Technology and Health Care 22 (2014) 1–11 DOI 10.3233/THC-130766 IOS Press
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A pilot study to assess perceptions of using SMS as a medium for health information in a rural setting Sneha Priyaaa , Shruti Murthyb, Swati Sharanb , Krishna Mohana,b and Ashish Joshic,∗ a Saveetha
Medical College, Chennai, India of Healthcare Technologies Society, New Delhi, India c Center for Global Health and Development, College of Public Health, UNMC, Omaha, NE, USA b Foundation
Received 7 October 2013 Accepted 29 October 2013 Abstract. BACKGROUND: Information and Communication Technologies (ICTs) in health is not merely about technology but a means to reach various optimal outcomes across the entire health system. OBJECTIVE: The objective of this pilot study is to assess the perceptions of receiving health messages through SMS among individuals living in rural Indian settings. METHODS: A convenient sample of 100 individuals aged 18 years and above and living in rural settings of Kuthampakkam village in Chennai, a Southern part of India were enrolled during September 2013. Individuals having the mobile phone and agreeing to participate were enrolled in the study. Individuals with physical and mental challenges or involved in other clinical trials were excluded from the study. Information was gathered on the variables including socio-demographics, individual familiarity with use of technology, mobile phone usage and the perceptions of using SMS for obtaining health information. Information was gathered using a series of quantitative assessments. Descriptive analysis was performed to report means and standard deviations for the continuous variables and frequency analysis was reported for the categorical variables. Analysis of variance (ANOVA) was used to compare the means of the various continuous variables as compared to the chi-square analysis that was performed to compare the frequency distribution for the categorical variables. All analysis was performed using SAS v9.1. RESULTS: A convenient sample of 100 rural individuals was enrolled. The average age of the study participants was 34 years (SD = 17), with more than half of them being males (54%; n = 54), and 47% (n = 47) of them had education less than high school. Results showed that more than half of the individuals had no computers either at home (61%; n = 61) or work (68%; n = 68). 100% of them had mobile phones in their household. Text messaging was common in more than half of the study participants. Results showed that the majority of the study participants agreed that receiving calls on the mobile phones for receiving health messages would be the most preferred method. Results showed that the individuals in the age group of 21–40 years, males, with some college education, and in the income category of 50,000–1,00,000 were most likely to obtain SMS based health messages. CONCLUSIONS: ICT based health programs need to be established so that the audience receives the optimal technological platform program necessary to obtain health messages. This also suggests that future research is needed to determine the population that would actually adopt the use of SMS based health interventions rather than using SMS as a tool for delivery of health information to all. Keywords: SMS, mobile phone, health messages, practice, mobile health ∗
Corresponding author: Ashish Joshi, Centre for Global Health and Development, Department of Health Services Research Administration, College of Public Health, University of Nebraska Medical Centre, Omaha, NE, USA. Tel.: +1 402 559 237; E-mail: [email protected]. c 2014 – IOS Press and the authors. All rights reserved 0928-7329/14/$27.50
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S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information
1. Background Information and Communication Technologies (ICTs) in health is not merely about technology but a means to reach various optimal outcomes across the entire health system [1]. ICTs for health have been defined as tools that facilitate communication and processing and transmission of information by electronic means [1–4]. ICTs have been widely used for improving health including health promotions, human resources for health, and health-service delivery [1–4]. ICTs have great potential to make major impacts in improving the health and well being of poor and marginalized populations, combating poverty, and encouraging sustainable development and governance. With over 4 billion mobile subscriptions [5,6], mobile telephony has surged worldwide. Researchers and practitioners are utilizing the mobile telephony to support social and economic development initiatives ranging from disease surveillance to increasing access to financial services [5–7]. Results from the previous studies have shown that 74% of American adults use the internet, 60% of them use broadband connections at home and more than half of them (55%) connect to the internet wirelessly either via their laptops or through their handheld device like a smart phone. Some 46% of adults now own laptop and, among them, 83% connect via WiFi and 28% connect via wireless broadband. Results of a prior study also showed that 83% of adults have cell phones or smartphones and, among them, 35% have accessed the internet via their phone [8]. Developing country like India faces challenges in approaching important public health burdens because of limited healthcare workforces, limited financial support, high burden of disease, lack of education and information, high cost of access to care, and cultural barriers [9–11]. Results show that there are significant socio-demographic influences on access, device, usage, and activities, and differences in activities by device type and