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mHealth Interventions in South Africa: A Review:

mHealth Interventions in South Africa: A Review: The South African health care system, despite recording some significant improvements since independence, still faces a number of health challenges. Mobile technologies application in health care, also known as mHealth, has been shown as feasible in helping alleviate some of South Africa’s disease burden and cause improvements in health care outcomes. Although some feasibility studies have shown the potentials of mHealth, there is a paucity of literature establishing clear outcomes of mHealth interventions in South Africa. This study, therefore, is a systematic review of literature that was carried out to evaluate empirical evidence on the effect of mHealth interventions on health outcomes in South Africa. Academic databases such as PubMed, ScienceDirect, EBSCOhost, and Scopus were searched for empirical studies relating to mHealth interventions in South Africa carried out between 2011 and March 2016. The search, after the screening, yielded 40 papers, of which six randomized controlled studies were eligible for review by the PRISMA guideline. Findings revealed that mHealth interventions using mobile phones and text messages had been targeted at improving treatment adherence and eliciting behavioral actions in patients. However, while mHealth portends the potential to improve health outcomes and possibly transform the health system, there was no sufficient evidence to confirm the effect of the mHealth interventions on improved health outcomes. The study concludes that there is a need for more intervention studies to show evidence of the impact of mHealth interventions on health outcomes and health care delivery processes in South Africa. Keywords mobile health, mobile phone, health care, systematic review, South Africa abound, as the country is still burdened with diseases such as Introduction HIV/AIDs, TB (South Africa contributes about 73% of the The health care system of a country is arguably the driver of burden in the African Region), and high neonatal and mater- every other sector, and hence, optimum functionality must be nal mortality ratios (Rispel, 2016; WHO, 2016). maintained. The health care system in South Africa is The adoption and application of information and commu- reported to have witnessed significant improvements since nications technology (ICT) tools have been seen as a sort of the end of apartheid in 1994. These improvements have been silver lining through which health systems in various coun- geared at reducing inequalities in health care access, tries can be improved. Notably, the prevalence and penetra- increased primary health care facilities, enactment of tion of mobile technologies, especially mobile phones in enabling policies and regulatory frameworks, and implemen- developing countries, have proven to be a major ingredient tation of priority health programs (Odine, 2015; Rispel, needed to improve health care service delivery. According to 2016). The World Health Organization (WHO) country pro- Gupta (2014), the epidemic of mobile technology is pervad- file on South Africa also notes an increase in life expectancy ing the African region, and it is being used to tackle health caused by innovative practices, especially the proportional problems. Statistics from the International T elecommunications increase in the treatment and care afforded to patients with Union (ITU) shows a steady increase in mobile phone sub- HIV/AIDs and tuberculosis (TB), and improved access to scription in South Africa. Evidently, South Africa has one of immunizations (World Health Organization [WHO], 2016). Even with these improvements, the health care system is still beleaguered with a number of challenges. In fact, as noted by University of KwaZulu-Natal, Durban, South Africa Rispel (2016), the national response to the country’s disease Corresponding Author: burden has not been sufficient, thus, compromising many of Adebowale I. Ojo, School of Management, IT & Governance, University of the earlier gains and improvements. This is evidenced in KwaZulu-Natal, Durban 4000, South Africa. health care inequalities and poor health outcomes that Email: ojoa@ukzn.ac.za Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open the highest mobile phone penetrations in the world, as about messaging aimed at combating HIV/AIDS), SIMPill (a med- 149 per 100 inhabitants are subscribed to a mobile phone net- ication adherence solution), and MomConnect which is a work (International Telecommunications Union, 2014). The mobile phone application that makes it possible for pregnant increasing rate of mobile phone penetration has garnered con- women to receive messages based on the stage of their preg- siderable interest among governments, world bodies such as nancy to help them improve their health and that of their the United Nations, WHO, and World Bank, and researchers babies (Akter & Ray, 2010; Cargo, 2013; Curioso & Mechael, alike regarding its application in improving health care deliv- 2010; Odine, 2015; Rivett & Tapson, 2009; Seebregts, Tanna, ery systems. This has led to the term mHealth. Fogwill, Barron, & Benjamin, 2016; Waldman & Stevens, 2015; WHO, 2013). Also, some feasibility studies have been carried out in the South African context. The use of mobile Background phones is feasible for clinic reminders and adherence mes- The Global Observatory for e-health of the WHO defined sages (Crankshaw et al., 2010; Georgette et al., 2016; mHealth as the “medical and public health practice sup- Nachega et al., 2016), cost-effective learning opportunities ported by mobile devices, such as mobile phones, patient for health workers (Woods, Attwell, Ross, & Theron, 2012), monitoring devices, personal digital assistants and other data collection by health workers (Tomlinson et al., 2009; wireless devices” (WHO, 2011). Considering the prolifera- van Heerden, Norris, Tollman, Richter, & Rotheram-Borus, tion of mobile phones even in remote areas, and their afford- 2013), monitoring and evaluation by community health ability and wireless access, they are increasingly seen as the workers (Neupane et al., 2014), reliable and sustainable technology of choice for improving health outcomes in injury severity scoring in a high-volume trauma center developing countries. Studies have reported that mHealth (Spence, Zargaran, Hameed, Navsaria, & Nicol, 2016), data offers opportunities in the areas of strengthening health sys- for injury surveillance (Zargaran et al., 2014), supporting the tems, and causing an improvement in health outcomes and malnutrition management of children under the age of 5 health care service delivery in general (Curioso & Mechael, (Nyumbeka & Wesson, 2014), cardiovascular screening 2010; Free et al., 2013; Ojo, 2017). Furthermore, to charac- (Gaziano et al., 2015), and mapping indoor residual spraying terize mHealth, Labrique, Vasudevan, Kochi, Fabricant, and (IRS) spray events in relation to malaria cases (Eskenazi Mehl (2013), outlined 12 areas of mHealth applications in et al., 2014). However, studies evaluating the effectiveness their review. These are applications targeted at educating cli- of these interventions are limited. ents and communicating a behavioral change, enhancing It is evident from the foregoing that mHealth is a