What is mHealth?
Mobile Health or mHealth is the concept to describe the uses of mobile devices in health care. The most important benefit of this kind of personal devices such as cellphones or PDAs is that enable interaction, communication and delivery of medical information between health workers and patients. There is a subtle but important distinction between ehealth and mhealth. The first mainly uses information and communication technology (ICT)[i] such as computers, mobile phones and satellite communications for health services and information. The second one is using mobile communication devices (PDAs and mobile phones) for health services and information.[ii] Despite these definitions ehealth and mHealth are closely related and sometimes they overlap.
With around 6 billion mobile phones in the World, mHealth it is seen as a very powerful tool for the future of health care. The benefits are particularly strong in developing countries where the penetration of mobile devices is increasing, and it is larger than other kind of technology or health infrastructure. The improvements of the uses of mhealth are in areas such as: 1. - Patient health (improve compliance of treatment and medication's adherence, improve disease management and public awareness) 2.- System outcomes (resource used more efficiently).

[i] http://www.vitalwaveconsulting.com/pdf/2011/mHealth.pdf
[ii] http://www.vitalwaveconsulting.com/pdf/2011/mHealth.pdf













The most common uses of mHealth are:

Helpline


It consists of a specific phone number that any individual is able to call to gain access to a range of medical services. These include phone consultations, counseling, service complaints, and information on facilities, drugs, equipment, and/or available mobile health clinics. Health hotlines (medical call centres) play an important role particularly in preventative medicine and disease diagnosis, strengthening over-burdened health facilities and healthcare service delivery, especially in developing countries.


‍Press Feed
**A scientific audit of smartphone applications for the management of obesity.**Terms: Cellular Phone | Computers, Handheld | Humans | Information Services | Medical Informatics ...
Wednesday, June 01, 2011
**Ask, don't tell - mobile phones to improve HIV care.**
Chronic care | Hotlines and information services | Mass messaging campaigns | Health education ...
Thursday, November 07, 2013
**Mobile technology: a synopsis and comment on "mobile phone-based interventions for smoking cessation".**
Timeliness of care | Efficacy | Tobacco Use | Health education or promotion | Hotlines and information services | Mass messaging campaigns | SMS | Internet | Text | Drug users | Video ...
Friday, September 27, 2013
**Text4Baby: using text messaging to improve maternal and newborn health.**

Hotlines and information services | Mass messaging campaigns | SMS | Text ...
Wednesday, June 15, 2011
**[Public health accessible to all: use of smartphones in the context of healthcare in Italy].**
prevention | Health education or promotion | Hotlines and information services | Preventive ...
Friday, June 07, 2013
**A study on Singaporean women's acceptance of using mobile phones to seek health information.**
and practices | Pre-prototype | Hotlines and information services | Installed application ...
Tuesday, November 29, 2011
**Adherence to evidence-based guidelines among diabetes self-management apps.**
Diabetes | Chronic care | Health education or promotion | Hotlines and information services | ...
Friday, September 27, 2013
**Mobile social network services for families with children with developmental disabilities.**
Chronic care | Health education or promotion | Hotlines and information services | Provider training ...
Tuesday, July 19, 2011
**Telesurveillance of circular frame pin sites: one year's experience at a specialist unit.**
and transportation | Limited demonstration | Feasibility | Injuries | Chronic care | Hotlines and information services | Treatment adherence | Remote client-to-provider consultations (Telemedicine) | ...
Friday, May 20, 2011
**A mobile phone-based Communication Support System for elderly persons.**
Unnecessary referrals and transportation | Timeliness of care | Chronic care | Hotlines and information services | Remote client-to-provider consultations (Telemedicine) | Voice | Installed application ...



5344549272_2dd86a366a_o.jpg
Education: Best Practices
Text4baby is supported by a broad, public-private partnership that includes government, corporations, academic institutions, professional associations, tribal agencies and non-profit organizations. Founding partners are the National Healthy Mothers Health Babies Coalition, Voxiva, CTIA—The Wireless Foundation and Grey Healthcare Group. Johnson & Johnson is a founding sponsor of the program. Premier sponsors of Text4baby include Wellpoint, Pfizer and Care First Blue Cross and Blue Shield. U.S. government partners include the White House Office of Science and Technology Policy, the Department of Health and Human Services and the Department of Defense Military Health System. Voxiva provides the mobile health platform, and free messaging services are provided by participating wireless service providers.


Federally qualified health centers, state government agencies, health plans, hospitals, health delivery networks, health clinics and businesses are examples of the diverse group of outreach partners. These outreach partners are instrumental in spreading the word about Text4baby and encouraging women they serve to sign up for the program.

Press Feed
[Development and effects of a health promotion program utilizing the mail function of mobile phones].
was to develop a health education program, named "i-exerM," utilizing the mail function of the mobile ...
Monday, November 29, 2004
Design, development, and formative evaluation of a smartphone application for recording and monitoring physical activity levels: the 10,000 Steps "iStepLog".
effective health promotion delivery strategy. This article describes the development and formative ...
Wednesday, April 03, 2013
Innovative approaches to using new media and technology in health promotion for adolescents and young adults.
networking in health promotion, and discusses issues to consider as practitioners move toward integrating new media into clinical and health education settings. DOI/Link to source: Not available MeSH Terms: ...
Monday, March 19, 2012
[Public health accessible to all: use of smartphones in the context of healthcare in Italy].
prevention | Health education or promotion | Hotlines and information services | Preventive ...
Friday, June 07, 2013
A randomised controlled trial using mobile advertising to promote safer sex and sun safety to young people.
to safer sex and sun safety and (ii) pilot the use of mobile advertising for health promotion. Mobile ...
Thursday, September 08, 2011
A mobile phone enabled health promotion program for middle-aged males.
To prevent this, delivery of health promotion programs targeting lifestyle modifications of physical activity and nutrition in middle-aged males has been essential, but often difficult. ManUp health promotion program ...
Thursday, October 10, 2013
Does a text messaging intervention improve knowledge, attitudes and practice regarding iodine deficiency and iodized salt consumption?
MeSH Terms: Adult | Deficiency Diseases | Diet | Female | Health Education | Health Knowledge, Attitudes, Practice | Health Promotion | Humans | Iodine | Iran | Middle Aged | ...
Tuesday, November 20, 2012
Text4Baby: using text messaging to improve maternal and newborn health.
Parents | Women (only) | Antenatal care | Postpartum care | Health education or promotion | ...
Wednesday, June 15, 2011
Response patterns to interactive SMS health education quizzes at two sites in Uganda: a cohort study.
Measurement | Female | Health Knowledge, Attitudes, Practice | Health Promotion | Humans | Male | ...
Friday, March 15, 2013
Real-time social support through a mobile virtual community to improve healthy behavior in overweight and sedentary adults: a focus group analysis.
| Client | Prototype | Functionality | Individual based | Obesity | Preventive | Health ...
Thursday, July 14, 2011
Protocol of a randomized controlled trial of sun protection interventions for operating engineers.
http://dx.doi.org/10.1186/1471-2458-13-273 MeSH Terms: Analysis of Variance | Construction Industry | Follow-Up Studies | Health Education | Health Knowledge, Attitudes, Practice | Health Promotion | Humans | Michigan | Models, ...
Tuesday, April 09, 2013
Are current tobacco pictorial warnings in India effective?
| Advertising as Topic | Data Collection | Female | Health Communication | Health Education | Health Knowledge, Attitudes, Practice | Health Promotion | Humans | India | Male | ...
Tuesday, April 26, 2011
Cell phone usage among adolescents in Uganda: acceptability for relaying health information.
| HIV Infections | Health Promotion | Humans | Internet | Male | Sexual Behavior | ...
Thursday, September 08, 2011
Vulnerabilities in mHealth implementation: a Ugandan HIV/AIDS SMS campaign.
Culture | Female | HIV Infections | Health Education | Health Knowledge, Attitudes, Practice | Health Promotion | Humans | Information Dissemination | Text Messaging | Uganda | Vulnerable ...
Wednesday, April 03, 2013
Avatars using computer/smartphone mediated communication and social networking in prevention of sexually transmitted diseases among North-Norwegian youngsters.
the Internet, social media and/or smartphones, should be valued for sexual health promotion for their potential ...
Friday, January 04, 2013
SMART MOVE - a smartphone-based intervention to promote physical activity in primary care: study protocol for a randomized controlled trial.
Risk Reduction Behavior | Sedentary Lifestyle | Time Factors mTERG Terms: Health education ...
Thursday, June 13, 2013
The potential of an online and mobile health scorecard for preventing chronic disease.
Chronic care | Health education or promotion | Surveillance | Digital form ...
Thursday, September 15, 2011
Promoting behavior change from alcohol use through mobile technology: the future of ecological momentary assessment.
Health education or promotion | Treatment adherence | Disease management | Internet | Text | ...
Monday, November 21, 2011
SEXINFO: a sexual health text messaging service for San Francisco youth.
Feasibility Studies | Female | Focus Groups | Health Education | Health Promotion | Health Status ...
Monday, February 25, 2008
Desired features of smartphone applications promoting physical activity.
Cellular Phone | Computers, Handheld | Consumer Satisfaction | Female | Health Education | Health Promotion | Health Surveys | Humans | Internet | Male | Middle Aged | Qualitative Research | ...
Wednesday, November 30, 2011



