Student Blog: Lucy Kaluvu’s Research on Mhealth in Kenya

Posted by Nicole Moran on January 23, 2020 at 12:28 pm



ELIMINATION OF BOTTLENECKS IN HIV PREVENTION, CARE AND TREATMENT: THE MOBILE HEALTH (MHEALTH) OPPORTUNITY IN KENYA.

At the Share-Net 8th Annual Student Meeting: Linking research, policy and practice, ISS ,The Hague

My name is Lucy Kaluvu. I am a healthcare provider from Kenya and currently a global health research intern at the Julius Center for Health Sciences and Primary Care, University Medical Center (UMC),Utrecht. Prior to starting my masters studies, I worked at a Level 4 district hospital in Kilifi, Kenya working closely with immunocompromised oral cancer patients.

My most memorable interaction was with a 55-year-old HIV positive patient, whose late diagnosis had resulted in late stage oral Kaposi Sarcoma. Kaposi Sarcoma is an AIDS-defining illness caused by the Human Herpes Virus-81.Her delayed HIV diagnosis and commencement of anti-retroviral therapy had increased the magnitude and spread of the cancer. This sparked my interest in the reasons behind delayed HIV diagnosis and treatment, especially for those living in low-resource setups.

During my master’s studies at the KIT Royal Tropical Institute, I decided to focus my thesis dissertation on the barriers to access of HIV prevention, care and treatment services and how digital technology can be used to eliminate these barriers. With the guidance of my thesis advisor, Mr. Hermen Ormel (Senior Advisor, Sexual and Reproductive Health and Rights, KIT Royal Tropical Institute) and my thesis academic tutor, Dr Lisanne Gerstel (Health and Education Advisor, Global Health, KIT Royal Tropical Institute), I embarked on a rollercoaster journey of lots of coffee, limited sleep and lots of hard work!

Why mobile health (Mhealth)?

“Mhealth offers significant potential in positively changing the lives of people and with good health you have a great work force” Deputy head of DFID, Tony Gadner2.

Mhealth is the application of medical and public health through mobile communication devices3. Globally, there are more than 5 billion mobile phone subscribers. More than 80% of them reside in low- and middle-income countries (LMICs). In Kenya, the mobile phone penetration is at 93%3.

Why are mobile phone so appealing?

Mobile phones are portable, with ease of access and sharing capabilities, hence they can reach more people. In the context of HIV/AIDS, mhealth strategies can be used to create HIV awareness, promote HIV testing and improve the level of ART adherence among PLHIV. Moreover, such interventions can also be applied in

The main objective of my study was to identify the barriers of access to HIV services. I also wanted to understand why, despite the potential of mobile technology in health, mhealth interventions were not popular with governments and policy makers. Moreover, I wanted to explore the available mhealth evidence and the gaps in evidence evaluation.

I realized that although mobile health projects have been conducted in Low-middle income countries and in Kenya, they suffer from “mhealth pilotitis”4. The majority of mhealth projects remain in pilot phase and rarely reach full scalability. Also, I noticed significant gaps in mhealth intervention guidelines and limited published evidence on the effectiveness of mhealth interventions.

I applied the Levesque model of access to healthcare services to identify the main barriers to access of HIV services. I also used the Mhealth and ICT framework by Labrique et al to identify the different mhealth functions, as a guide into my literature search.

The World Health Organization (WHO) Digital Health Intervention guidelines 2019 played a major role in the categorization of mhealth studies based on quality and certainty of evidence6.

Figure 1: Mhealth and ICT framework7

“Until the ‘m’ is removed from mHealth and mobile becomes just another mainstream channel for delivering health services, it will continue to languish at the margins”, says Axel Nemetz, Head of mHealth Solutions, Vodafone Global Enterprise5.

 

Main Findings

  • The main demand and supply side barriers to access of HIV services identified were low income/poverty, low literacy levels, gender and cultural factors. The main supply side factors were poor professional values, stigma and discrimination, low provider capacity and infrastructure8,9.
  • I found that poverty and gender factors had an influence on HIV knowledge, condom use and sexual behavior.
  • Differences in socio-economic status had an impact on education, service affordability and high-risk sexual behavior.
  • Stigma and discrimination was found to affect health-seeking behavior and medication adherence.
  • Provider attitude was found to influence health-seeking behavior and community attitude towards HIV services. Moreover, scarcity and low-quality services affects uptake and patient retention.
  • I also found that mhealth applications can be applied over a wide range of areas: client education, electronic health records, point-of-care diagnostics, electronic decision support, training of healthcare workers, supply chain management and as financial incentives to promote behavior change.
  • Mhealth applications have led to an increase in antenatal and postnatal coverage. They have been used to improve clinic attendance through appointment reminders.
  • Mlearning has improved the supervision and training of healthcare workers, especially in remote settings.
  • Financial incentives have been used to facilitate behavior change and increase school enrollment of youth.
  • Limited evidence was found on targeted mhealth interventions for key population groups. This is despite their unmet need for sexual and reproductive health services and their significant contribution to the HIV burden.

