers of ehealth projects have been funded by development agencies over the last decade (here the definition of eHealth includes mHealth and telehealth). We estimate that the total for the major agencies including PEPFAR, USAID, the World Bank, the Global Fund and other bilateral aid agencies is between three and five Billion dollars, though getting access to the information can be very difficult. The key questions of whether these eHealth systems function well and whether they have a beneficial impact on health is rarely answered. 
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Impact of a mHealth intervention for peer health workers on AIDS care in rural Uganda: a mixed methods evaluation of a cluster-randomized trial.
2011 | AIDS and Behavior | 1776-1784 (9 pp)
Link to article
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.
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Improved Response to Disasters and Outbreaks by Tracking Population Movements with Mobile Phone Network Data: A Post-Earthquake Geospatial Study in Haiti
2011 | PLoS Medicine
Link to Journal Article
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Improvement of maternal health services through the use of mobile phones.
2011 | Tropical Medicine and International Health | 622-6. (5 pp)
Link to article
OBJECTIVE: To analyse, on the basis of the literature, the potential of mobile phones to improve maternal health services in Low and Middle Income Countries (LMIC). METHODS: Wide search for scientific and grey literature using various terms linked to: maternal health, mobile telecommunication and LMIC. Applications requiring an internet connection were excluded as this is not widely available in LMIC yet.
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Key Issues in Mobile Health
2011 | Clinical Trials Research Unit | Pages: 6
PDF
Abstrract: mHealth or mobile health describes the use of mobile communications devices for health-related purposes. There is much interest in mHealth internationally at this time; including interest in interventions developed in New Zealand/by New Zealanders. A recent research project examined the key issues in the implementation of mHealth and the current opportunities to address those issues in the U.S.
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mHealth Evidence Workshop Video
2011 | US Department of Health & Human Services
Website Link
Mobile health (mHealth) has the potential to simultaneously reduce the cost of health care and improve our health by encouraging healthy behaviors, providing continuous monitoring to prevent or reduce health problems, reducing acute health care visits, and providing personalized, real-time intervention in the mobile environment. However, traditional methods of evaluation needed to address efficacy and safety in mHealth are not well aligned to the pace of technological development.
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mHealth New horizons for health through mobile technologies. Based on the findings of the Second Global Survey on eHealth.
2011 | WHO Global Observatory for eHealth Series | (131 pp)
Link to PDF
This WHO survey, completed by 114 member states, documents the status of mHealth and covers four aspects: adoption of programs, types of programs, evaluation status and implementation barriers. Reporting is by World Bank region and income group. The survey also categorizes mHealth services into 14 categories. Analysis of the findings shows the dominance of pilot projects addressing single issues and the need for interoperability and globally accepted standards of practices.
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Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders
2011 | AIDS | Pages: 9
Link to Journal Article
Abstract: Objective: There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART).
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Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders
2011 | AIDS 25(6) | 825-834
OBJECTIVE: There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya. DESIGN: A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up.
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Optimal HAART adherence over time and time interval between successive visits: their association and determinants.
2011 | AIDS Care | 1417-24. (8 pp)
Link to article
 We aimed to investigate the determinants of optimal highly active antiretroviral therapy (HAART) adherence and time interval between successive clinic visits, and the association between these two processes. This was done by reviewing routinely collected patient information in the Centre for the AIDS Programme of Research in South Africa (CAPRISA). Records of 688 patients enrolled in the CAPRISA AIDS treatment (CAT) programme between 2004 and 2006 were analysed. Patients were considered adherent if they had taken at least 95% of their prescribed drugs.
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Special Delivery: An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World
2011 | Maternal Child Health Journal | Pages: 10
Summary: Mobile health (mHealth) encompasses the use of mobile telecommunication and multimedia into increasingly mobile and wireless health care delivery systems and has the potential to improve tens of thousands of lives each year. The ubiquity and penetration of mobile phones presents the opportunity to leverage mHealth for maternal and newborn care, particularly in under-resourced health ecosystems.
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Special Delivery: An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World.
2011 | Maternal Child Health Journal | 10 pp
Link to article
 The article assesses mHealth services in maternal, newborn, and child health (MNCH) through a literature review.  The review comprised of 34 articles and reports that highlighted the use and limitations of mHealth applications in MNCH care.  The studies were organized according to functions provided by mobile health technologies including emergency medical response, point-of-care support, health promotion, and data collection.
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Supporting patient adherence to antiretrovirals using mobile phone reminders: patient responses from South India
2011 | AIDS Care | 6 pp
Link to article
 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.