Diagnostic and treatment support (link)


The systems designed to provide health workers in remotes areas with guidelines and advices about diagnosis and treatment. There are different ways to provide assistance. One alternative is through mobile phone applications, which can be used by health workers to make diagnosis. Other alternatives are to have information direct to the patients. This is most commonly known as telemedicine. In this case the patient would send a picture of a injury, illness or wound to a physician that can provide a proper treatment. Telemedicine reduces transportation costs and time.

Furthermore, the mhealth provide a solution for remote monitoring and medication compliance for patients. On the one side the mobile devices are facilitators for health workers to keep track of treatments of patients’ conditions, medication adherence and also follow-up appointments. However, it has been seen that patients in remote and not remote areas that receive a reinforcement of treatment through mhealth (SMS or voice messages) increase the adherence of the treatment. The cases of patients with AIDS and diabetes are common examples. The efforts in some other chronic diseases also are gaining traction in developing countries.
The case of the noncommunicable diseases (NCDs) also known as chronic diseases (are not passed from one person to another), are good example where mhealth can created a large difference. Examples of these diseases are diabetes, cancer, cardiovascular and respiratory diseases. According to the WHO, these are some of the leading causes of death both in developed and developing countries. The WHO informs that out of 57 million deaths globally in one year, 36 millions are attributable to NCDs. The common risk factors are tobacco use, excess of alcohol, unhealthy diet and physical inactivity. Furthermore, the treatments have to be completed in a very rigid way. Mhealth can be a real game-changer in the way these diseases evolve particularly in emerging nations. More information: WHO mhealth

Communication and training for healthcare workers (link)


Projects and systems to connect health workers with information via their mobile devices. Through this, health workers can perform their functions in a more self-sufficient way. The idea is also to connect health workers with other health workers, medical institutions, the ministries of health, and other agencies or organizations dealing with health care. In developing country there is a shortage of health workers, therefore training new ones and increase the knowledge of the current ones is it pivotal to improve the overall efficiency of the health system.
Furthermore, communication using mobile devices can built bridges between different health institutions and people. This can create a better process and reduce administrative gaps for a more efficient process. The process of patient referral is one of the most common practices where communication is central and there is room for improvement. Here mhealth can be a change factor. The case of the of the work of the BBC Media action in India with the Mobile Academy is a remarkable example of the communication and training of health workers. More on this: BBC Media Action Policy Briefing


Disease and epidemic outbreak tracking7561267772_cbc1fc0c05_o.jpg


mHealth interventions can also be implemented to send and receive data in disease incidence, outbreak, and public health emergencies[1]. In the past, these interventions have been applied to monitor mosquito-borne diseases such as malaria and dengue in countries like Botswana, Uganda and Mexico. In Botswana, for example, rural healthcare workers gather malaria data and upload the information to a central database using mobile phones. The field workers can also notify the Ministry of Health officials and other health workers in the area through SMS text messages, tagging data with a GPS coordinate, pictures, video, and audio. This creates a direct link between rural health workers and central health services, which is helpful for evidence-based decision-making.
mHealth interventions can also be useful to track tuberculosis cases. In Pakistan, family doctors and community health workers get financial incentives for screening patients and referring suspected cases to TB centers. The cases are reported through mobile phones, and, after the data is processed, they receive a text message with a count of the casesthey´ve helped to detect. This data is used to calculate the financial incentive they earn,which is then transferred electronically to their bank accounts.
The biggest drawback is that some of these interventions require wireless communications networks in remote areas, which is mostly unavailable in areas where it’s most needed.

Remote monitoring / Remote data collection


One of the biggest challenges for development practice is collecting information from remote areas, particularly patient data. A lack of health data is one of the largest barriers to overcoming health challenges[2]. mHealth interventions in this sector can consist of interactive voice response systems that enable field healthcare workers to collect and transmit data through mobile phones. Similar to interventions designed for disease and epidemic outbreak tracking, the data collected is added to a centralized database available to medical institutions or government bodies. It can also be used for maintaining care-giver appointments or ensuring medication regime adherence, which is one of the biggest applications of mHealth worldwide.


[1] mHealth Alliance. What is mHealth? Frequently Asked Questions. 2013. http://mhealthalliance.org/about/faq
[2] Vital Wave Consulting. mHealth for Development: The Opportunity of Mobile Technology for Healthcare in the Developing World. Washington, D.C. and Berkshire, UK: UN Foundation-Vodafone Foundation Partnership, 2009.



Yvonne McPherson, BBC Media Action US. Watch video at TEDx SIPA 2013


Dr. Jess Ghannam, health advocate. Watch video at TEDx UNPlaza




[i] http://www.vitalwaveconsulting.com/pdf/2011/mHealth.pdf
[ii] http://www.vitalwaveconsulting.com/pdf/2011/mHealth.pdf
[iii] www.vitalwaveconsulting.com/pdf/2011/mHealth.pdf
http://en.wikipedia.org/wiki/MHealth#Diagnostic_support.2C_treatment_support.2C_communication_and_training_for_healthcare_workers
[iv] www.vitalwaveconsulting.com/pdf/2011/mHealth.pdf
http://en.wikipedia.org/wiki/MHealth#Diagnostic_support.2C_treatment_support.2C_communication_and_training_for_healthcare_workers


mHealth in Latin America: An Outlook
550px-Latin_America_(orthographic_projection)_svg.png

According to a report of the UN and Vodafone Foundations by 2011 51 mhealth project in developing countries. 10 of them in Latin America and Peru appear as the most prominent of the region. The areas that this project are covering are Education and Awareness, Remote Monitoring, Remote Data Collection, Communication and Training for Healthcare Workers, Disease and Epidemic Outbreak tracking , Diagnostic and Treatment Support. The first mhealth project in the region was launched in Peru in 2001. Alerta MINSA (disease surveillance system). The objective was to collect information about diseases that pose threat to the public health in the country from health professional.


70 out of 100 people in the region have a cellphone and the number is increasing the same as the new technologies penetration such as 3G. The average in the region for cellphone penetration is 106 per cent. According to the Inter- American Developing Bank, 360 million of people of the region live with US$ 300 each month. 160 out of them have access to mobile phones. Therefore the penetration mobile devices represent a great opportunity for using mhealth as a way to improve healthcare, particularly in remote regions of the continent. However, it seems countries in the region do not have a clear distinction between telemedicine and the uses of ICT in health and specifics projects in mhealth. Sometimes these two concepts are confused.