potential decision support, enabling communication between care pro- tool for alleviating some of the health care challenges in viders, tracking vital events, collecting and reporting health- South Africa. However, there is a paucity of literature on sys- related data, and the management of human resources. Other tematic reviews that have assessed evidence on the extent to areas of mHealth applications are electronic health records, which mHealth interventions have generally improved health supply chain management, point-of-care testing for patients, outcomes in South Africa. In addition, a study describing the education for care providers, work planning, and financial state of mHealth implementation in South Africa reports that management. most initiatives are donor-funded, with no clear evidence of a business model that can ensure sustainability (Botha & Booi, 2016). The authors concluded that there is a need to mHealth in South Africa explore the effectiveness of mHealth strategies in the South The mHealth application landscape in South Africa is also African context. This is only expedient, considering that pre- burgeoning. A report by GSMA, a body that represents the vious similar studies have either focused on a specific tech- interests of mobile operators worldwide, indicates there are nology against a specific disease (Mukund Bahadur & 83 existing mHealth services in South Africa, with the major- Murrayb, 2010) or now requires to be up to date in the face ity focusing on HIV/AIDs and women and children (Cargo, of the rapid advances in technology (Aranda-Jan, Mohutsiwa- 2013). Also, the GSMA mHealth tracker, a web page that Dibe, & Loukanova, 2014; Betjeman, Soghoian, & Foran, curates mHealth products and services all over the world, 2013; Free et al., 2013; Krishna, Austin Boren, & Balas, shows there are 98 mHealth initiatives in South Africa, mak- 2009). Therefore, this study aims to fill this gap by attempt- ing it the highest in Africa (GSMA, n.d.). This is further cor- ing to assess via a systematic review of literature, the effec- roborated by Ojo (2017) who notes that about 47% of tiveness of mHealth interventions in improving health care mHealth applications in Africa are implemented in Southern outcomes in the context of South Africa. Africa. Worthy of mention are mHealth applications in the country that have received international acclamations due to Method their potentials to improve health outcomes. These applica- tions include Cell-Life MAMA SMS (a text messaging solu- A literature search for peer-reviewed publications was con- tion targeting women who are pregnant and those with babies ducted using four databases: PubMed, ScienceDirect, aged up to 3 months), Project Masiluleke (a specialized text EBSCOhost, and Scopus. Considering the rapid advances in Ojo 3 Figure 1. PRISMA flow diagram. mobile technology, the search was limited to articles pub- still remain the gold standard in assessing the outcome of lished between 2011 and March 2016. A combination of medical interventions (Barton, 2000). Studies not entirely MeSH terms, mHealth and South Africa, was first used as carried out in South Africa, without a control group, and keywords for the search. Second, a combination of free-text without a mobile device intervention, and evaluative or pilot words, mobile phone/cell phone and health and South Africa, studies were excluded. was also used. A total number of 395 records were retrieved from the Results search. Subsequently, the Endnote reference management software (version X7) was used to check for and remove After a careful examination taking into consideration the duplicated articles. A manual verification was also carried inclusion and exclusion criteria, six studies were found out. From the search results, all potential articles for full-text eligible for review. The PRISMA flow diagram as shown review were screened using the titles and abstracts (N = 243). in Figure 1 presents the inclusion and exclusion process. The full text of articles was retrieved and reviewed (N = 40). The full text of the six studies included for review was Also, a systematic search of the reference lists of the full retrieved, and information regarding study design, the texts was conducted to identify studies that may have been objective of the study, the mobile technology used, loca- missed. For the selection of articles to be included in the tion, intervention, and outcome were extracted. Table 1 review, the inclusion criteria were studies that were peer- shows the characteristics of the included studies. reviewed and utilized a form of randomized control trials Four studies included in the review were solely RCTs, (RCTs) or such having a control group that evaluated a while the other two were mixed studies that utilized RCTs mobile health intervention in South Africa. This study and focus groups. Furthermore, all of the interventions focused on articles that have adopted RCTs because RCTs described in the reviewed studies were mobile phone based. 4 Table 1. Characteristics of Included Studies. Province/study design/device/ S/N Author year media Participants Objectives Intervention Outcome/result 1. Bobrow et al. (2016) Cape Town/three-arm parallel Patients treated for To test the efficacy of an SMS system A structured program of clinic A small reduction in systolic blood group RCT/Mobile Phone/ hypertension integrated with clinical care in improving appointment, medication pressure control compared Text Message blood pressure control and treatment pick-up reminders, medication with usual care at 12 months. adherence compared with usual care by adherence support and There was no evidence that people with hypertension. hypertension-related an interactive intervention education delivered remotely increased this effect. using an automated system with either informational or interactive SMS. 2. Constant, de Tolly, Cape Town/RCT/Mobile Phone/ Adult women To evaluate whether automated text Messaging intervention— Anxiety decreased more, and Harries, and Myer Text Message undergoing early messages to women undergoing Intervention group received less emotional stress was (2014) medical abortion medical abortion can reduce anxiety automated text messages over experienced. and discomfort and whether the the duration of the period Text messages following messages can better prepare women for administration of abortion pill symptoms they experience may assist in managing symptoms and appear highly acceptable to recipients 3. Constant, de Tolly, Cape Town/RCT/Mobile Adult women who To establish whether women having a Self-assessment of complete Self-assessment was feasible but Harries, and Myer Phone/Text Message, instant were eligible for medical abortion could self-assess medical abortion via mobile inadequate in predicting on-going (2015) message chat application or an early medical whether their abortion was complete phone pregnancies or the need for unstructured supplementary abortion using an automated, interactive vacuum aspiration. service data (USSD) system questionnaire on their mobile phones. 4. de Tolly, Skinner, Country-wide/RCT/Mobile Random users To investigate the effectiveness of using Four intervention groups Potential of SMSs to influence Nembaware, and phone/SMS SMS to encourage uptake of HIV that received three or 10 uptake of HCT—There is a Benjamin (2012) Counseling and Testing (HCT). informational (INFO) or threshold number of SMSs motivational (MOTI) SMSs needed for positive impact. 