usage [12]. Mobile phone subscriptions have been growing rapidly in developing countries [13]. Mobile phone diffusion has reached more than 40% of the population [14,15] thus connecting millions of previously unconnected people. Results show a growing shift towards using mobile phones with the ability to offer short message services (SMS). Several advantages include it being less expensive than alternate methods of communication such as landline phones and the Intranet [16,17]. Mobile-supported information systems have emerged widely to try to provide scalable and sustainable options for addressing public health challenges of developing countries [18]. The low access to Intranet in some areas has suggested that SMS may be a more viable and more accessible to a larger population for health information communication [19]. The current expansion of mobile health (M-Health) applications can provide an opportunity to overcome public health challenges. M-Health applications consist of SMS or texting, voice services and other packet data services such as WAP, GPRS etc. [20]. SMS is a communication protocol standardized in the Global System for Mobile communications allowing messages of 160 characters maximum to be interchanged from a mobile phone or a computer to one or many mobile phones simultaneously [13, 15]. SMS has the ability to send near-real time personalized and tailored information to thousands of recipients all over the world through the Global System for Mobile communications network [13]. Developing countries have the majority of mobile phone subscribers but will also account for the 80% of the new users [13,14]. Innovative applications of mobile technology to existing health care delivery and monitoring systems offer great promise for improving the quality of life. They make communication among researchers, clinicians, and patients easier, and as chronic disease becomes more prevalent, mobile technologies offer care strategies that are particularly suited to combating these conditions. Results of the prior studies have shown that SMS intervention is very successful for sexual health promotion among the young people of age group 16–29 years [16] and in the improvement in perinatal and postnatal care among the pregnant
S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information
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women of Argentina [17]. Results show that a 2-way text message systems or a toll free number is a better option for people who don’t have easy access to internet [17]. There have been number of m-health projects in developing settings. Use of mobile Phones and RapidSMS to improve Child Nutrition Surveillance in Malawi [18], SIMPill- embedded mobile phone chip in medicine bottle to remind patients in South Africa [19] ; Cell-Preven [20]. Mobile phone can be used by health care workers to send SMS with real-time data on symptoms experienced by clinical trial participants, so that immediate care can be provided in case of adverse circumstances. Frontline-SMS-a bulk SMS solution and OpenRosa are the commonly available applications for bulk messaging. These applications can be used in various health domains such as volunteering support, monitoring of patients and control of diseases [9]. In a past study in India, there was a significant increase of women performing breast self-examination after 2 months when receiving breast cancer prevention messages through SMS reminders [13,20]. However only highly educated women working in the private sector and having mobile phones were included [13,20]. However, there are some issues related to use of m-health technology and include lack of timely responses, mobile network fluctuation, and lack of financial incentives, maintenance and SMS costs, high mobile turnover and potential misuse or private use of SMS [13,21,22]. A study reported language as one of the barrier to this technology [13,21,22]. High maintenance and SMS costs, high mobile phone turnover and security of the system are also few challenges to this technology [13,21,22]. Whether the message has been delivered and received by the concerned person or not is also an important issue. Data protection and confidentiality is an important concern in this regard [13,21,22]. The objective of this pilot study is to assess the perceptions of receiving health messages through SMS among individuals living in rural Indian settings. 2. Methods A convenient sample of 100 individuals aged 18 years and above and living in rural settings of Kuthampakkam village in Chennai, a Southern part of India were enrolled during September 2013. Individuals were enrolled using simple random technique. The total population covered in the village is 5,150. 39% (n = 2000) of them were age 18 years and above and of which 60% (n = 1,200) were having mobile phones. A random number was assigned to all eligible numbers and a random selection was done. Individuals agreeing to participate were enrolled in the study. Individuals with physical and mental challenges or involved in other clinical trials were excluded from the study. The study was approved by Institutional Review Board at Foundation of Healthcare Technologies Society, New Delhi, India (IRB#FHTS/027/2013). 2.1. Data collection instruments – Socio-demographic characteristics: Variables gathered included age (years), gender, family type (joint/nuclear/extended), number of household members, educational status (primary/middle/high school/intermediate/no college/some college/graduate or postgraduate/no schooling) and occupational status. – Familiarity with technology: Variables gathered included familiarity with using computers, whether individuals had computers or internet at work or home, and frequency of usage of computer and internet.