Moreover, the report Touching Lives through Mobile Health of 2012 (PwC and GSMA), shows how the mhealth can be also a profitable area of business in the region. The study states that the mhealth industry will be worth US$23 billion by 2017 and out of this total, US$1.6 billion of that amount will correspond to Latin America. The sector is expected to grow at a 50% annual rate over the next six years.[i].
BID pic.jpg
Source: BID/IADB

In terms of Health issues, the region is facing a change in the type of diseases that has more penetration. According to the Inter-America Developing Bank, the region is facing a reduction in the child mortality, tuberculosis, infections illness, malnutrition, diarrhea and birth complication, but at the same time degenerative and chronic diseases are rising (diabetes, cardiovascular diseases and cancer). In fact the IADB has funded at least three mhealth project MiDoctor: to improve engagement and care of patients with type 2 diabetes in Chile; WawaRed: to provide continuum care for pregnant women and newborn in Peru and ChagasMovil: a surveillance tool for dengue and Chagas in Argentina. Other projects in the region include the collection, mother and child care, disease surveillance and pre-hypertsension care. There is even one experience en Peru call Cell PREVEN to monitoring health treatments among female sex workers in the country..
The uses of mhealth to reduce risk factor for these diseases represent also an opportunity for the region. However any project of mhealth should take into consideration the very diverse realities of Latin America countries. More information: BID Salud Móvil

Until now the mhealth projects of the region have been mostly pilot programs. The main usage of mobile health has been for monitoring health issues and treatment support including the uses of call centers for this purpose. One important area left out is prevention and education. This is precisely one of the most urgent topics, specially considering that non communicable disease are increasing in the region and the need for bolster awareness about risk factor is essential.

[i] http://pulsosocial.com/en/2013/05/31/mhealth-an-untapped-multi-million-dollar-industry-in-latin-america/


Watch video of Dr. Camilo Erazo









References:
http://mhealth.andeanquipu.org/download/reporte_ingles.pdf
http://idbdocs.iadb.org/wsdocs/getdocument.aspx?docnum=2095617
http://www.kit.nl/net/KIT_Publicaties_output/ShowFile2.aspx?e=1996
**www.vitalwaveconsulting.com/pdf/2011/mHealth.pd**
http://pulsosocial.com/en/2013/05/31/mhealth-an-untapped-multi-million-dollar-industry-in-latin-america/


Country Case Analysis

A.- México

800px-Flag_of_Mexico_svg.png
Antecedentes
Con una población superior a los 120 millones de habitantes (Instituto Nacional de Estadística y Geografía, 2010), México se coloca como uno de los países en América Latina con mayor penetración tecnológica. No sólo cuenta con un alto número de usuarios de Internet
[1] (38.4% de la población), sino también una suscripción a servicios de telefonía celular del 87%, similar a la de países como China, Serbia y Turquía (El Banco Mundial, 2013). Bajo este contexto, es posible visualizar la introducción de herramientas tecnológicas que pudiesen contribuir a la solución de los problemas más latentes que México presenta, particularmente en lo que concierne a la salud pública.

En México, uno de los principales problemas relacionados con la salud es la obesidad, padecimiento que afecta al 32% del total de la población. Este número ha aumentado un 24% desde el año 2000 (Organización para la Cooperación y el Desarrollo Económicos, 2013), lo que representa un serio problema para México, ya que el incremento en la prevalencia de obesidad augura aumentos en la ocurrencia de otros padecimientos, tales como diabetes y enfermedades cardiovasculares (Eduardo Alegría Ezquerra, 2008). De hecho, las principales causas de muerte en el país están relacionadas con la obesidad: en 2008, el 14% de las muertes registradas a nivel nacional fueron consecuencia de Diabetes Mellitus Tipo 2, seguido de cardiopatías isquémicas con 11%, y enfermedades cerebrovasculares, con 5.6% (Secretaría de Salud, 2013).

México requiere mayores esfuerzos para reducir éstas cifras. A pesar del incremento en el gasto público (PIB) en materia de salud pública durante los últimos años (de 5.1% en 2000 a 6.5% en 2009) (Organización Mundial de la Salud , 2011), México se encuentra entre los países afiliados a la OCDE con el menor presupuesto destinado a la salud pública: 3% menor al promedio de los 34 países miembros (Organización para la Cooperación y el Desarrollo Económicos, 2013).

En este contexto, las intervenciones de mHealth podrían ayudar a incrementar el acceso a servicios de salud a un mayor número de habitantes, mejorando la salud pública de los mexicanos. De acuerdo a un reporte sobre el impacto de mHealth en Mexico y Brasil - publicado por la Asociación Global para las Comunicaciones Móviles (GSMA, por sus siglas en inglés) – mHealth podría facilitar el acceso a más de 15.5 millones de personas al sistema de salud universal en México, sin necesidad de incrementar el número de médicos. Adicionalmente, podrían ahorrarse cerca de 3 mil 800 millones de pesos, del gasto público invertido en el sector salud, sin comprometer el número actual de beneficiados. Estos ahorros podrían significar extender cobertura a 2.3 millones de personas (PricewaterhouseCoopers, 2013).

Durante los últimos años, México ha experimentado un incremento en los servicios vinculados a mHealth. A excepción de pocos casos, la mayoría de éstas iniciativas se engloban bajo el programa “Conectados con tu Salud”, desarrollado por el Instituto Carso de la Salud (ahora nombrado Instituto Carlos Slim de la Salud), en colaboración con Telcel, la compañía de telecomunicaciones más importante de México y América Latina. A continuación se enlistan con una breve descripción:

CardioNet. Nace en 2008 como una herramienta para tratar padecimientos relacionados con la obesidad. Una de sus principales características es incluir una herramienta que evalúa conductas de riesgo, para después proveer al usuario información mediante mensaje de texto (SMS) sobre cómo llevar una vida más saludable.

VidaNET. Proyecto que surge en el 2010 como continuación de CardioNet. Consistió en un sistema basado en telefonía móvil mediante el envío de recordatorios (mensajes de texto SMS) a pacientes de VIH/SIDA para tomar sus medicamentos, mantener su cita médica y mantenerse al día con sus pruebas de laboratorio.

Diabediario.Plataforma en línea diseñada para pacientes diabéticos con el fin de auxiliar en el control de la enfermedad. Similar a las iniciativas previas, consiste en la configuración de un sistema de recordatorio de citas médicas y toma de medicamentos. El usuario registra sus datos, por lo que es un servicio personalizado. El sistema fue implementado hasta el 2012 y se encuentra en evaluación.

Además de las plataformas desarrolladas bajo el programa “Conectados con tu Salud”, también se encuentra la iniciativa “Usos de la tecnología móvil para el manejo de la diabetes en madres con alto riesgo en México” (Using mobile technology for diabetes management among high-risk mothers in Mexico). Desarrollada por la organización Project HOPE, en colaboración con la Fundación Bristol-Myers Squibb, el proyecto consiste en el envío de textos informativos sobre la prevención y el tratamiento de la diabetes gestacional[2], así como recordatorios para citas médicas, con el fin de educar a cerca de 1,000 madres en condiciones de marginación. El proyecto fue lanzado en Febrero de 2013.