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Test messages as a learning tool for midwives
2011 | South Africa Medical Journal | Pages: 2
Link to pdf
Abstract: The use of cell phone text messaging to improve access to continuing healthcare education in under-resourced settings is not well documented. We aimed to assess whether this method of education is acceptable to South African midwives in both the public and private sectors. Essential healthcare lessons from the Maternal Care book of the Perinatal Education Programme (PEP) were delivered via text message to more than 2 500 midwives each week for a period of 6 months.
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Text messaging to improve adherence to malaria guidelines
2011 | Tha Lancet | 750-2. (3 pp)
Link to article
 The massive increase in funding for malaria control in the past decade1 has led to a sharp rise in the procurement of artemisinin combination therapies (ACTs)-the recommended first-line treatment for uncomplicated Plasmodium falciparum malaria. However, availability of these life-saving drugs varies between countries, and positive health outcomes need not only ACTs to be available at all levels of the health-care system, but also health workers to prescribe them according to national guidelines and patients to adhere to their treatment regimens.
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The challenges and opportunities of conducting a clinical trial in a low resource setting: the case of the Cameroon mobile phone SMS (CAMPS) trial, an investigator initiated trial
2011 | Trials | 145 (1 pp)
Link to article
 Conducting clinical trials in developing countries often presents significant ethical, organisational, cultural and infrastructural challenges to researchers, pharmaceutical companies, sponsors and regulatory bodies. Globally, these regions are under-represented in research, yet this population stands to gain more from research in these settings as the burdens on health are greater than those in developed resourceful countries.
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The effect of mobile phone text-message reminders on Kenyan health workers' adherence to malaria treatment guidelines: a cluster randomised trial
2011 | Lancet | Pages: 9
PubMed
ABSTRACT: BACKGROUND: Health workers' malaria case-management practices often differ from national guidelines. We assessed whether text-message reminders sent to health workers' mobile phones could improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya. METHODS: From March 6, 2009, to May 31, 2010, we did a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya.
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The effect of mobile phone text-message reminders on Kenyan health workers' adherence to malaria treatment guidelines: a cluster randomised trial.
2011 | Tha Lancet | 795-803. (9 pp)
Link to article
Background: Health workers' malaria case-management practices often diff er from national guidelines. We assessed whether text-message reminders sent to health workers' mobile phones could improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya. Methods: From March 6, 2009, to May 31, 2010, we did a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya.
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A phone-counseling smoking-cessation intervention for male Chinese restaurant workers
2010 | Journal of Community Health | 579-585. (7pgs)
Link to article
A smoking cessation program was developed in New York City to reach male Chinese restaurant staff. Male Chinese immigrants smoke more than any population within the exception of Native Americans. The development of the study involved the recruitment of 100 restaurant workers for a phone-counseling smoking cessation intervention. Counseling was done in Chinese language and compared baseline smoking to a follow up on use 6 months after the intervention. The results found that phone counseling as a complement to field outreach can enable smoking cessation for hard-to-reach population groups.
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A text message-based intervention to bridge the healthcare communication gap in the rural developing world.
2010 | Technol Health Care. 18: 137-144 | 8
document
Limited health service provision in many developing countries is exemplified by the shortage of skilled health workers. Geographic barriers are one of the many factors inhibit patient care and communication from practitioners. Community health workers (CHWs) have long filled the patient-physician void but still have to contend with the time associated with travel to remote locations. The focus on this study is on the novel application of Frontline SMS network in Malawi to strengthening communication between CHWs and district-level physicians. Frontline was piloted with 75 CHWs in St.
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Cell phone short messaging service (SMS) for HIV/AIDS in South Africa: a literature review
2010 | Stud Health Technol Inform 160(Pt 1): 530-534 | 5
document
The HIV/AIDS pandemic is one of the most serious threats to global health. HIV/AIDS is a chronic illness, requiring patient empowerment to enhance adherence to treatment regimes if it is to be managed effectively. While healthcare costs are rising, people still have expectations of high-quality care. This literature review-based study explored the use of cell phone (mobile phone) short messaging services (SMS) in health care, in particular for HIV/AIDS in South Africa. From an initial corpus of 212 papers, 28 were reviewed.
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Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial
2010 | Lancet. 376: | 1838-1845
BACKGROUND: Mobile (cell) phone communication has been suggested as a method to improve delivery of health services. However, data on the effects of mobile health technology on patient outcomes in resource-limited settings are limited. We aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load. METHODS: WelTel Kenya1 was a multisite randomised clinical trial of HIV-infected adults initiating antiretroviral therapy (ART) in three clinics in Kenya.