5. Hacking et al. (2016) Cape Town/RCT and focus Hypertension Patients To test whether the dissemination of The intervention group received No statistically significant changes group/Mobile phone/SMS health information via SMS led to 90 SMSs over a period of 17 in overall health knowledge were improvements in health knowledge and weeks. observed between the control self-reported health-related behaviors. and intervention groups. 6. Lau et al. (2014) Cape Town/RCT and focus Pregnant Women To increase antenatal health knowledge The intervention group received Intervention failed to improve group/Mobile phone/SMS and awareness by disseminating text text messages staggered antenatal health knowledge. messages about clinic procedures at according to the week of antenatal visits, and how to be healthy pregnancy at the time of during pregnancy recruitment. Note. HIV = human immunodeficiency virus; RCT = randomized control trials; SMS = short message service. Ojo 5 While the mobile phone interventions were driven by adopt- sent text messages tailored to their stage of pregnancy as and ing text messaging platforms in five of the reviewed studies, when recruited into the study. Findings from the study revealed it was based on the text messaging platform, instant message no statistically significant effect of the text messages on the chat application, and unstructured supplementary service women’s antenatal health knowledge. However, the authors data (USSD) system in one study. Thematically and in line further conducted a focus group discussion with the pregnant with the categorization of mHealth interventions provided by women with which they concluded that text messages could Labrique et al. (2013), all of the studies under review could encourage health-seeking behavior. generally be characterized as interventions aimed at client In a similar behavioral intervention RCT involving the education and behavior change communication. This is fur- use of mobile phones and automated text messages, the ther discussed in the following. authors assessed the effect of automated text messages on reducing anxiety and discomfort among women undergoing medical abortion, and preparing them for the symptoms they Treatment Adherence would experience (Constant, de Tolly, Harries, & Myer, An RCT assessed the effect of automated treatment adher- 2014). They reported that the text message intervention ence support text messages on blood pressure of hyperten- caused a decrease in anxiety in the women, as they also expe- sive patients (Bobrow et al., 2016). The study had three rienced less emotional stress. Thus, they concluded that text groups: a usual care control group, a support group whose messages following the administration of abortion pills members received only text messages aimed at motivating might assist in managing symptoms experienced by women them to collect and take their medicines while providing edu- undergoing a medical abortion. cational contents about hypertension and its treatment, and a The study by Constant, de Tolly, Harries, and Myer (2015) group who in addition to the text messages could respond to was part of a larger RCT described in the preceding para- some messages via a free “please call me” request. The text graph in which the benefits of sending information via text messages were automatically sent to the patients over a messages to strengthen and simplify medical abortion was period of 1 year. These text messages were enabled by an investigated. In the randomized trial, they sought to find out open-source web-based medical record system. The message whether women undergoing medical abortion could assess was said to be tied to the patients’ clinic appointments. Their themselves on the completeness of the abortion and whether findings revealed that the text message intervention had only the assessment was accurate enough in predicting provider’s small impact on blood pressure of the intervention groups assessment of the need for follow-up. The device used was compared with the usual care group—This was in the form the mobile phone owned by the respondents who were of a small reduction in their systolic blood pressure. They women aged 18 years and above, and eligible for medical concluded that although their text messages could support abortion. The self-assessment was achieved through an adherence to hypertension treatment, their study did not pro- instant message application or a USSD system. They con- vide sufficient evidence to suggest the text message interven- cluded that while the mobile self-assessment was feasible, it tion had a significant effect on adherence or blood pressure. was not enough to predict a need for follow-up. A finding of interest to this review is the respondents’ preference for USSD over the instant messaging application. It was recom- Health Education and Information mended in the study that combining other technologies such A study assessed whether health information disseminated as telemedicine and provision of informational text messages via text messages caused an improvement in the knowledge could improve the use of mobile phones for self-assessment and behavior of hypertensive patients as related to their state in the context of medical abortion. of health (Hacking et al., 2016). The experimental group Also, an RCT investigated the effectiveness of text mes- received 90 text messages spanning 19 weeks. Their study sages in encouraging HIV counseling and testing (HCT) revealed that, overall, there was no statistically significant among participants who were randomly recruited via text change in the knowledge of those who received the text mes- messages (de Tolly, Skinner, Nembaware, & Benjamin, sages compared with those who did not. However, those who 2012). There were four intervention groups and a control received text messages had positive increases in self-reported group. The four intervention groups received either three or behavior changes. They concluded that text messages were 10 informational or motivational styled text messages effective in causing positive self-reported behavior change accordingly. Findings from the study revealed that while among hypertensive patients. those that received 10 motivational styled text messages Similarly, another study sought to assess the effect of text were more likely to go for HCT, the interventions when taken messages relating to antenatal visits, clinical procedures, and together did not have a statistically significant effect on maintaining a healthy lifestyle during pregnancy on the knowl- encouraging people to get tested for HIV. They, however, edge and awareness of pregnant women about antenatal health concluded that text messages have the potential to be used as (Lau et al., 2014). The study included pregnant women in vari- interventions encouraging people to take health-related ous stages of their pregnancy. The experimental group were actions. 