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S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information
– Mobile phone usage: Information was also gathered on the variables including having mobile phone in a household or with an individual, average time that an individual spends on mobile phone calls and text messaging. Additional information gathered from the study participants included information about the various features of the mobile phones that the users commonly use such as internet, camera and gaming. Information was also gathered to gather feedback about the main benefits and challenges of using internet on the mobile phone. Information was also gathered about the costs that individuals are spending on making mobile enabled phone calls, text messaging and internet. – Perceptions of using SMS for health information: Information was also gathered about current sources that individuals utilized to obtain health information. Health information topics included information about disease condition, prevention, treatment, monitoring and obtaining health advice from healthcare professionals. Further information was also gathered if individuals were currently receiving health information through mobile phones, and their perceptions about future use of mobile phones as means for obtaining health information. Information about the current and future costs that individuals spend to receive health information through mobile phones was also recorded. 2.2. Statistical analysis Descriptive analysis was performed to report means and standard deviations for the continuous variables and frequency analysis was reported for the categorical variables. Analysis of variance (ANOVA) was used to compare the means of the various continuous variables as compared to the chi-square analysis that was performed to compare the frequency distribution for the categorical variables. All analysis was performed using SAS v9.1. 3. Results 3.1. Socio-demographics The average of the study participants was 34 years (SD = 17), with more than half of them being males (54%; n = 54), and 47% (n = 47) of them had education less than high school. More than half of the study participants were married (54%; n = 54) and lived in a nuclear family structure (61%; n = 61) (Table 1). 3.2. Access to technology Results showed that more than half of the individuals had no computers either at home (61%; n = 61) or work (68%; n = 68). 100% of them had mobile phones in their household. However, less than half of them had internet access on their mobile phones. Text messaging was most common in more than half of the study participants (Fig. 1). 3.3. Familiarity with use of technology Results showed that 47% of the individuals were not at all familiar with using computers. Majority of them had never used a computer before (45%: n = 45) and more than half of them had never used internet (58%; n = 58) (Table 2)
S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information
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Table 1 Socio-demographic characteristics Variables Age, years 20 21–40 41–60 61 and above Gender, Males Education Less than high school High school some college Graduate or Postgraduate Marital status Married Single Family structure Nuclear Joint Household members 1–3 4–5 6 and above Annual Household Income, INR 100,000
Results N = 100 Mean = 34; SD = 17 30 40 20 10 54% (n = 54) 47% 36% 17% 54% 44% 61% 38% Mean=4; SD=1 29% 58% 13% Mean = 1,03,404; SD = 1,54,376 38 35 27
Fig. 1. Frequency distribution of access to technology. (Colours are visible in the online version of the article; http://dx.doi.org/ 10.3233/THC-130766)
3.4. Sources of health information The most common sources of health information were doctors (42%; n = 42), family members (11%; n = 11) and friends (9%; n = 9) (Table 2). Internet was the least used source of health information (Table 3).