Desafíos del mHealth en México
A pesar del potencial que éstas iniciativas representan, México enfrenta una serie de obstáculos sistémicos que impiden una mayor penetración de éstas tecnologías en el ámbito actual. A continuación se enlistan las principales barreras que presenta el mercado mexicano:

  • No existe suficiente evidencia sobre la efectividad de las intervenciones de mHealth que se han realizado en el país, indispensable para convencer a los proveedores de asistencia médica y a los reguladores sobre los beneficios de mHealth.
  • Los seguros médicos no cuentan con cobertura para el uso de servicios médicos vinculados al mHealth, así como tampoco existen mecanismos de reembolso de gastos derivados del uso de estos servicios. Esto hace incosteable el acceso a servicios de mHealth, particularmente para comunidades de bajo ingreso.
  • Los limitados presupuestos dirigidos al sector salud restringen el financiamiento de investigación y desarrollo de soluciones de mHealth.
  • La falta de conocimiento sobre los beneficios de mHealth entre los proveedores de asistencia médica impide el acceso a servicios vinculados a mHealth para los usuarios. Esta falta de conocimiento también fomenta una renuencia dentro de las instituciones de salud a incluir soluciones de mHealth como tratamientos disponibles éstos usuarios.
  • No existe claridad sobre cómo los procesos de certificación de equipo médico pueden ser aplicados a las intervenciones de mHealth en México.
  • No existe la promoción de la interoperabilidad[3], así como estándares en cuestión de tecnologías para facilitar el escalamiento y desarrollo de proyectos que involucren mHealth.
  • Los incentivos financieros y de desempeño actuales dentro del sector salud están diseñados para evaluar cuantitativamente (por ejemplo, número total de consultas realizadas), más que la calidad de los resultados clínicos. Esto impide la implementación de intervenciones mHealth, pues están asociadas en gran parte al tratamiento de padecimientos fuera de hospitales, consultorios y clínicas de salud.
  • La segmentación del sistema de salud pública mexicano limita el intercambio de información y el alineamiento de procesos y protocolos. Ya que no existen incentivos para fomentar éste intercambio, las intervenciones de mHealth no están integradas y esto restringe su escalamiento.
  • La inexistencia de un marco regulatorio que facilite la rendición de cuentas por parte de los stakeholders involucrados en el desarrollo de intervenciones mHealth dificulta la evaluación y monitoreo de intervenciones mHealth.

Referencias
  • autor, S. (2011, Marzo 11). The Communication Initiative. Retrieved from Instituto Carlos Slim de la Salud: http://www.comminit.com/content/instituto-carlos-slim-de-la-salud-carlos-slim-health-institute
  • Eduardo Alegría Ezquerra, J. M. (2008). Obesidad, síndrome metabólico y diabetes: implicaciones cardiovasculares y actuación terapéutica. Revista Española de Cardiología, 752–764.
  • El Banco Mundial. (2013, November 26). World Development Indicators. Retrieved from Data: http://data.worldbank.org/indicator
  • Instituto Nacional de Estadística y Geografía. (2010). Principales resultados del censo de Población y Vivienda 2010. Mexico, D.F.: Instituto Nacional de Estadística y Geografía.
  • Organización Mundial de la Salud . (2011). WHO Global Health Expenditure Atlas. Ginebra: WHO.
  • Organización para la Cooperación y el Desarrollo Económicos. (2013). Base de datos de la OCDE sobre la salud 2013 - México en comparación. París: OCDE.
  • PricewaterhouseCoopers. (2013). Socio-economic impact of mHealth - An assessment report for Brazil and Mexico. India: Asociación Global para las Comunicaciones Móviles .
  • Secretaría de Salud. (2013, Noviembre 26). Sistema Nacional de Información en Salud. Retrieved from Mortalidad - Información tabular: http://www.sinais.salud.gob.mx/descargas/xls/Principales_CausasxEF_2008.xls

[1]Suscripción a un servicio público de telefonía móvil bajo el uso de tecnología celular, la cual provee acceso a una red telefónica pública conmutada. Se incluyen suscripciones pre-pagadas y de pospago (The World Bank, 2013).
[2]Diabetes Gestacional es hiperglucemia con inicio o primer reconocimiento durante el embarazo. Sus síntomas son similares a los de la diabetes Tipo 2. La diabetes gestacional es más frecuentemente diagnosticada durante un screening prenatal que durante el reporte de síntomas (OMS, 2013).
[3] La interoperabilidad es la capacidad de los sistemas de información y de los procedimientos a los que éstos dan soporte, de compartir datos y posibilitar el intercambio de información y conocimiento entre ellos (Gobierno de España, 2013)

B.- Venezuela


800px-Flag_of_Venezuela_svg.png
Venezuela es un país de casi 30 millones de habitantes. El ingreso per cápita es de USD 12,430. La esperanza de vida al nacer es de 72 años para hombres y 79 años para mujeres. La probabilidad de morir antes de alcanzar los cinco años es 15/1000 entre los nacidos vivos. El gasto total de salud por habitante es de USD 659, lo cual representa un 52% del PIB.
La Salud en Venezuela depende de un red pública financiada por el estado venezolano y de multitud de sistemas privados. Existe una red de centros de salud, clínicas populares y ambulatorios como parte del programa Barrio Adentro, que incluye Centros Diagnósticos integrales (CDI), Salas de Rehabilitación integral (SRI) y Centros de alta tecnología (CAT). La cobertura, en temas de infraestructura y alcance, es buena. Sin embargo, no hay coordinación central y muchas veces los esfuerzos son duplicados. La mala administración hace que los equipos que se dañan no se repongan y que las medicinas y otros equipos medico-quirúrgicos no lleguen a tiempo a donde se necesitan.

Iniciativas locales

La gobernación de Miranda, Venezuela, puso en marcha el servicio “Su Salud”. Se trata de una prueba piloto que tiene como objetivo introducir la historia clínica de algunos pacientes en una base de datos digital. La digitalización de estos datos permitirá que los médicos accedan a la red y conozcan, así, las necesidades de los pacientes. La clave de acceso a la historia clínica electrónica y el código de registro será la cédula de identidad.
Desafíos

  • El promedio de velocidad de descarga de información en Venezuela considerando todos los proveedores de acceso a la Internet es de 2.03 Mbps, mientras que el promedio del mundo es de 15.71 Mbps. Esto complica la gestión de trámites y procesos de mhealth que requieran internet.
  • La fragmentación del sistema de salud pública venezolano limita el intercambio de información y el alineamiento de procesos y protocolos. Por ejemplo, la unificación de las historias médicas en una base de datos digital es algo que no se fomenta de modo centralizado.
  • La falta de conocimiento sobre los beneficios de mHealth entre los proveedores de asistencia médica limita el acceso a servicios vinculados a mHealth. La falta de conocimiento también fomenta una renuencia dentro de las instituciones de salud a incluir soluciones de mHealth como tratamientos disponibles usuarios.


Oportunidades
  • En Venezuela, la penetración móvil es del 97,59% y de los suscriptores activos es del 92,55% , representando una disponibilidad de aproximadamente 93 suscriptores en el uso del sistema de telefonía móvil por cada 100 habitantes. Con la mensajería de texto se le puede llegar, literalmente, a todos los sectores de la población.
  • A pesar de que existen marcos legales que favorecerían la aplicación de mhealth (como la recientemente aprobada Ley de Telesalud), no hay proyectos concretos que se lleven a nivel nacional. ¡Esta es la mejor oportunidad para empezar!




C.- Chile


800px-Flag_of_Chile_svg.png
Chile is a middle income country in the South cone of Latin America with a total population of more than 17 million people. The projects of mHealth are at a pilot level and getting some traction within municipalities.
Chile has 24.4 millions of active cell phones; this means that for each 100 persons there are 140 cell phone devices[i]. This makes Chile the country in Latin America with the highest penetration of mobile phones at a 130 percent. On average 5.7 billion of messages are sent daily and 94% are actually read. In general, people who access the public health system belong to a low income part of the society and in this segment the penetration of cell phones is on average 85 percent[ii].
Furthermore, in terms of digital infrastructure and connectivity Chile is the leader in the region, however the usage does not reflect the strength of the country’s infrastructure. Specifically, there is space for a more efficient use of the existing resources[iii].
Telecom Chile The Economist.jpg
The Economist/ITU