6 SAGE Open mHealth interventions on health outcomes and health care Discussion delivery processes. Six studies that were RCTs were included in this review. The review focused on RCTs rather than pilot projects or feasibil- Acknowledgment ity studies to draw clear inferences about the effect of I would like to acknowledge the contribution of the Southern mHealth interventions on health outcomes or health care African Systems Analysis Center, the National Research delivery processes in the South African health system. Of the Foundation, and the Department of Science and Technology in six studies reviewed, only one (Constant et al., 2014) South Africa, as well as the International Institute of Applied emphatically reported a significant effect as a result of the Systems Analysis in Austria. mHealth intervention. Others, while not reporting statisti- cally significant effect, only confirmed the feasibility of Declaration of Conflicting Interests mHealth interventions. Findings from this study are similar The author(s) declared no potential conflicts of interest with respect to other reviews that revealed that although mHealth has the to the research, authorship, and/or publication of this article. potential to improve health outcomes in Africa, the evidence base is not enough to warrant large-scale interventions Funding (Aranda-Jan et al., 2014; Betjeman et al., 2013). It is also The author(s) received no financial support for the research, author- pertinent to note that the major mobile technology in use is ship, and/or publication of this article. text messaging or short message service (SMS) made possi- ble by the mobile phone owned by respondents. This result is References not unexpected, considering that almost every individual in the country owns a mobile phone and can access their text Akter, S., & Ray, P. (2010). mHealth: An ultimate platform to serve the unserved. Yearbook of Medical Informatics, 94-100. messages. Studies reviewed focused more on interventions Retrieved from https://imia.schattauer.de/en/contents/archive/ targeted at causing a health action or behavioral change in issue/2348/manuscript/13550.html patients and consumers of health care—specifically adher- Aranda-Jan, C. B., Mohutsiwa-Dibe, N., & Loukanova, S. (2014). ence support, emotional support, and health behavior. It is Systematic review on what works, what does not work and also not surprising that majority of the studies under review why of implementation of mobile health (mHealth) proj- focused on some of the disease burdens eminent in the coun- ects in Africa. BMC Public Health, 14(1), Article 188. try—HIV/AIDS, hypertension, and maternal mortality. doi:10.1186/1471-2458-14-188 Evidently, it also seems researchers are more interested in Barton, S. (2000). Which clinical studies provide the best evidence? health outcomes, at the expense of health care delivery pro- The best RCT still trumps the best observational study. British cess, going by the fact that the studies reviewed focused only Medical Journal, 321, 255-256. doi:10.1136/bmj.321.7256.255 on patients, and none focused on health care practitioners. Betjeman, T. J., Soghoian, S. E., & Foran, M. P. (2013). mHealth in Sub-Saharan Africa. International Journal of Telemedicine and Applications, 2013, Article 482324. doi:10.1155/2013/482324 Limitation Bobrow, K., Farmer, A. J., Springer, D., Shanyinde, M., Yu, L. M., Brennan, T., . . . Levitt, N. (2016). Mobile phone text messages This article is not without some limitations. The study is lim- to support treatment adherence in adults with high blood pres- ited in time and design scope, as it focused only on RCTs and sure (SMS-Text Adherence Support [StAR]): A single-blind, studies published within a 5-year span. Also, the gray litera- randomized trial. Circulation, 133, 592-600. doi:10.1161/ ture that may have yielded some valuable publications were CIRCULATIONAHA.115.017530 not consulted. Oversight on the part of the author in selecting Botha, A., & Booi, V. (2016, May). mHealth Implementation in studies for inclusion in this study is also not improbable. South Africa. IST-Africa 2016 Conference Proceedings. However, a more elaborate and collaborative study review- doi:10.1109/ISTAFRICA.2016.7530667 ing the mHealth landscape in the country is underway. Cargo, M. (2013). South Africa mHealth landscape. GSMA mHealth. Retrieved from https://www.gsma.com/mobilefordevelopment/ programme/mhealth/south-africa-mhealth-landscape/ Conclusion Constant, D., de Tolly, K., Harries, J., & Myer, L. (2014). Mobile phone messages to provide support to women during the home Conclusively, this study does not provide sufficient evidence phase of medical abortion in South Africa: A randomised con- to affirm mHealth interventions as causing significant trolled trial. 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Collecting maternal health informa- Article 284. doi:10.1186/1471-2393-14-284 tion from HIV-positive pregnant women using mobile 8 SAGE Open phone-assisted face-to-face interviews in Southern Africa. Zargaran, E., Schuurman, N., Nicol, A. J., Matzopoulos, R., Journal of Medical Internet Research, 15(6), Article e116. Cinnamon, J., Taulu, T., . . . Hameed, S. M. (2014). The doi:10.2196/jmir.2207 electronic trauma health record: Design and usability Waldman, L., & Stevens, M. (2015). Sexual and reproductive health of a novel tablet-based tool for trauma care and injury and rights and mHealth in policy and practice in South Africa. surveillance in low resource settings. Journal of the Reproductive Health Matters, 23(45), 93-102. doi:10.1016/j. American College of Surgeons, 218, 41-50. doi:10.1016/ rhm.2015.06.009 j.jamcollsurg.2013.10.001 World Health Organisation. (2011). mHealth: New horizons for health through mobile technologies (Vol. 3). Geneva: World Health Organization. Author Biography World Health Organisation. (2013). Supporting pregnant women Adebowale I. Ojo holds a PhD in Information Resources and new mothers in South Africa: Cell-life’s MAMA SMS. Management, with a specialisation in Health Information Geneva: World Health Organization. Management from Babcock University, Nigeria. He is a postdoctoral World Health Organisation. (2016). South Africa: Country health research fellow in the School of Management, IT & Governance at profile. Geneva: World Health Organization. the Westville campus of the University of KwaZulu-Natal, Durban, Woods, D., Attwell, A., Ross, K., & Theron, G. (2012). Text mes- South Africa. He teaches health informatics courses at the Information sages as a learning tool for midwives. South African Journal of Resources Management Department of Babcock University, Nigeria. Science, 102, 100-101. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SAGE Open SAGE

mHealth Interventions in South Africa: A Review:

SAGE Open , Volume 8 (1): 1 – Mar 28, 2018

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Abstract