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S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information Table 2 Level of familiarity with the use of technology Variables How familiar are you with using computer? How comfortable do you feel using computers? How often do use a computer? How often do you use Internet? How often do you use your computer at work? How often do you use the internet at work?
Variables Consult a doctor Use a search engine Consult friends Consult family Go to library Through books Consult Wikipedia
Always 42 1 9 11 3 5 3
Not at all familiar 47 Not at all comfortable 44 Daily 23 Daily 24 Daily 16 Daily 14
Responses Somewhat familiar 30 Somewhat comfortable 36 Sometimes 18 Sometimes 17 Sometimes 51 Sometimes 31
Very familiar 23 Very comfortable 20 Never 45 Never 58 Never 3 Never 5
Table 3 Sources of health information Sources of health information Often Sometimes Rarely or never 9 20 24 4 7 36 12 23 39 13 25 37 8 4 43 10 15 44 2 2 31
I don’t know 4 40 16 14 32 23 50
Table 4 Percentage distribution of the individuals spending time spent on mobile phone and its various features Time spent on mobile phone Average in a day Internet/browser/applications Camera Games Text messaging
I do not use 68 59 67 59
3 hours 11
2 8
Results showed that the majority of the study participants agreed that receiving calls on the mobile phones for receiving health messages would be the most preferred method (Fig. 2). Games (23%) and text messaging (21%) were the most common mobile phone related features that were utilized by the study participants. More than half of them (66%; n = 66) were spending high school some college Graduate or Postgraduate less than high school Annual Household Income (INR) 0–50000 50001–100000 above 100000 Familiarity with computer use Not at all comfortable Somewhat comfortable Very comfortable Frequency of computer use Daily Never sometimes Frequency of internet use Daily Never sometimes Internet Access at work Don’t Know No Yes
Would you find it useful to receive SMS based health information or not? Not useful N = 27 Useful N = 73 p value N % N % p = 0.140 10 33.3% 20 66.7% 6 15.0% 34 85.0% 7 35.0% 13 65.0% 4 40.0% 6 60.0% p = 0.244 15 32.6% 31 67.4% 12 22.2% 42 77.8% p = 0.293 16 23.2% 53 76.8% 5 29.4% 12 70.6% 6 42.9% 8 57.1% p = 0.696 12 31.6% 26 68.4% 8 22.9% 27 77.1% 7 25.9% 20 74.1% p = 0.399 13 29.5% 31 70.5% 11 30.6% 25 69.4% 3 15.0% 17 85.0% p = 0.576 7 30.4% 16 69.6% 17 28.8% 31 71.2% 3 16.7% 15 83.3% p = 0.561 5 20.8% 19 79.2% 21 30.4% 40 69.6% 1 14.3% 6 85.7% p = 0.021 7 63.6% 4 36.4% 15 21.7% 54 78.3% 5 25% 15 75.0%
compared to those who did not feel it useful. Results found internet access at work (p = 0.02) as the only significant variable necessary to facilitate receiving health messages. None of the other variables were significant (Table 6). 4. Discussion Our study aimed to understand people’s perception regarding the use of SMS services as an intervention in a rural setting of India. Since mobile phone subscription is increasing at a faster rate with around 4.6 billion subscription globally [6], we found that all the participants have a mobile phone in their household but only 76% of them actually own it. People have mostly used it for text messaging while very few of them have used internet on their phone. Results of our study showed that there was a limited access and usage of technology for obtaining health messages. Majority of the individuals agreed to receive phone calls on the mobile rather than SMS. However more than half of the study participants agreed that SMS based health messages will be useful. One of the reasons of having calls over the mobile phones being preferred than receiving SMS
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S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information