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Implementing medical information systems in developing countries, what works and what doesn't
2010 | AMIA Annual Symposium Proceedings | 232-236 (5pgs)
Link to article
The availability of inexpensive technology hardware and greater internet access has enabled the emergence of Global Health Informatics and novel applications such electronic medical records (EMRs). Organizations such as Partners in Health (PIH) have developed open-source platforms for EMRs, which are among the implementing systems that have been operating in resource-limited settings. Multiple lessons have been taken from analysis of data collection procedures involving electronic resources.
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mHealth - an Ultimate Platform to Serve the Unserved.
2010 | Yearbook of Medical Informatics | 94-100 (7 pp)
Link to article
The article is a summary of current research and developments of mobile health (mHealth) services in public health and clinical practices. mHealth applications present novel and inexpensive opportunities to heighten accessibility, personalize service, and facilitate field-based care. While mHealth may address many service-related gaps in resource-limited settings, barriers such as interoperability of health information services and lack of provider knowledge in mHealth applications remain.    
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Rural health centres, communities and malaria case detection in Zambia using mobile telephones: a means to detect potential reservoirs of infection in unstable transmission conditions
2010 | Malaria Journal 9:96 | 1-7
PubMed
Abstract: BACKGROUND: Effective malaria control depends on timely acquisition of information on new cases, their location and their frequency so as to deploy supplies, plan interventions or focus attention on specific locations appropriately to intervene and prevent an upsurge in transmission. The process is known as active case detection, but because the information is time sensitive, it is difficult to carry out.
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Sentinel surveillance system for early outbreak detection in Madagascar
2010 | BMC Public Health. 10: 31 | 8
document
A paper-based sentinel surveillance of infectious disease outbreak in Madagascar used only a passive approach until early 2007. Low diagnosis of new cases of disease remained in remote regions. Tthe Indian Ocean chikungunya outbreak highlighted the absence of an efficient surveillance system and drew attention to the necessary upgrade of passive systems for the early detection of outbreaks.
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SMS for Life: a pilot project to improve anti-malarial drug supply management in rural Tanzania using standard technology
2010 | Malaria Journal | 298. (9 pgs)
Link to articel
The maintenance of adequate anti-malarial drugs such as artemisinin-based combination therapy (ACT)  in health facilities is a major logistics challenge for the national health system in Tanzania. Supported by the Roll Back Malaria partnership, a 21-week ‘SMS for Life’ Pilot was implemented by a private-public partnership to improve supply chain management of ACT access and stock levels in 129 health facilities through a novel data processing system, used in mobile phones.
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Text messaging as a tool for behavior change in disease prevention and management.
2010 | Epidemiology Review | 56-69 (14pgs.)
Link to article
As rapidly growing mode of interpersonal communication, mobile phone text messaging has been found as a novel method to facilitate behavior change interventions for disease management and prevention. A review was conducted of 12 randomized control trials which each assessed text messaging as a primary mode of communication in the disease prevention or management intervention. Most studies in the review (10) included an interactive text messaging component while only 2 were unidirectional, with the provider being the only sender of messaging.
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The emergence of mobile-supported national health information systems in developing countries
2010 | Studies in Health Technology and Informatics | 540-544 (5 pp)
Link to article
National health information systems in developing countries are facing a major barrier in scaling information collection, synthesis, and dissemination to the lowest level of the health system. The paper looks at how mobile health (mHealth) capabilities can strengthen data programming in field-based sites. Solutions and barriers were identified for scaling mHealth capabilities in resource-limited settings.  
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Using mobile phones to improve clinic attendance amongst an antiretroviral treatment cohort in rural Uganda: a cross-sectional and prospective study
2010 | AIDS Behavior | 1347-1352 (6pgs)
Link to article
Nearly 22 million people live with HIV/AIDS in sub-Saharan Africa, with the rate of uptake in anti-retroviral therapy (ART) increasing among these populations. Near perfect treatment adherence is important to virologic suppression and missed visits for treatment contribute toward virologic failure. High levels of adherence in resource-limited settings are possible with novel solutions in the integration of mHealth into ART services. The study assessed mobile phone access and use in an ART cohort in rural Uganda to determine its feasibility for adherence improvement.
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Lifelink: 3G-based mobile telemedicine system.
2009 | Telemedicine Journal & eHealth | 241-247.(7pp)
Link to article
 Wired telemedicine systems are undermined by the high cost of infrastructure in archipelagic countries (e.g. Philippines) with limited resources. In compensating for low doctor-to-patient ratios., Lifelink, a 3G-based facility that wirelessly transfers real-time medical information from a remote location, connects hard-to-reach patient to advanced medical care. A randomized study that assessed electrocardiogram (ECG) readings from cardiac patients demonstrated at least 80% effectiveness in matching their diagnosis to readings done in the mobile device connected to Lifelink.