The South African health care system, despite recording some significant improvements since independence, still faces a number of health challenges. Mobile technologies application in health care, also known as mHealth, has been shown as feasible in helping alleviate some of South Africa’s disease burden and cause improvements in health care outcomes. Although some feasibility studies have shown the potentials of mHealth, there is a paucity of literature establishing clear outcomes of mHealth interventions in South Africa. This study, therefore, is a systematic review of literature that was carried out to evaluate empirical evidence on the effect of mHealth interventions on health outcomes in South Africa. Academic databases such as PubMed, ScienceDirect, EBSCOhost, and Scopus were searched for empirical studies relating to mHealth interventions in South Africa carried out between 2011 and March 2016. The search, after the screening, yielded 40 papers, of which six randomized controlled studies were eligible for review by the PRISMA guideline. Findings revealed that mHealth interventions using mobile phones and text messages had been targeted at improving treatment adherence and eliciting behavioral actions in patients. However, while mHealth portends the potential to improve health outcomes and possibly transform the health system, there was no sufficient evidence to confirm the effect of the mHealth interventions on improved health outcomes. The study concludes that there is a need for more intervention studies to show evidence of the impact of mHealth interventions on health outcomes and health care delivery processes in South Africa. Keywords mobile health, mobile phone, health care, systematic review, South Africa abound, as the country is still burdened with diseases such as Introduction HIV/AIDs, TB (South Africa contributes about 73% of the The health care system of a country is arguably the driver of burden in the African Region), and high neonatal and mater- every other sector, and hence, optimum functionality must be nal mortality ratios (Rispel, 2016; WHO, 2016). maintained. The health care system in South Africa is The adoption and application of information and commu- reported to have witnessed significant improvements since nications technology (ICT) tools have been seen as a sort of the end of apartheid in 1994. These improvements have been silver lining through which health systems in various coun- geared at reducing inequalities in health care access, tries can be improved. Notably, the prevalence and penetra- increased primary health care facilities, enactment of tion of mobile technologies, especially mobile phones in enabling policies and regulatory frameworks, and implemen- developing countries, have proven to be a major ingredient tation of priority health programs (Odine, 2015; Rispel, needed to improve health care service delivery. According to 2016). The World Health Organization (WHO) country pro- Gupta (2014), the epidemic of mobile technology is pervad- file on South Africa also notes an increase in life expectancy ing the African region, and it is being used to tackle health caused by innovative practices, especially the proportional problems. Statistics from the International T elecommunications increase in the treatment and care afforded to patients with Union (ITU) shows a steady increase in mobile phone sub- HIV/AIDs and tuberculosis (TB), and improved access to scription in South Africa. Evidently, South Africa has one of immunizations (World Health Organization [WHO], 2016). Even with these improvements, the health care system is still beleaguered with a number of challenges. In fact, as noted by University of KwaZulu-Natal, Durban, South Africa Rispel (2016), the national response to the country’s disease Corresponding Author: burden has not been sufficient, thus, compromising many of Adebowale I. Ojo, School of Management, IT & Governance, University of the earlier gains and improvements. This is evidenced in KwaZulu-Natal, Durban 4000, South Africa. health care inequalities and poor health outcomes that Email: ojoa@ukzn.ac.za Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open the highest mobile phone penetrations in the world, as about messaging aimed at combating HIV/AIDS), SIMPill (a med- 149 per 100 inhabitants are subscribed to a mobile phone net- ication adherence solution), and MomConnect which is a work (International Telecommunications Union, 2014). The mobile phone application that makes it possible for pregnant increasing rate of mobile phone penetration has garnered con- women to receive messages based on the stage of their preg- siderable interest among governments, world bodies such as nancy to help them improve their health and that of their the United Nations, WHO, and World Bank, and researchers babies (Akter & Ray, 2010; Cargo, 2013; Curioso & Mechael, alike regarding its application in improving health care deliv- 2010; Odine, 2015; Rivett & Tapson, 2009; Seebregts, Tanna, ery systems. This has led to the term mHealth. Fogwill, Barron, & Benjamin, 2016; Waldman & Stevens, 2015; WHO, 2013). Also, some feasibility studies have been carried out in the South African context. The use of mobile Background phones is feasible for clinic reminders and adherence mes- The Global Observatory for e-health of the WHO defined sages (Crankshaw et al., 2010; Georgette et al., 2016; mHealth as the “medical and public health practice sup- Nachega et al., 2016), cost-effective learning opportunities ported by mobile devices, such as mobile phones, patient for health workers (Woods, Attwell, Ross, & Theron, 2012), monitoring devices, personal digital assistants and other data collection by health workers (Tomlinson et al., 2009; wireless devices” (WHO, 2011). Considering the prolifera- van Heerden, Norris, Tollman, Richter, & Rotheram-Borus, tion of mobile phones even in remote areas, and their afford- 2013), monitoring and evaluation by community health ability and wireless access, they are increasingly seen as the workers (Neupane et al., 2014), reliable and sustainable technology of choice for improving health outcomes in injury severity scoring in a high-volume trauma center developing countries. Studies have reported that mHealth (Spence, Zargaran, Hameed, Navsaria, & Nicol, 2016), data offers opportunities in the areas of strengthening health sys- for injury surveillance (Zargaran et al., 2014), supporting the tems, and causing an improvement in health outcomes and malnutrition management of children under the age of 5 health care service delivery in general (Curioso & Mechael, (Nyumbeka & Wesson, 2014), cardiovascular screening 2010; Free et al., 2013; Ojo, 2017). Furthermore, to charac- (Gaziano et al., 2015), and mapping indoor residual spraying terize mHealth, Labrique, Vasudevan, Kochi, Fabricant, and (IRS) spray events in relation to malaria cases (Eskenazi Mehl (2013), outlined 12 areas of mHealth applications in et al., 2014). However, studies evaluating the effectiveness their review. These are applications targeted at educating cli- of these interventions are limited. ents and communicating a behavioral change, enhancing It is evident from the foregoing that mHealth is a potential decision support, enabling communication between care pro- tool for alleviating some of the health care challenges in viders, tracking vital events, collecting and reporting health- South Africa. However, there is a paucity of literature on sys- related data, and the management of human resources. Other tematic reviews that have assessed evidence on the extent to areas of mHealth applications are electronic health records, which mHealth interventions have generally improved health supply chain management, point-of-care testing for patients, outcomes in South Africa. In addition, a study describing the education for care providers, work planning, and financial state of mHealth implementation in South Africa reports that management. most initiatives are donor-funded, with no clear evidence of a business model that can ensure sustainability (Botha & Booi, 2016). The authors concluded that there is a need to mHealth in South Africa