based health messages could attribute to high cost of the text messages that still exists in developing countries including India. To the best of our knowledge, this is the first pilot study aimed to explore the role of SMS based health messages in rural population in India. This raises an important challenge that despite the growing rise of mobile phones in rural settings, SMS based health messages might still not be used in practice despite being considered useful. There was limited number of individuals that were inclined to pay for the SMS based health messages. Results also showed that people like to receive health information by consulting their doctors and their family members. There were a growing numbers of individuals who were aware about how technology can be utilized to improve their healthcare. This shows that there is an urgent need to create more awareness about the usefulness and effectiveness of SMS based health messages especially among individuals living in rural settings. Games and text messaging are the most common mobile phone features that are being used by the people. Results of our study are similar to a previous study where games were used to increase participation and promote disease prevention behaviours [12]. Participants were ready to receive health information on their mobile phones in the form of calling messages rather than through internet or any other form. These findings are similar to an earlier study where pregnant women living in rural settings agreed that they would like to receive health information through phone calls rather than through messages [16]. There are several limitations to the current pilot study. One of the limitations is the small sample size, cross sectional nature of the study design, localized to rural settings. These results might not be applicable to individuals living in the urban settings and it would be interesting to explore the impact of the digital divide in adoption of SMS based health messages. The study suggests that individualized ICT based health programs need to be established so that the audience receives the optimal technological platform program necessary to obtain health messages. This also suggests that future research is needed to determine the population that would actually adopt the use of SMS based health interventions rather than using SMS as a tool for delivery of health information to all. Further, there is a need to integrate delivering health messages through use of games and interactive communication strategies as it can be a great mean for potential social change. References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10]
Bukachi F & Pakenham-Wash N, Information Technology for Health in developing Countries. Chest 2007; 132(5): 1624-1630. Chetley A, Davies J, Trude B, McConnell H & Ramirez R. Improving Health, Connecting People: The Role of ICT in the Health Sector in Developing Countries. Washington D.C., World Bank, Information for Developed Program (infoDev), 31 May-2006. Dzenowagis J & Gael K. Connecting for health: global vision, local insight: report for the World Summit on the Information Society. Geneva 2005. World Health Organization. “eHealth resolution.” 58th World Health Assembly, Resolution 28 (2005): 25. Donner J, Gitau S & Marsden G, After Access- Challenges facing Mobile Only Internet Users in the Developing World. 28th international conference on Human factors in computing systems. 2010. ITU Online Statistics, ICT eye, International Telecommunication Union, Geneva, 2009. Donner J, Verclas K & Toyama K, Reflections on MobileActive08 and the M4D Landscape. in Pettersson, J.S. ed. Proceedings of the First International Conference on M4D, Karlstad University Studies, Karlstad, Sweden, 2008. Lenhart A, Purcell K, Smith A & Zickur K, Social Media and Mobile Internet use among Teens and Young Adults. America: Pew Research Center, 3 February-2010. Asangansi I & Braa K. The Emergence of Mobile-Supported National Health Information Systems in Developing Countries, Medinfo, 2010. Cole-Lewis H & Kershaw T, Text messaging as a tool for behavior change in disease prevention and management. Epidemiologic Reviews, 2010, 32.