Telecom Chile.jpg
Source: Telecomunication Deputy MInistry -Chile




There are examples of national and international experience in the use of cell phone and SMS to improve public health. At the country level, the Ministry of Health started in 2011 a trial program (MeTA-TB)[iv] to increase the participation in the treatment of people diagnosed with tuberculosis. After a year, 84 percent of the patients enrolled in this free SMS program indicated that the text messages actually help them to fulfill the treatment.
At a local level, two Municipalities (Conchalí and Puente Alto) started in 2012 with free text message program (also trial version) to remind people about their scheduled appointment. They detected that a lot of resources were wasted when people failed to cancel appointments in advance or simply forgot about their scheduled appointment. For instance in Conchalí, during the first 20 days of the plan, 507 messages were sent and 90 percent of them were received and 15 percent of the appointments of the clinic were rescheduled. In Puente Alto the program was intended to encourage people that are at risk of having Diabetes 2 to go to their local clinic to have them examined[v]. The same kind of project to treat diabetes and hypertension (MiDoctor) has been implemented during 2013 in another municipality (Lo Barnechea). By August 2013, 1,000 patients were enrolled and more than 5,000 SMS were sent with recommendations of self-care, community resources available and information about these chronic diseases. Also more than 3,000 thousand calls were effected to monitored of the treatments[vi].
For the implementation of these cases, the institutions outsourced to local technology firms. Specifically, they developed the software and systems needed to send and monitor the messages and the health authorities give them the supplies and information to do it. Also at the municipal level the Inter-America Developing Bank (IADB) has provided assistance in some cases through the program called “Ciudadano Móvil” (Mobile Citizen)[vii].
The trial programs in Chile are aligned with the experience in Latin America region. In Perú there is the program call WaWaNet which provides guidance and education to pregnant woman using free SMS. Mexico has a similar texting system to remind mothers of the vaccination dates for their children under 5 years old.[viii].
Nevertheless, the trend in Chile is that text messages have been replaced by smartphone apps that allow free text chatting (for example Whatsapp). During the first half of 2013 SMS usage dropped 9.1 percent. But the penetration of smartphones is also increasing, 19 percent of the population has one and the market for these devices increased around 60 percent during 2012.[ix].

Hypertension: a challenge for mHealth in Chile:
More than 26 percent of the people in Chile have hypertension (1 out of 4 individuals). In males over 45 years old the percentage rises to 44 percent[i]. The treatment of hypertension in the primary care system is given by a standardized protocol from the Ministry of Health (Clinic Guide)[ii], which is periodically updated.
Health-stub.gif
After a patient is diagnosed with hypertension is enrolled in the health program at her/his local clinic, where he/she receives treatment and education about this disease. Once examined, the patient should be checked at least every 3 months. However, the person usually doesn’t have any symptoms. Due to this issue there are a significant number of people missing their health appointments. Currently, the clinic gives the patient a “schedule card” for the upcoming check-up. Since the primary care system is under the administration of each Municipality, the policies to keep track of each patient vary in different regions. In most cases if one patient does not respond to the hypertension program for 6 months he/she should be contacted via a phone call or home visit. The risk of missing an appointment could lead to severe heart conditions (for example vascular accidents, heart attacks), and eventually death.

Since the hypertension treatment program is nationally conducted it is very homogeneous. In each control, the patient is subject to several criteria including nutrition and arterial pressure. Also the person receives a revision and update of medical prescription and health education tips. This is a protocol followed by all the primary care clinics throughout the country. Nevertheless, the policy to prevent people enrolled in the hypertension program from missing out their doctor’s appointment is not homogeneous and depends on the ability of each local clinic. There are no human resources designated to contact patients that have missed their appointment, thus it is a problem that hinders the effectiveness of the program.
Hypertension can be positively correlated with aging; therefore elder people are more likely to have this condition. The numbers show that 75 percent of people over 65 years old have hypertension. [iii]. At the same time they are more reluctant to use cell phones.

Recommendation: Implement afree text messaging system to improve the control of patient with hypertension should become a national policy guided by the Ministry of Health. Local primary care clinics are administrated by each Municipality and their policies varies in term of following up patients. Thus, there is space to implement a national homogeneous strategy to improve the control of patients with this disease.
Since the Ministry has already engaged in similar trial program, the implementation for hypertension could follow the same pattern. The Ministry can continue with a trial programs at the municipal level and then expand to a national level. Furthermore, the institution has already the expertise to negotiate with telephone companies to reduce the cost of the text messaging. This should be an advantage to create this national homogeneous strategy for controlling hypertension delivering SMS.



[i] Telecommunications Deputy Ministry
http://www.subtel.gob.cl/images/stories/apoyo_articulos/notas_prensa/informe_seriesq2_2013_vfinal.pdf
[ii] Ministry of Health, Chile
http://www.slideshare.net/Cesfamgarin/plan-piloto-me-ta-tb-informe-final
[iii] Connectivity Scorecard, Chile
http://www.connectivityscorecard.org/countries/chile
[iv] Ministry of Health, Chile
http://www.slideshare.net/Cesfamgarin/plan-piloto-me-ta-tb-informe-final
[v] La Tercera (Newspaper)
http://diario.latercera.com/2012/03/25/01/contenido/pais/31-104639-9-consultorio-avisa-atenciones-medicas-por-mensaje-de-texto.shtml
e-Healthreporter
http://www.ehealthreporter.com/es/noticia/verNoticia/266/la-expansion-de-los-telefonos-celulares-como-herramienta-de-salud-
[vi] http://cl.wayra.org/es/noticia/lo-barnechea-implementa-midoctor-con-gran-exito
http://cl.wayra.org/es/noticia/midoctor-y-socialdiabetes-innovadoras-soluciones-ehealth
[vii] Inter-American Developing Bank
http://www.iadb.org/es/noticias/articulos/2008-10-31/telefonia-movil-salud-para-todos,4847.html#.UlW23xCF21M
http://www.mobilecitizen.bidinnovacion.org/es/the_program.html
[viii] e-Healthreporter
http://www.ehealthreporter.com/es/noticia/verNoticia/266/la-expansion-de-los-telefonos-celulares-como-herramienta-de-salud-
http://wiki.wawanet.org/formatos:primercontrol:seccion15
[ix] Telecommunications Deputy Ministry
http://www.subtel.gob.cl/images/stories/apoyo_articulos/notas_prensa/informe_seriesq2_2013_vfinal.pdf


[i] Health National Survey 2009-2010
http://www.redsalud.gov.cl/portal/url/item/99bbf09a908d3eb8e04001011f014b49.pdf
[ii] Ministry of Health, Chile
http://www.redsalud.gov.cl/archivos/guiasges/hipertension_arterial_primaria.pdf
[iii] Health National Survey 2009-2010
http://www.redsalud.gov.cl/portal/url/item/99bbf09a908d3eb8e04001011f014b49.pdf



How to start a mHealth project in Latin America?
1.- Identificar el problema causas y consecuencias
Todo proyecto tiene su origen en la existencia de un problema que afecta la vida de un conjunto de personas. Durante el análisis de los problemas determinaremos entonces cuál es ese problema central que solucionaremos, sus causas y consecuencias. Es conveniente que el proceso de identificación del problema sea participativo, para poder integrar todas las perspectivas.

Una vez que tenemos nuestro listado de problemas y hemos elegido cuál de ellos será el problema central, comenzamos a analizar las relaciones de causa y efecto entre ellos, lo que nos generará como resultado la construcción del árbol de problemas.


El árbol de problemas es una herramienta que nos permite visualizar cuál es el problema central que atenderemos (el tronco del árbol), cuáles son sus causas (las raíces del árbol) y cuáles sus consecuencias (las ramas del árbol). La construcción de este árbol nos permite elegir cuál será el camino que seguiremos para darle solución al problema central, tomando en cuenta los recursos con los que contamos.
rbol de problemas UNESCO.gif
UNESCO




2.- Entender el contexto (población, cultura, legislación) y hacer análisis de actores


a. Debes encontrar un perfil poblacional y sanitario de la región o comunidad en la que deseas hacer tu proyecto de mhealth.
Revisar el último censo del país es una buena idea para encontrar más datos sobre la población a investigar.
La OMS tiene perfiles sanitarios para casi todos los países
b. Una vez establecido el contexto, identifica y enumera todos los actores relevantes para el problema que identificaste.