explore the effectiveness of mHealth strategies in the South The mHealth application landscape in South Africa is also African context. This is only expedient, considering that pre- burgeoning. A report by GSMA, a body that represents the vious similar studies have either focused on a specific tech- interests of mobile operators worldwide, indicates there are nology against a specific disease (Mukund Bahadur & 83 existing mHealth services in South Africa, with the major- Murrayb, 2010) or now requires to be up to date in the face ity focusing on HIV/AIDs and women and children (Cargo, of the rapid advances in technology (Aranda-Jan, Mohutsiwa- 2013). Also, the GSMA mHealth tracker, a web page that Dibe, & Loukanova, 2014; Betjeman, Soghoian, & Foran, curates mHealth products and services all over the world, 2013; Free et al., 2013; Krishna, Austin Boren, & Balas, shows there are 98 mHealth initiatives in South Africa, mak- 2009). Therefore, this study aims to fill this gap by attempt- ing it the highest in Africa (GSMA, n.d.). This is further cor- ing to assess via a systematic review of literature, the effec- roborated by Ojo (2017) who notes that about 47% of tiveness of mHealth interventions in improving health care mHealth applications in Africa are implemented in Southern outcomes in the context of South Africa. Africa. Worthy of mention are mHealth applications in the country that have received international acclamations due to Method their potentials to improve health outcomes. These applica- tions include Cell-Life MAMA SMS (a text messaging solu- A literature search for peer-reviewed publications was con- tion targeting women who are pregnant and those with babies ducted using four databases: PubMed, ScienceDirect, aged up to 3 months), Project Masiluleke (a specialized text EBSCOhost, and Scopus. Considering the rapid advances in Ojo 3 Figure 1. PRISMA flow diagram. mobile technology, the search was limited to articles pub- still remain the gold standard in assessing the outcome of lished between 2011 and March 2016. A combination of medical interventions (Barton, 2000). Studies not entirely MeSH terms, mHealth and South Africa, was first used as carried out in South Africa, without a control group, and keywords for the search. Second, a combination of free-text without a mobile device intervention, and evaluative or pilot words, mobile phone/cell phone and health and South Africa, studies were excluded. was also used. A total number of 395 records were retrieved from the Results search. Subsequently, the Endnote reference management software (version X7) was used to check for and remove After a careful examination taking into consideration the duplicated articles. A manual verification was also carried inclusion and exclusion criteria, six studies were found out. From the search results, all potential articles for full-text eligible for review. The PRISMA flow diagram as shown review were screened using the titles and abstracts (N = 243). in Figure 1 presents the inclusion and exclusion process. The full text of articles was retrieved and reviewed (N = 40). The full text of the six studies included for review was Also, a systematic search of the reference lists of the full retrieved, and information regarding study design, the texts was conducted to identify studies that may have been objective of the study, the mobile technology used, loca- missed. For the selection of articles to be included in the tion, intervention, and outcome were extracted. Table 1 review, the inclusion criteria were studies that were peer- shows the characteristics of the included studies. reviewed and utilized a form of randomized control trials Four studies included in the review were solely RCTs, (RCTs) or such having a control group that evaluated a while the other two were mixed studies that utilized RCTs mobile health intervention in South Africa. This study and focus groups. Furthermore, all of the interventions focused on articles that have adopted RCTs because RCTs described in the reviewed studies were mobile phone based. 4 Table 1. Characteristics of Included Studies. Province/study design/device/ S/N Author year media Participants Objectives Intervention Outcome/result 1. Bobrow et al. (2016) Cape Town/three-arm parallel Patients treated for To test the efficacy of an SMS system A structured program of clinic A small reduction in systolic blood group RCT/Mobile Phone/ hypertension integrated with clinical care in improving appointment, medication pressure control compared Text Message blood pressure control and treatment pick-up reminders, medication with usual care at 12 months. adherence compared with usual care by adherence support and There was no evidence that people with hypertension. hypertension-related an interactive intervention education delivered remotely increased this effect. using an automated system with either informational or interactive SMS. 2. Constant, de Tolly, Cape Town/RCT/Mobile Phone/ Adult women To evaluate whether automated text Messaging intervention— Anxiety decreased more, and Harries, and Myer Text Message undergoing early messages to women undergoing Intervention group received less emotional stress was (2014) medical abortion medical abortion can reduce anxiety automated text messages over experienced. and discomfort and whether the the duration of the period Text messages following messages can better prepare women for administration of abortion pill symptoms they experience may assist in managing symptoms and appear highly acceptable to recipients 3. Constant, de Tolly, Cape Town/RCT/Mobile Adult women who To establish whether women having a Self-assessment of complete Self-assessment was feasible but Harries, and Myer Phone/Text Message, instant were eligible for medical abortion could self-assess medical abortion via mobile inadequate in predicting on-going (2015) message chat application or an early medical whether their abortion was complete phone pregnancies or the need for unstructured supplementary abortion using an automated, interactive vacuum aspiration. service data (USSD) system questionnaire on their mobile phones. 4. de Tolly, Skinner, Country-wide/RCT/Mobile Random users To investigate the effectiveness of using Four intervention groups Potential of SMSs to influence Nembaware, and phone/SMS SMS to encourage uptake of HIV that received three or 10 uptake of HCT—There is a Benjamin (2012) Counseling and Testing (HCT). informational (INFO) or threshold number of SMSs motivational (MOTI) SMSs needed for positive impact. 5. Hacking et al. (2016) Cape Town/RCT and focus Hypertension Patients To test whether the dissemination of The intervention group received No statistically significant changes group/Mobile phone/SMS health information via SMS led to 90 SMSs over a period of 17 in overall health knowledge were improvements in health knowledge and weeks. observed between the control self-reported health-related behaviors. and intervention groups. 