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Ronald RE & James KE, Comparing Internet and Mobile phone Usage: Digital Divides of Usage, Adoption and Dropouts. ScienceDirect, 2003, September-October; 27(8–9). Déglise C, Suggs LS & Odermatt P, Short message service (SMS) applications for disease prevention in developing countries. Journal of Medical Internet Research 2012; 14(1). GSM Association. “Universal Access-How mobile can bring communications to all.” Atlanta, GA: GSM Association (2006). Available from http://www.gsma.com/publicpolicy/wp-content/uploads/2012/03/universalaccessfullreport.pdf. Wikipedia- The Free Encyclopedia. URL http://www.webcitation.org/5xXmiDvlJ, Accessed on October 2013. The World in 2009: ICT Facts and Figures, Geneva, ITU Telecom World, 5-9 October, 2009. Cormick G, Kim NA, Rodgers A, Gibbons L, Buekens PM, Belizán JM & Althabe F, Interest of Pregnant Women in the use of SMS (Short Message Service) Text Messages for the Improvement of Perinatal And Postnatal Care. Reproductive Health 2012; 9:9 RapidSMS- Build Scalable Mobile Services with Python. Available from https://www.rapidsms.org/. Curioso WH, Karras BT, Campos PE, Buendia C, Holmes KK & Kimball AM, Design and Implementation of CellPREVEN: A Real-Time Surveillance System for Adverse Events Using Cell Phones in Peru. NCBI 2005; 2005 PMC1560594. Ebrahim S, Kinra S, Bowen L, Andersen E, Ben-Shlomo Y, Lyngdoh T & Reddy KS, The effect of rural-to-urban migration on obesity and diabetes in India: a cross-sectional study. PLoS Medicine 2010; 7(4): e1000268. Khokhar A, Short text messages (SMS) as a reminder system for making working women from Delhi Breast Aware. Asian Pacific Journal of Cancer Prevention 2009. Text to Change. Text To Change: Spread the Message, Stop the Virus. Available from http://ict4uganda.wordpress.com/ 2009/03/31/text-to-change-spreading-the-message-to-stop-the-virus/. Text to Change: HIV/AIDS Education, Data Gathering and Uptake of VCT via Mobile Telephony. Available from http:// 50.56.97.242/projects/text-change-hivaids-education-data-gathering-and-uptake-vct-mobile-telephony-0.
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A pilot study to assess perceptions of using SMS as a medium for health information in a rural setting Sneha Priyaaa , Shruti Murthyb, Swati Sharanb , Krishna Mohana,b and Ashish Joshic,∗ a Saveetha
Medical College, Chennai, India of Healthcare Technologies Society, New Delhi, India c Center for Global Health and Development, College of Public Health, UNMC, Omaha, NE, USA b Foundation
Received 7 October 2013 Accepted 29 October 2013 Abstract. BACKGROUND: Information and Communication Technologies (ICTs) in health is not merely about technology but a means to reach various optimal outcomes across the entire health system. OBJECTIVE: The objective of this pilot study is to assess the perceptions of receiving health messages through SMS among individuals living in rural Indian settings. METHODS: A convenient sample of 100 individuals aged 18 years and above and living in rural settings of Kuthampakkam village in Chennai, a Southern part of India were enrolled during September 2013. Individuals having the mobile phone and agreeing to participate were enrolled in the study. Individuals with physical and mental challenges or involved in other clinical trials were excluded from the study. Information was gathered on the variables including socio-demographics, individual familiarity with use of technology, mobile phone usage and the perceptions of using SMS for obtaining health information. Information was gathered using a series of quantitative assessments. Descriptive analysis was performed to report means and standard deviations for the continuous variables and frequency analysis was reported for the categorical variables. Analysis of variance (ANOVA) was used to compare the means of the various continuous variables as compared to the chi-square analysis that was performed to compare the frequency distribution for the categorical variables. All analysis was performed using SAS v9.1. RESULTS: A convenient sample of 100 rural individuals was enrolled. The average age of the study participants was 34 years (SD = 17), with more than half of them being males (54%; n = 54), and 47% (n = 47) of them had education less than high school. Results showed that more than half of the individuals had no computers either at home (61%; n = 61) or work (68%; n = 68). 100% of them had mobile phones in their household. Text messaging was common in more than half of the study participants. Results showed that the majority of the study participants agreed that receiving calls on the mobile phones for receiving health messages would be the most preferred method. Results showed that the individuals in the age group of 21–40 years, males, with some college education, and in the income category of 50,000–1,00,000 were most likely to obtain SMS based health messages. CONCLUSIONS: ICT based health programs need to be established so that the audience receives the optimal technological platform program necessary to obtain health messages. This also suggests that future research is needed to determine the population that would actually adopt the use of SMS based health interventions rather than using SMS as a tool for delivery of health information to all. Keywords: SMS, mobile phone, health messages, practice, mobile health ∗