Luego investiga analiza las características y los aspectos propios de los actores, tales como su poder de influencia sobre la situación de protección, sus fines, sus estrategias, su legitimidad y sus intereses (incluyendo su voluntad de contribuir en la solución del problema). Una vez que tengas esa información, puedes plantear una estrategia de trabajo con cada uno de ellos, y finalmente organizar un listado de los actores que pueden ayudarte en la solución del problema.
c. Finalmente, haz un sencillo marco legal: enumera las leyes o reglamentos que favorecerían u obstaculizarían el desarollo de tu proyecto.





analisis de actores.jpg
http://enfoquedelmarcologico.blogspot.com/




3.- Enumerar los recursos de salud disponibles
El sistema de salud abarca todas las organizaciones, las instituciones y los recursos de los que emanan iniciativas cuya principal finalidad es mejorar la salud. Por sistema de atención sanitaria, en cambio, entendemos las instituciones, las personas y los recursos implicados en la prestación de atención de salud a los individuos.
Debes tener una idea general de como funciona el sistema de atención sanitaria en tu país para diseñar la mejor solución posible.
Debes tomar en cuenta: (a) estructura (b) financiamiento y (c) participación.
Muchas de las funciones de los sistemas de atención sanitaria están condicionadas al logro previo de una financiación suficiente. Si no se ponen en marcha mecanismos de financiación sostenibles, las ideas innovadoras orientadas a fortalecer la base de atención primaria de los sistemas de atención sanitaria no generarán resultado alguno.



sistemas nacionales de salud.gif
Roemer (1991)




4.- Capital Humano


Lo importante a considerar en este punto es la posibilidad de reconocer a los actores y experiencias locales. Por ejemplo: Existen ingenieros informaticos o empresas que se dedican a temas de mhealth en el pais? El objetivo es tambien generar un equipo multidisciplinario para asegurar el exito de la intervencion a traves de soluciones moviles. En este punto es de especial importancia la figura de los trabajadores de la salud. Son ellos los que tienen la mayor expereriencia del trabajo en terreno, por lo tanto, el uso de mhealth debe ir en estrecha cooperacion con la labor que los trabajadores de la salud ya estan realizando. Si ellos son capaces de utilizar y beneficariarse de manera organica del proyecto, es mas probable que este sea exitoso.


5. Análisis de las Telecomunicaciones
Al momento de conceptualizar una intervención de mHealth, es importante tener amplio conocimiento sobre el sector de las telecomunicaciones en la región en la que se desea implementar el proyecto. Es necesario conocer la infraestructura existente y el potencial de crecimiento, así como los planes de desarrollo de los gobiernos a nivel local y nacional. De la misma forma, se debe tener conocimiento sobre las leyes y los reglamentos que existen al respecto. Esto debe incluir los derechos del consumidor, así como de privacidad de los potenciales usuarios.

6. Tecnología de acuerdo al país


De acuerdo un estudio del BID Salud Móvil, la tecnologia 2G es la dominante en la region en 2007. Esta tendencia esta cambiando hacia una mayor penetracion del 3G. Lo importante es poder definir bien la penetracion que exite en el pais o localidad de la tecnologia. Tambien es relevante definir si la poblacion esta mas acostumbrada a los mensajes de textos, de voz o imagenes. Incluso se debe cosniderar el uso del protocolo USSD (
Unstructured Supplementary Service Data), esta tecnologia puede ser muy beneficiosa cuando existe mayor penetracion de tecnologia 2G por su bajo costo, lo malo es que no posee capacidad de almacenamiento. Ademas es importante saber cual es el accesso a Internet que poseen. Esto es por si se quiere ampliar la experiencia de la salud movil y recibir informacion adicional a traves del uso de computadores. Obviamente que los costos de cualquier aplicacion debe ser considerada para poder escoger la tecnologia.


7. Actores políticos y redes


Para este paso se debe considerar quienes son los actores politicos, sociales y academicos que estan trabajando en proyectos similares. La capacidad de generar alianzas y redes con ellos generara que el proyecto tenga mayor respaldo para una eventual ampliacion de su alcance. La generacion de redes asegurara que el proyecto sea conocido entre los actores relevantes del area. Ademas de ganar en visibilidad, le dara mayor sustento para eventuales auspiciadores.



8. Monitoreo y Evaluación
El monitoreo y la evaluación son dos de los componentes más críticos de una intervención de mHealth, y constituyen uno de los temas más debatidos en el campo. Como se ha mencionado anteriormente, la mayoría de los estudios indican que existe una gran falta de información sobre monitoreo y evaluación de proyectos de mHealth que ya han sido implementados[1]. Esto tiene graves consecuencias para el sector, ya que ésta falta de información obstaculiza el establecimiento de lineamientos para el desarrollo de intervenciones más efectivas, así como el desarrollo de un cuerpo teórico que permita analizar a las intervenciones de mHealth desde distintas perspectivas. Por ejemplo, en Uganda se implementaron más de 36 iniciativas entre 2008 y 2009, sin embargo 23 de ellas no fueron más allá de proyectos piloto[2]. Esto indica que la existencia de mayor información sobre previas intervenciones ayudaría a incrementar el número de intervenciones exitosas.

A pesar de lo anterior, se han desarrollado recientemente distintos modelos para la evaluación y el monitoreo de intervenciones de mHealth. La mayoría de ellos llaman al uso de ensayos controlados aleatorios (randomized control trials), a tomar en cuenta la retroalimentación constante por parte de los usuarios, a aplicar rigurosos métodos de investigación para determinar efectividad, así como incorporar fundamentos de teorías del cambio de comportamiento (CITA). Por otro lado, Flay y colegas[3] han establecido una serie de lineamientos para una correcta evaluación de una intervención mHealth: dos pruebas de eficacia de alta calidad y dos pruebas de efectividad de alta calidad, seguido de divulgación de la investigación que determina que la intervención fue realizada con apego al modelo utilizado, así como información sobre los costos de la intervención. Sin embargo, actualmente no existen intervenciones de mHealth que cumplan con estos estándares.
Para el caso de Latinoamérica, se sugiere investigar y analizar distintos modelos y casos de estudio (por ejemplo, el proyecto Text4baby), a fin de determinar la viabilidad de su implementación.

Literatura a considerar:
  • W. Douglas Evans , Lorien C. Abroms , Ronald Poropatich , Peter E. Nielsen & Jasmine L. Wallace (2012). Métodos de evaluación de salud móvil: Estudio del Caso Tex4baby (Mobile Health Evaluation Methods: The Text4baby Case), Journal of Health Communication: International Perspectives, 17:sup1, 22-29. http://dx.doi.org/10.1080/10810730.2011.649157
  • El Banco Mundial (2004). Monitoreo y Evaluación: Herramientas, métodos y aproximaciones. El Banco Mundial. http://lnweb90.worldbank.org/oed/oeddoclib.nsf/DocUNIDViewForJavaSearch/A5EFBB5D776B67D285256B1E0079C9A3/$file/MandE_tools_methods_approaches.pdf
  • William Brown, Po-Yin Yen, Marlene Rojas, Rebecca Schnall, (2013) Consideraciones para el Modelo de Evaluación de Usabilidad de Tecnologías de la Información para la Salud, para la valoración de tecnología móbil para la salud (mHealth) (Assessment of the Health IT Usability Evaluation Model (Health-ITUEM) for evaluating mobile health (mHealth) technology). Journal of Biomedical Informatics 46:6, pages 1080-1087.
  • Robyn Whittaker , Sally Merry , Enid Dorey & Ralph Maddison (2012). Proceso de evaluación y desarrollo de intervenciones mHealth: Ejemplos desde Nueva Zelanda (A Development and Evaluation Process for mHealth Interventions: Examples From New Zealand), Journal of Health Communication: International Perspectives, 17:sup1, 11-21. http://dx.doi.org/10.1080/10810730.2011.649103