NB: Digital, design and infrastructural limitations remain a major challenge in the efficiency and scalability of most mhealth interventions.

The Ministry of Health is keen to ensure an enabling regulatory environment to encourage innovation and use of mobile technology in improving the health of Kenyans. The other pillars are telemedicine, health information system, e-learning and information for citizens”, says Dr Izak Odongo, Ministry of Health Kenya2.

 

Main recommendations

I Government

  • To address key infrastructural challenges by expanding electricity supply coverage, construction of good quality roads and allocation of more human resource personnel, especially in hard-to reach areas.
  • With reference to the WHO Digital Health Intervention Guidelines, the current Kenya national e-health strategy should incorporate mhealth evidence evaluation guidelines. This will ensure prioritization of studies whose certainty of evidence is high10.

II  Ministry of Health Kenya

  • The MOH should collaborate with non-governmental organizations and donors to create better alignment of mhealth interventions with the national health strategy. This will facilitate better uses of resources and evidence collection.
  • The MOH should also invest in digital training for health workers countrywide and refresher courses every two to three years to enable better use of mhealth applications and increased efficiency

III Area of research

  • More mhealth intervention studies should be done for key populations such as female sex workers (FSW), men having sex with men(MSM) and intravenous drug users (IDU).

Conclusion

Mhealth interventions have the potential to improve treatment adherence, facilitate remote supervision and training of healthcare workers, improve access to education material, promote behavior change and improve supply chain transparency. However, design and infrastructural challenges deter the promotion of mhealth interventions above other conventional methods. Also, more high-quality studies are required to produce high certainty of evidence needed to inform policy and integrate mhealth interventions into the healthcare system.

Reflection on thesis writing.

The research process and thesis writing was very rewarding for me. I was able to improve my skills in literature search, sentence construction and scientific writing. This was the beginning of my path towards pursuing a career in research. My advice to those embarking on their thesis journey is to enjoy every step. As always, the next research task will be harder, but you will have experience. I am grateful to Share-Net Netherlands for the opportunity to do my first poster presentation at the 8th Annual Student Meeting: Linking Research, Policy and Practice.

Future plans

I am currently working on a systematic review on multimorbidity, communicable and non-communicable diseases with a great team. It is a new area of research and I am embracing the challenge. In March this year, I will be doing another poster presentation of this thesis at the Geneva Health Forum 2020.God speed!

 

 

REFERENCES

  1. Butt FM, Chindia ML, Vaghela VP, Mandalia K. Oral manifestation of HIV/AIDS in a Kenyan provincial hospital. East African Medical Journal. 2001;78(8):398-401.
  2. Kenya [Internet]. Mhealth: Embracing mobile money to access health care. Available from: http://www.ke.undp.org/content/kenya/en/home/ourwork/inecgr/successstories/mhealth–embracing-embracing-mobile-money-to-access-health-care.html
  3. United Nations -Vodafone Foundation Partnership. Mhealth for Development: The Opportunity of Mobile Technology for Healthcare in the Developing World [Internet]. 2009. Available from: http://www.globalproblems-globalsolutions-files.org/unf_website/assets/publications/technology/mhealth/mHealth_for_Development_full.pdf
  4. Labrique, A. B., Vasudevan, L., Kochi, E., Fabricant, R., & Mehl, G. (2013). mHealth innovations as health system strengthening tools: 12 common applications and a visual framework. Global health, science, and practice, 1(2), 160-71. DOI:10.9745/GHSP-D-13-00031.
  5. Kenya[Internet]. Pilotitis: What is the cure? Available from: https://www.gsma.com/mobilefordevelopment/programme/mhealth/pilot-itis-whats-the-cure/
  1. World Health Organization. Recommendations on digital interventions for health systems strengthening [Internet]. 2019. Available from: https://apps.who.int/iris/bitstream/handle/10665/311941/9789241550505-eng.pdf?ua=1
  2. Levesque JF, Harris MF, Russell G. Patient-centered access to health care: conceptualizing access at the interface of health systems and populations. International journal for equity in health. 2013 Dec;12(1):18.
  3. Nadise NJ, Ziraba AK, Inungu J, Khamadi SA, Ezeh A, Zulu EM, Kebaso J, Okoth V, Mwau M. Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya. Health & place. 2012 Sep 1;18(5):1144-52
  4. Sia D, Onadja Y, Nandi A, Foro A, Brewer T. What lies behind gender inequalities in HIV/AIDS in sub-Saharan African countries: evidence from Kenya, Lesotho, and Tanzania. Health policy and planning. 2013 Dec 17;29(7):938-49.
  5. The Ministry of Health. Kenya National e-Health Strategy 2011–2017 [Internet]. Ministry of Health.2011 April. Available from: http://publications.universalhealth2030.org/uploads/kenyanation_ehealth_strategy.pdf

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