6. Lau et al. (2014) Cape Town/RCT and focus Pregnant Women To increase antenatal health knowledge The intervention group received Intervention failed to improve group/Mobile phone/SMS and awareness by disseminating text text messages staggered antenatal health knowledge. messages about clinic procedures at according to the week of antenatal visits, and how to be healthy pregnancy at the time of during pregnancy recruitment. Note. HIV = human immunodeficiency virus; RCT = randomized control trials; SMS = short message service. Ojo 5 While the mobile phone interventions were driven by adopt- sent text messages tailored to their stage of pregnancy as and ing text messaging platforms in five of the reviewed studies, when recruited into the study. Findings from the study revealed it was based on the text messaging platform, instant message no statistically significant effect of the text messages on the chat application, and unstructured supplementary service women’s antenatal health knowledge. However, the authors data (USSD) system in one study. Thematically and in line further conducted a focus group discussion with the pregnant with the categorization of mHealth interventions provided by women with which they concluded that text messages could Labrique et al. (2013), all of the studies under review could encourage health-seeking behavior. generally be characterized as interventions aimed at client In a similar behavioral intervention RCT involving the education and behavior change communication. This is fur- use of mobile phones and automated text messages, the ther discussed in the following. authors assessed the effect of automated text messages on reducing anxiety and discomfort among women undergoing medical abortion, and preparing them for the symptoms they Treatment Adherence would experience (Constant, de Tolly, Harries, & Myer, An RCT assessed the effect of automated treatment adher- 2014). They reported that the text message intervention ence support text messages on blood pressure of hyperten- caused a decrease in anxiety in the women, as they also expe- sive patients (Bobrow et al., 2016). The study had three rienced less emotional stress. Thus, they concluded that text groups: a usual care control group, a support group whose messages following the administration of abortion pills members received only text messages aimed at motivating might assist in managing symptoms experienced by women them to collect and take their medicines while providing edu- undergoing a medical abortion. cational contents about hypertension and its treatment, and a The study by Constant, de Tolly, Harries, and Myer (2015) group who in addition to the text messages could respond to was part of a larger RCT described in the preceding para- some messages via a free “please call me” request. The text graph in which the benefits of sending information via text messages were automatically sent to the patients over a messages to strengthen and simplify medical abortion was period of 1 year. These text messages were enabled by an investigated. In the randomized trial, they sought to find out open-source web-based medical record system. The message whether women undergoing medical abortion could assess was said to be tied to the patients’ clinic appointments. Their themselves on the completeness of the abortion and whether findings revealed that the text message intervention had only the assessment was accurate enough in predicting provider’s small impact on blood pressure of the intervention groups assessment of the need for follow-up. The device used was compared with the usual care group—This was in the form the mobile phone owned by the respondents who were of a small reduction in their systolic blood pressure. They women aged 18 years and above, and eligible for medical concluded that although their text messages could support abortion. The self-assessment was achieved through an adherence to hypertension treatment, their study did not pro- instant message application or a USSD system. They con- vide sufficient evidence to suggest the text message interven- cluded that while the mobile self-assessment was feasible, it tion had a significant effect on adherence or blood pressure. was not enough to predict a need for follow-up. A finding of interest to this review is the respondents’ preference for USSD over the instant messaging application. It was recom- Health Education and Information mended in the study that combining other technologies such A study assessed whether health information disseminated as telemedicine and provision of informational text messages via text messages caused an improvement in the knowledge could improve the use of mobile phones for self-assessment and behavior of hypertensive patients as related to their state in the context of medical abortion. of health (Hacking et al., 2016). The experimental group Also, an RCT investigated the effectiveness of text mes- received 90 text messages spanning 19 weeks. Their study sages in encouraging HIV counseling and testing (HCT) revealed that, overall, there was no statistically significant among participants who were randomly recruited via text change in the knowledge of those who received the text mes- messages (de Tolly, Skinner, Nembaware, & Benjamin, sages compared with those who did not. However, those who 2012). There were four intervention groups and a control received text messages had positive increases in self-reported group. The four intervention groups received either three or behavior changes. They concluded that text messages were 10 informational or motivational styled text messages effective in causing positive self-reported behavior change accordingly. Findings from the study revealed that while among hypertensive patients. those that received 10 motivational styled text messages Similarly, another study sought to assess the effect of text were more likely to go for HCT, the interventions when taken messages relating to antenatal visits, clinical procedures, and together did not have a statistically significant effect on maintaining a healthy lifestyle during pregnancy on the knowl- encouraging people to get tested for HIV. They, however, edge and awareness of pregnant women about antenatal health concluded that text messages have the potential to be used as (Lau et al., 2014). The study included pregnant women in vari- interventions encouraging people to take health-related ous stages of their pregnancy. The experimental group were actions. 6 SAGE Open mHealth interventions on health outcomes and health care Discussion delivery processes. Six studies that were RCTs were included in this review. The review focused on RCTs rather than pilot projects or feasibil- Acknowledgment ity studies to draw clear inferences about the effect of I would like to acknowledge the contribution of the Southern mHealth interventions on health outcomes or health care African Systems Analysis Center, the National Research delivery processes in the South African health system. Of the Foundation, and the Department of Science and Technology in six studies reviewed, only one (Constant et al., 2014) South Africa, as well as the International Institute of Applied emphatically reported a significant effect as a result of the Systems Analysis in Austria. mHealth intervention. Others, while not reporting statisti- cally significant effect, only confirmed the feasibility of Declaration of Conflicting Interests mHealth interventions. Findings from this study are similar The author(s) declared no potential conflicts of interest with respect to other reviews that revealed that although mHealth has the to the research, authorship, and/or publication of this article. potential to improve health outcomes in Africa, the evidence base is