9.- Expansión del proyecto (Scaling up)
Durante el desarrollo de un proyecto de mHealth es imprescindible considerar el potencial de crecimiento hacia otras regiones y/o grupos de atención. De hecho, un reporte realizado por El Banco Mundialrevela que existe gran interés por parte de las agencias financiadoras para apoyar la expansión de proyectos de mHealth[4]. Sin embargo, existe una carencia de información básica sobre los proyectos que ya han sido implementados. Es decir, no existen guías de mejores prácticas para involucrar a los grupos de interés, ni evaluaciones de eficiencia y/o eficacia de éstas iniciativas. Así, es difícil contemplar una expansión basada en evidencias (evidence-based scale up), la vía más efectiva para un crecimiento exitoso.
Bajo este escenario, distintos autores sugieren una serie de recomendaciones sobre evidencia, interoperabilidad, el rol de los gobiernos, las empresas privadas e investigadores en relación a la expansión de intervenciones mHealth:
  • En términos tecnológicos, es necesario establecer una arquitectura abierta para el desarrollo de aplicaciones que pudiesen facilitar el desarrollo de sistemas informáticos escalables y sustentables.
  • Es necesario pensar en estrategias de evaluación que pudiesen poner a prueba las múltiples características de las intervenciones de mHealth, con el fin de proveer suficiente evidencia base.
  • La expansión de proyectos mHealth debe ser precedida por pruebas de eficacia y eficiencia para tener una base apropiada.
  • Gobiernos, financiadores y la iniciativa privada debe cooperar con el fin de establecer estándares para crear un ecosistema autónomo comercialmente viable para la innovación.
  • Es importante también definir el término “expansión”. En este sentido, el creciente involucramiento por parte de la iniciativa privada en las intervenciones de mHealth, principalmente de las empresas proveedoras de tecnologías móbiles, sugiere mantener cierta cautela. Es muy probable que el sector privado considere “expansión” como ampliación de su mercado, en lugar de incrementos en la calidad de vida de las comunidades. No hay duda en que las alianzas de los sectores público y privado son fundamentales en el campo de las tecnologías mHealth, sin embargo éstas no deben realizarse a expensas del beneficio social.

Literatura a considerar:
  • Lemaire J (2011). Expansión de salud móvil: Elementos necesarios para el crecimiento exitoso de mHealth en países en desarrollo (Scaling up mobile health: Elements necessary for the successful scale up of mHealth in developing countries). Ginebra: Advanced Development for Africa. http://www.k4health.org/sites/default/files/ADA_mHealth%20White%20Paper.pdf
  • Estrin D, Sim I (2010) Dando sentido a la información de salud móvil: Una arquitectura abierta para mejorar la salud individual y pública (Making Sense of Mobile Health Data: An Open Architecture to Improve Individual – and Population-Level Health). Science 330: 759–760. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3510692/


[1] Tomlinson M, Rotheram-Borus MJ, Swartz L, Tsai AC (2013). Expandiendo mHealth: ¿Dónde está la evidencia? (Scaling Up mHealth: Where Is the Evidence?) PLoS Med 10(2): e1001382. doi:10.1371/journal.pmed.1001382
[2] Lemaire J (2011). Expansión de salud móvil: Elementos necesarios para el crecimiento exitoso de mHealth en países en desarrollo (Scaling up mobile health: Elements necessary for the successful scale up of mHealth in developing countries). Ginebra: Advanced Development for Africa.
[3]Flay BR, Biglan A, Boruch RF, Castro FG, Gottfredson D, et al. (2005) Standards of evidence: criteria for efficacy, effectiveness and dissemination. Prev Sci 6: 151–175. doi: 10.1007/s11121-005-5553-y.
[4] Qiang CZ, Yamamichi M, Hausman V, Altman D (2011) Mobile applications for the health sector. Washington: World Bank.

10. Modelos de financiamiento






Q&A with mHealth experts

Interview with Dr. Jess Ghannam


He is a clinical professor and the Chief of Medical Psychology at the University of California, San Francisco, and also practices at the UCSF Helen Diller Comprehensive Cancer Center.

Ghannam received his A.B. in Psychology from the University of Michigan, Ann Arbor in 1979, before going on to earn an M.A. in Psychology, an M.S. in Medical Sciences and a Ph.D. in Clinical Psychology from the University of California, Berkeley. In addition, he was a post-doctoral fellow in Psychology at Stanford University in California.
Transcript of Interview – 18th, October 2013.

D: We are students currently enrolled in the “New Media in Development Communication” course at SIPA. We saw your TEDx video and the idea is to do something - maybe small - but helpful to the field. We have some questions for you today to better focus our project.

E: The three of us are coming from Latin America and we want to know about risk factors. Can you tell us if there is a significant difference between the risk factors in people from Latin America compared to people in other parts of the world? Have you noticed any specific trends on that?

P: Yes, I actually have. I’ve done some work in Mexico and in Latin America, and the similarities between Mexico and the Middle East, for example - what happens with increases in economic trade, and increases in economic coordination between the United States, Mexico and the Middle East - one of the unfortunate consequences are the so-called “Free Trade Agreements”. These countries start to import more food from the U.S., and the food that they’re importing is terribly unhealthy. The other thing that happens with these agreements is that the kinds of economies change, for example from working the land to industrial jobs. So you have all these people that were used to work in the land now working 12, 14 hours a day, and their diets changing dramatically, obviously. And I think that if you plot the trend of what has happened in Mexico and in Latin America since these Free Trade Agreements, you’ll see the most dramatic changes in the health - you know, obesity, type-2 diabetes, cardiovascular diseases, all of these things. We have the same thing in the Middle East, especially in Palestine and the Gulf countries.

A second thing is the rise of cellphones. For all the positive things about cellphones, there are also some negative things. You can correlate the increase in use of cellphones to the decrease in the amount of physical activity among young people.

So you have the economy, you have changes in the diet as a result of those economic changes, and then you have the rise in mobile technology usage, which actually makes people more passive instead of more active. Those are the trends that I see.

F: In our class, we we’re analyzing the usage of the new media, and how from cellphones and new devices one can improve certain aspects of people´s lives. We are also interested in analyzing the psychology behind these interventions, specially the psychology of the people that we want to help. Can you provide us with a hint of how this influences the way one might want to implement a project?

I have a lot to say about that. For people who have diabetes, obesity, people that have problems with their weight – and this happens all around the world – they get disconnected, disengaged from themselves, from their families and from their communities. We see that especially with the Latino community in San Francisco. The people who are most at risk are the people that feel very disconnected. They are here – they’re disconnected from their families (that are not in the US). They’re disconnected from their communities – everybody has to work so much that they are unable to connect as a family so much – and the kids, specially the young, adolescent girls, they really are lost psychologically being in this country. They are struggling with who they are; their parents are also having a difficult time. And I think when that happens it puts them at risk for poor health outcomes.

F: So you would have the psychology of these people. But what about… let’s put an example: I come from Chile, where you would have a high rate of hypertension in the country. Would it make sense for a health prevention program to maybe set up some kind of cellphone reminder to people that have hypertension to go to the doctors appointment? Since hypertension doesn’t have any painful symptoms people forget to go to the doctor’s appointment. Do you have any advice regarding this situation?

Yes, we call hypertension “the quiet killer”, because by the time the person notices, it’s too late. I think that texts and text reminders are really, really good. We’ve done that with our diabetes program in Palestine with pre-diabetic teenagers. We would text them just to check in. Were they making their changes with their diet? Were they exercising? In general we had very good results. But the thing that made good results is that we would bring them all together as a group and we would do psycho-educational training. It would be kind of a support group. And if you look at the difference in the success rates between people that just get the text alerts versus those who get the text alert plus the group, you’d do so much better if you bring people together and develop a relationship. That’s really the whole basis of the successful projects that I’ve done. It really comes down to building relationships at the grassroots level with communities. The bonding and the sense of community is absolutely the most important thing about predicting success in any of these projects. That’s the multiplier effect of bringing twenty, forty people together. You can have one or two people reaching fifty people. And the human connection that you have with people, and the connection that each person has with one another is what makes it even more successful than just text alerts. You have to bridge technology with social relationships.

