Patient engagement lessons from Africa

by Dr Nick

I was raised in Gabon on the equatorial west coast of Africa

and though I’ve never practiced there, I consider myself African and continue to be interested in the delivery of healthcare on the continent. Though health resources are scarce, my colleagues there have made creative use of the tools available. In Gabon, and indeed across much of the rest of Africa, text messages are routinely used to provide timely health messages about medications, clinic appointments, health risks and general health information. They are way ahead of the U.S. in proactive use of mobile technology for health improvement.

Below are a few examples of the remarkable achievements they’ve made with cell phones and text messages. Most of the examples were compiled by IRIN, a news service that focuses on humanitarian news and analysis, plus a few others that I’ve added to the list:

Health check-up by text message

  • A recent study published in The Lancet noted that Kenyan patients who received weekly text message check-ups were 12 percent more likely than a control group to have an undetectable level of HIV virus a year after starting life-prolonging antiretroviral (ARV) treatment.
  • In the south-central Ghanaian village of Bonsaaso, using mobile phones to contact health workers has lowered the maternal death rate.
  • TxtAlert, a product of the Praekelt Foundation, is a mobile tool that sends unique, automated SMS reminders to patients on chronic medication. This reminds them to take their medication or perform other necessary tasks. A special tool, called “Please Call Me” allows patients to call their doctors even if they don’t have any airtime available by pinging their doctor who then calls back.
  • A pilot project in Cape Town, South Africa, used text messages to improve adherence to tuberculosis regimens.
  • Medic Mobile allows patients to get home-based care even if they can’t be physically visited by a caregiver. The organization launched a pilot program in Malawi, where more than 100 patients received treatment for TB after their symptoms were noticed by the community and reported by text message.

Health information

Health literacy is often low in Africa, and text messages have proven an effective way to increase knowledge

  • In Tanzania, text messages are sent to pregnant women based on their due dates, providing important information that is relevant to each stage of their pregnancy.
  • On Valentine’s Day 2008, a Dutch NGO started an eight-week campaign in Uganda’s southwestern district of Mbarara with the slogan, “Don’t guess the answers, learn the truth about HIV.” The campaign led to a 100 percent increase in visits to the voluntary counseling and testing center run by the NGO’s health partner. This year, the same NGO used a text message quiz to test malaria knowledge in a fishing village in eastern Uganda.
  • In Ethiopia, people can call a confidential hotline anonymously with HIV-related queries.
  • On a 24-hour toll-free medical hotline in the Republic of Congo, set up by the government, the UN Children’s Fund (UNICEF) and a mobile telephone network operator, health professionals respond to queries about pediatric emergencies.

I could go on, and on and on, listing successful use of cell phones and text messages. The bottom line is that African health workers are using this technology in useful and creative ways to provide communication with patients.

Many U.S. medical professionals have been reluctant to use text messages and other mobile technology, and lag far behind their African colleagues in this area.

So what’s behind this disparity? Two factors, both related to infrastructure, have boosted use in Africa and delayed use in the U.S. First, because there is no significant landline infrastructure in much of Africa, cell phones account for 90% of all phones on the continent. In the cities, adoption has been near universal. (Pre-paid cell minutes are now used as a form of currency, as an alternative to sometimes volatile official currencies.) In many remote locations, where even clean water and electricity are scarce, you can get a cell signal and power a cell phone with a small solar charger to gain access to voice calls, text messages and the Internet. Cell phones have become a vital link for the continent.

With scarce health infrastructure and near-universal adoption of cell phones, health care workers were quick to see the usefulness of text messages, which only cost about 2 cents each.

Conversely, in the U.S., we have highly advanced medical infrastructure that has been in place for decades. A large proportion of primary care physician practices were established long before cell phones became widely used, and they still depend largely on the landline infrastructure they’ve always used. Same for most hospitals and outpatient clinics. Changing protocols, workflows and thinking patterns for these organizations isn’t easy, particularly if there is no urgent incentive to do so.

Many healthcare organizations also are concerned about HIPAA compliance and security in mobile patient communications; while those are valid considerations, there is a host of information that can be exchanged through mobile devices that wouldn’t violate the patient privacy regulations. And with a secure patient portal that can be accessed via smartphone, physicians can use mobile technology to share even protected information.

So why should physicians and hospitals change the way they work? Three reasons: meaningful use attestation, better outcomes and market competition.

While texting is not a part meaningful use attestation, it is a tool that could help you meet the criteria for getting patients to log in and view their health records. A text message with a link to your portal could prompt many to take a look just out of curiosity. And chances are, they’ll use their smartphone, not a PC to access your portal. Just this year, the number of users who access the internet with a mobile device exceeded the number who use a PC to gain access. So you’d better be sure your portal is mobile-friendly.

Perhaps the most immediate value of texting and other patient engagement strategies is improved care and better outcomes. Currently, we are not doing a good job of patient communication and education, despite putting time, energy and staff resources on the task.

Often, physicians, nurses and health educators are talking to patients who are too scared, too stunned by a new diagnosis, or just too intimidated by the healthcare system to be mentally and emotionally available to learn. Much of what we tell them is forgotten by the time they are out the door. And even those who don’t completely forget instructions often miss medication doses and appointments due to the forgetfulness that plagues all of us. And they often have trouble taking the advice we give and putting it to use in the real world.

Text message reminders could be used to remedy many of these problems. If the texts are scheduled to automatically send at the time that is most useful to a patient, the immediacy of the information would help patients follow through on treatment and be more engaged in their care.

The third reason that we should start using text messages is that the population under 40, and especially those under 30, use text messages as a primary communication tool. I have kids in that under 30 group, and they never answer the phone when I call or reply to emails (I doubt they even open emails). But a text message gets their attention. In fact, the average teenager sends 3,339 text messages each month. That’s more than 100 texts per day.

Granted, adults don’t text nearly that much, but those age 25-44 send texts more often than they call. And email is declining for many users, because they hate sorting through all the ads. Instead of emails and phone calls, they text and use Facebook and other social media to communicate with friends. Even business use of texts are on the increase, because it offers immediacy without the intrusion of a voice call.

So if you want to remind a patient about an appointment, odds are that a text message is a more reliable vehicle than either a phone call (which usually ends up as a voice mail that is never heard) or an email (which is likely to be missed among all the ads, if the person even bothers to check the inbox). If you send a text reminder at the time that a patient should be taking medication, chances go way up that the dose won’t be missed.

If you have a robust, mobile-friendly patient portal, you can use text messages to alert your patients to information they need on the portal – like their health records, useful research information and links to lifestyle advice like healthy recipes and exercise tips. With a secure portal, you can exchange even the most sensitive data with patients, even from a mobile device.

As this under-30 cohort becomes an increasingly larger portion of your patient population, they will expect your organization to communicate with them in ways that make sense to them, not you. Call only during office hours and wait on hold? I don’t think so. They will expect to use their smartphones to schedule appointments through your portal and receive information and ask questions through your portal, with text alerts to let them know when to check back for answers.

And if your organization can’t do that, they will find another one that will. Because the more future-ready, forward-thinking organizations have already made a move in that direction.

This piece originally appeared in MedCity News

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