not enough to warrant large-scale interventions Funding (Aranda-Jan et al., 2014; Betjeman et al., 2013). It is also The author(s) received no financial support for the research, author- pertinent to note that the major mobile technology in use is ship, and/or publication of this article. text messaging or short message service (SMS) made possi- ble by the mobile phone owned by respondents. This result is References not unexpected, considering that almost every individual in the country owns a mobile phone and can access their text Akter, S., & Ray, P. (2010). mHealth: An ultimate platform to serve the unserved. Yearbook of Medical Informatics, 94-100. messages. Studies reviewed focused more on interventions Retrieved from https://imia.schattauer.de/en/contents/archive/ targeted at causing a health action or behavioral change in issue/2348/manuscript/13550.html patients and consumers of health care—specifically adher- Aranda-Jan, C. B., Mohutsiwa-Dibe, N., & Loukanova, S. (2014). ence support, emotional support, and health behavior. It is Systematic review on what works, what does not work and also not surprising that majority of the studies under review why of implementation of mobile health (mHealth) proj- focused on some of the disease burdens eminent in the coun- ects in Africa. BMC Public Health, 14(1), Article 188. try—HIV/AIDS, hypertension, and maternal mortality. doi:10.1186/1471-2458-14-188 Evidently, it also seems researchers are more interested in Barton, S. (2000). Which clinical studies provide the best evidence? health outcomes, at the expense of health care delivery pro- The best RCT still trumps the best observational study. British cess, going by the fact that the studies reviewed focused only Medical Journal, 321, 255-256. doi:10.1136/bmj.321.7256.255 on patients, and none focused on health care practitioners. Betjeman, T. J., Soghoian, S. E., & Foran, M. P. (2013). mHealth in Sub-Saharan Africa. International Journal of Telemedicine and Applications, 2013, Article 482324. doi:10.1155/2013/482324 Limitation Bobrow, K., Farmer, A. J., Springer, D., Shanyinde, M., Yu, L. M., Brennan, T., . . . Levitt, N. (2016). Mobile phone text messages This article is not without some limitations. The study is lim- to support treatment adherence in adults with high blood pres- ited in time and design scope, as it focused only on RCTs and sure (SMS-Text Adherence Support [StAR]): A single-blind, studies published within a 5-year span. Also, the gray litera- randomized trial. Circulation, 133, 592-600. doi:10.1161/ ture that may have yielded some valuable publications were CIRCULATIONAHA.115.017530 not consulted. Oversight on the part of the author in selecting Botha, A., & Booi, V. (2016, May). mHealth Implementation in studies for inclusion in this study is also not improbable. South Africa. IST-Africa 2016 Conference Proceedings. However, a more elaborate and collaborative study review- doi:10.1109/ISTAFRICA.2016.7530667 ing the mHealth landscape in the country is underway. Cargo, M. (2013). South Africa mHealth landscape. GSMA mHealth. Retrieved from https://www.gsma.com/mobilefordevelopment/ programme/mhealth/south-africa-mhealth-landscape/ Conclusion Constant, D., de Tolly, K., Harries, J., & Myer, L. (2014). Mobile phone messages to provide support to women during the home Conclusively, this study does not provide sufficient evidence phase of medical abortion in South Africa: A randomised con- to affirm mHealth interventions as causing significant trolled trial. Contraception, 90, 226-233. doi:10.1016/j.contra- improvements in health outcomes or health care processes in ception.2014.04.009 South Africa. No doubt, many mHealth projects are going on Constant, D., de Tolly, K., Harries, J., & Myer, L. (2015). Assessment and being implemented in the country. However, these proj- of completion of early medical abortion using a text question- ects are likely to remain pilot projects that continue to con- naire on mobile phones compared to a self-administered paper firm the potential of mobile technologies in health care but questionnaire among women attending four clinics, Cape with unclear evidence of outcomes and benefits. There is a Town, South Africa. Reproductive Health Matters, 22(Suppl. 44), 83-93. doi:10.1016/S0968-8080(14)43791-1 need for more intervention studies to ascertain the effect of Ojo 7 Crankshaw, T., Corless, I. B., Giddy, J., Nicholas, P. K., Eichbaum, Mukund Bahadur, K. C., & Murrayb, P. J. (2010). Cell phone Q., & Butler, L. M. (2010). Exploring the patterns of use and short messaging service (SMS) for HIV/AIDS in South the feasibility of using cellular phones for clinic appointment Africa: A literature review. Studies in Health Technology reminders and adherence messages in an antiretroviral treat- and Informatics, 160(PART 1), 530-534. doi:10.3233/978-1- ment clinic, Durban, South Africa. AIDS Patient Care and 60750-588-4-530 STDs, 24, 729-734. doi:10.1089/apc.2010.0146 Nachega, J. B., Skinner, D., Jennings, L., Magidson, F., Altice, Curioso, W. H., & Mechael, P. N. (2010). Enhancing “M-health” F. L., Burke, J. G., . . . Theron, G. (2016). Acceptability and with south-to-south collaborations. Health Affairs, 29, 264-267. feasibility of mHealth and community-based directly observed de Tolly, K., Skinner, D., Nembaware, V., & Benjamin, P. 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Collecting maternal health informa- Article 284. doi:10.1186/1471-2393-14-284 tion from HIV-positive pregnant women using mobile 8 SAGE Open phone-assisted face-to-face interviews in Southern Africa. Zargaran, E., Schuurman, N., Nicol, A. J., Matzopoulos, R., Journal of Medical Internet Research, 15(6), Article e116. Cinnamon, J., Taulu, T., . . . Hameed, S. M. (2014). The doi:10.2196/jmir.2207 electronic trauma health record: Design and usability Waldman, L., & Stevens, M. (2015). Sexual and reproductive health of a novel tablet-based tool for trauma care and injury and rights and mHealth in policy and practice in South Africa. surveillance in low resource settings. Journal of the Reproductive Health Matters, 23(45), 93-102. doi:10.1016/j. American College of Surgeons, 218, 41-50. doi:10.1016/ rhm.2015.06.009 j.jamcollsurg.2013.10.001 World Health Organisation. (2011). mHealth: New horizons for health through mobile technologies (Vol. 3). Geneva: World Health Organization. Author Biography World Health Organisation. (2013). Supporting pregnant women Adebowale I. Ojo holds a PhD in Information Resources and new mothers in South Africa: Cell-life’s MAMA SMS. Management, with a specialisation in Health Information Geneva: World Health Organization. Management from Babcock University, Nigeria. He is a postdoctoral World Health Organisation. (2016). South Africa: Country health research fellow in the School of Management, IT & Governance at profile. Geneva: World Health Organization. the Westville campus of the University of KwaZulu-Natal, Durban, Woods, D., Attwell, A., Ross, K., & Theron, G. (2012). Text mes- South Africa. He teaches health informatics courses at the Information sages as a learning tool for midwives. South African Journal of Resources Management Department of Babcock University, Nigeria. Science, 102, 100-101.

Journal

SAGE OpenSAGE

Published: Mar 28, 2018

Keywords: mobile health; mobile phone; health care; systematic review; South Africa

References