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The development and evaluation of a PDA-based method for public health surveillance data collection in developing countries
2009 | International Journal of Medical Informatics | Pages: 532-42
DOI |
Pubmed
Abstract: BACKGROUND AND PURPOSE: EpiData and Epi Info are often used together by public health agencies around the world, particularly in developing countries, to meet their needs of low-cost public health data management; however, the current open source data management technology lacks a mobile component to meet the needs of mobile public health data collectors. The goal of this project is to explore the opportunity of filling this gap through developing and trial of a personal digital assistant (PDA) based data collection/entry system.
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The HAART cell phone adherence trial (WelTel Kenya1): a randomized controlled trial protocol.
2009 | Trials. 10:87 | 1-10
Link to article
BACKGROUND: The objectives are to compare the effectiveness of cell phone-supported SMS messaging to standard care on adherence, quality of life, retention, and mortality in a population receiving antiretroviral therapy (ART) in Nairobi, Kenya. METHODS AND DESIGN: A multi-site randomized controlled open-label trial. A central randomization centre provided opaque envelopes to allocate treatments.
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Responding to the human resource crisis: peer health workers, mobile phones, and HIV care in Rakai, Uganda
2008 | AIDS Patient Care and STDs | 173-174. (2pgs)
Link to article
The Rakai Health Sciences Program (RHSP) has piloted a mHealth initiative with peer health workers (PHWs) for a rural ART program in Rakai, Uganda. PHWs are assigned between 15 and 20 patients for biweekly home visits. Nine PHWs were trained send to SMS messages with clinical and adherence data for higher-ranked providers. The pilot found that mobile phone were a simple support strategy in capturing data and following-up with adherence to home-based ART treatment. The system was optimal for heightened communication between PHWs and higher-level providers.  
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SMS STI: a review of the uses of mobile phone text messaging in sexual health
2008 | Int J STD AIDS. 19 | 287-290
Short messaging service (SMS) (a.k.a. text messaging) is a fast, low cost and popular mode of communication among young people, and these advantages can be used in a variety of ways in the field of sexual health. This paper reviews the current published and grey literature and discusses applications of SMS in sexual health and the evidence base for their effectiveness. Examples of uses of SMS in sexual health include: communication between sexual health clinics and patients, partner notification and contact tracing, contraception reminders and sexual health promotion and education.
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Current trends in Internet- and cell phone-based HIV prevention and intervention programs
2007 | Curr HIV/AIDS Rep 4(4): 201-207. | 8
document
In understanding the application of the internet and cell phones into HIV prevention and treatment, the study did a literature review of technology-based HIV research. The search found articles that highlighted the development of programs for at-risk populations such as men who sex with men (MSM) and the potential of integration of text messaging to effect change in risky behaviors for those living with HIV. The technology-based HIV research is still preliminary but offers future opportunities in advancement of HIV treatment and care.    
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Mobile phone consultation for community health care in rural north India.
2007 | Journal of Telemedicine and Telecare | 421-424. (4 pp)
Link to article
A feasibility study was done to understand the viability of clinical consultation through mobile phones in a community-level setting in rural northern India. A local physician initiated a free, 24-hour consultation service targeted to the general public. The service was advertised through local NGOs, youth empowerment group meetings, health education sessions, and outpatient sessions. A total of 660 calls were monitored. 63% called to seek initial consultation advice, 22% sought outpatient follow-up, and 4% were seeking appointments, while the remaining 11% called for other reasons.
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Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries?
2006 | Global Health. 2 | 14
Abstract: The ongoing policy debate about the value of communications technology in promoting development objectives is diverse. Some view computer/web/phone communications technology as insufficient to solve development problems while others view communications technology as assisting all sections of the population. This paper looks at evidence to support or refute the idea that fixed and mobile telephones is, or could be, an effective healthcare intervention in developing countries.
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The use of cell phone reminder calls for assisting HIV-infected adolescents and young adults to adhere to highly active antiretroviral therapy: a pilot study
2006 | AIDS Patient Care STDS 20(6) | 438-444
Long-term medication regimen adherence is challenging in all populations, but in the HIV-infected adolescent population the frequency of poverty, homelessness, substance abuse, and mental illness make highly active antiretroviral therapy (HAART) adherence even more challenging. In 2003, we developed a pilot program for HIV-infected adolescents and young adults between the ages of 16 and 24 who were either going to begin a HAART regimen for the first time or begin a new HAART regimen. Participants received a free cell phone with a local service plan for approximately 6 months.
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