If there is a way to take advantage of the family connections and use that in the social media context, something like FB or Google+, I think that the potential is really great. It’s never the same as actually being with people, seeing them directly and being with them and talking to them because of the limitations, but I definitely think its worth thinking about. There isn’t a lot of research that I’m aware of, looking at social media in disease prevention awareness. The research that is out there is not that good.

Unfortunately, part of the problem is that people who need it the most have the least access to broadband. People that are economically disadvantaged that are probably living in a more rural area. That’s my experience in Mexico.

F: In that sense, what do you think about technologies in countries where you don’t have broadband penetration as high as you would like? What technologies – because one tends to think that SMS is a pretty standard technology - but are there other technologies that you might suggest that help in disease prevention?

My feeling is that SMS is good, because it has greater penetration. You want to maximize the number of people you want to reach. And the combination of text - maybe once a day - with face to face engagement, for me it’s the most efficient way to reach the largest number of people, and it the highest possibility of behavioral change.

F: How do you deal with the fact that people can become somehow insensitive to these messages?

That´s why you have to build a relationship. If you get a text from someone that you have a good feeling about – a friend, a lover - you´ll always respond to that text, right? If you get a text from someone you don´t have a connection with, you don´t respond to them. It´s not the text by itself, it´s about who is sending it.

Build the relationship first, and once you built the relationship, use SMS or Social Media to leverage. What we did in Gaza, for example, we trained community health activists to go out and build the relationships with the people. If I train one hundred community activists to go out and meet families and schools - I can build that relationship with the community activist and then each activist can go and engage with a hundred people. It’s so much more efficient. Latin America is great for this because you have many great community activists, great political activists, now we should have great health activists.

F: That would be the way to scale the project, right?

Yes, that´s the scaling. But if you were to pilot the project, you could do it yourself. And once you pilot it, you can do the issue of scaling later on.

E: Going back to risk factors, what can you tell us about risk factors that people don´t usually look into, that people are not aware of?

For me the hidden risk factors – I mean, its easy to come up with all this factors that are medically proven, like diet, exercise, but really the hidden risk factors are the untreated psychological conditions that people have, for example untreated anxiety, untreated depression, untreated post traumatic stress disorder. When you have untreated conditions, you will not take care of yourself. These are the biggest risk factors that I just see globally. You heard that from my TEDx talk, the third largest global health burden its untreated depression. When you have untreated depression - the co-morbidity with hypertension, diabetes, and obesity- it just magnifies it tremendously. Those are the biggest risk factors.

D: If we need to focus on a specific age group, what would you recommend?

I would say teenage girls from 9 to 14. Just from my observations here in San Francisco, they really seem to be super high risk. It’s so sad to see a thirteen-year-old girl who is already pre-diabetic. Another thing about teenage girls is that they tend to be very responsive to the relationship building, much better than boys do. That´s my observation. They also respond better to SMS than boys do.

E: What are the best practices to build a campaign involving technology for disease prevention?

When you do a campaign on health prevention, it´s like a politician running for office. You have to have imagery, a logo, promote it in the media. You will see that when you have a good brand, people will definitely get interested. Have a campaign that you expose people with – there is a very interesting psychological cycle: that the more you see something, the more you like it. The more you see something, the more interest you show about it. This is how our brains are wired. In this sense, you want a campaign that has a simple message, which repeats itself over and over in multiple media. Those are the principles of a successful campaign.








ICT4D: Additional resources
Articles


‐ Failed ICT development projects: Sweeping it under the carpet and moving on?
http://vulnerabilityandpoverty.blogspot.com/2012/12/by‐inka‐barnett‐use‐of‐information‐and.html
Explains reasons for failure, provides links to information on ICT4D failures reports.


‐ Starting an ICT4D project? Try these questions first.
http://ajuonline.net/blog/?p=702
Article on best practices for the development of ICT4D projects.


‐ Using SMS to Strengthen Community Communications in the Democratic Republic of the Congo
https://bestict4d.wordpress.com/2013/06/27/using‐sms‐to‐strengthen‐community‐communications‐in‐
the‐democratic‐republic‐of‐the‐congo/
Article on the impact of SMS in community communications in Congo, particularly members of a Methodist
Church.


The Role of Mobile in Development: An Interview with Priya Jaisinghani, Mobile Solutions Director at USAID
https://bestict4d.wordpress.com/2013/06/18/the‐role‐of‐mobile‐in‐development‐an‐interview‐with‐priya‐
jaisinghani‐mobile‐solutions‐director‐at‐usaid/
Articule on best practices and examples of projects around the world.


Failure Report
‐ Engineers Without Borders, a Canadian NGO, publishes a yearly list of failed ICT projects, as means to
provide lessons of do´s and dont´s.
http://legacy.ewb.ca/en/whoweare/accountable/failure.html


Journal Article
‐ Short Message Service (SMS) Applications for Disease Prevention in Developing Countries
http://www.jmir.org/2012/1/e3/
This review illustrates that while many SMS applications for disease prevention exist, few have been
evaluated. The dearth of peer‐reviewed studies and the limited evidence found in this systematic review
highlight the need for high‐quality efficacy studies examining behavioral, social, and economic outcomes of
SMS applications and mobile phone interventions aimed to promote health in developing country contexts.


General Resources
‐ mHealth Evidence
http://www.mhealthevidence.org/
“mHealth” is the use of mobile information and communication technologies for improving health.


mHealthEvidence.org was designed to bring together the world’s literature on mHealth effectiveness, cost‐
effectiveness and program efficiency, to make it easier for software developers, researchers, program
managers, funders and other key decision‐makers to quickly get up to speed on the current state‐of‐the‐
art. It includes peer‐reviewed and grey literature from high‐, middle‐ and low‐resource settings.


‐ SPIDER
https://spidercenter.org/about
Provides funding for ICT for Development projects:
The Swedish Program for ICT in Developing Regions (Spider) is a resource center for ICT for Development
(ICT4D). Spider was established in 2004 and is based at the Department of Computer and Systems Sciences
(DSV) at Stockholm University. Spider is primarily financed by the Swedish International Development
Cooperation Agency (Sida).


Examples of Spider‐funded programs
Education
Mobile Online Learning for Human Rights
Reforms through citizen participation and government accountability
Period: July 2012 ‐ December 2012


The primary idea with this project is to explore how smartphones that utilize native applications
and mobile web applications can be used to enhance the quality of life and learning situation for
Kenyan citizens. Specifically for this Spider research area, we will provide a course in Human Rights
through a mobile Moodle client so that the participants can learn about human rights and
democracy for free via a smartphone. This course can be accessed and studied freely by any
Kenyan with access to a smartphone or other form of Internet connected device (e.g. tablet, PC,
etc.). Furthermore, the course intends to offer an open badge, i.e. (https://wiki.mozilla.org/Badges)
that can be seen as a form of “digital diploma” so that Kenyan citizens have “proof” of studying the
course.


Health
ICT4MPOWER: ICT for Medical Community Empowerment


The project objectives are:
‐ Improve the information flow from the community to the district and the regional levels of the
health care system. This should empower rural healthcare communities, for better health
outcomes for the rural population in Uganda using information and communication technology
(ICT).
‐ Develop a visual tool for the doctor to see what stage the patient is in, what side effects they
have towards drug treatment etc. A doctor can in a short amount of time, without looking at
hundreds of papers or asking nurses, look at that information on a patient from the digital
records and make the decision to change drug treatment.
‐ Transfer patients’ records to a digital system that should be able to provide the history of
treatment to a patient.
‐ The Electronic Health Record System is important for generating: ‐ Accurate client traceable
records. ‐ Data that allows tracking of indicators at all levels ‐ Monitoring for prevention and
control of diseases of epidemic potential
‐ Child Health Application: There is a need for better vaccination management in rural areas. The
clinical decision support system will generate a care program for any child registered at any
clinic. When vaccination or routine check‐up is imminent a message from the system is sent to
the community health worker’s phone, who visits the parents to remind them of vaccination.
These are the community health workers who received mobile phones in 2009 in Ruhira
Village, Isingiro District.

Download full research.pdf