Corresponding author: Ashish Joshi, Centre for Global Health and Development, Department of Health Services Research Administration, College of Public Health, University of Nebraska Medical Centre, Omaha, NE, USA. Tel.: +1 402 559 237; E-mail: [email protected]. c 2014 – IOS Press and the authors. All rights reserved 0928-7329/14/$27.50
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S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information
1. Background Information and Communication Technologies (ICTs) in health is not merely about technology but a means to reach various optimal outcomes across the entire health system [1]. ICTs for health have been defined as tools that facilitate communication and processing and transmission of information by electronic means [1–4]. ICTs have been widely used for improving health including health promotions, human resources for health, and health-service delivery [1–4]. ICTs have great potential to make major impacts in improving the health and well being of poor and marginalized populations, combating poverty, and encouraging sustainable development and governance. With over 4 billion mobile subscriptions [5,6], mobile telephony has surged worldwide. Researchers and practitioners are utilizing the mobile telephony to support social and economic development initiatives ranging from disease surveillance to increasing access to financial services [5–7]. Results from the previous studies have shown that 74% of American adults use the internet, 60% of them use broadband connections at home and more than half of them (55%) connect to the internet wirelessly either via their laptops or through their handheld device like a smart phone. Some 46% of adults now own laptop and, among them, 83% connect via WiFi and 28% connect via wireless broadband. Results of a prior study also showed that 83% of adults have cell phones or smartphones and, among them, 35% have accessed the internet via their phone [8]. Developing country like India faces challenges in approaching important public health burdens because of limited healthcare workforces, limited financial support, high burden of disease, lack of education and information, high cost of access to care, and cultural barriers [9–11]. Results show that there are significant socio-demographic influences on access, device, usage, and activities, and differences in activities by device type and usage [12]. Mobile phone subscriptions have been growing rapidly in developing countries [13]. Mobile phone diffusion has reached more than 40% of the population [14,15] thus connecting millions of previously unconnected people. Results show a growing shift towards using mobile phones with the ability to offer short message services (SMS). Several advantages include it being less expensive than alternate methods of communication such as landline phones and the Intranet [16,17]. Mobile-supported information systems have emerged widely to try to provide scalable and sustainable options for addressing public health challenges of developing countries [18]. The low access to Intranet in some areas has suggested that SMS may be a more viable and more accessible to a larger population for health information communication [19]. The current expansion of mobile health (M-Health) applications can provide an opportunity to overcome public health challenges. M-Health applications consist of SMS or texting, voice services and other packet data services such as WAP, GPRS etc. [20]. SMS is a communication protocol standardized in the Global System for Mobile communications allowing messages of 160 characters maximum to be interchanged from a mobile phone or a computer to one or many mobile phones simultaneously [13, 15]. SMS has the ability to send near-real time personalized and tailored information to thousands of recipients all over the world through the Global System for Mobile communications network [13]. Developing countries have the majority of mobile phone subscribers but will also account for the 80% of the new users [13,14]. Innovative applications of mobile technology to existing health care delivery and monitoring systems offer great promise for improving the quality of life. They make communication among researchers, clinicians, and patients easier, and as chronic disease becomes more prevalent, mobile technologies offer care strategies that are particularly suited to combating these conditions. Results of the prior studies have shown that SMS intervention is very successful for sexual health promotion among the young people of age group 16–29 years [16] and in the improvement in perinatal and postnatal care among the pregnant
S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information
3
women of Argentina [17]. Results show that a 2-way text message systems or a toll free number is a better option for people who don’t have easy access to internet [17]. There have been number of m-health projects in developing settings. Use of mobile Phones and RapidSMS to improve Child Nutrition Surveillance in Malawi [18], SIMPill- embedded mobile phone chip in medicine bottle to remind patients in South Africa [19] ; Cell-Preven [20]. Mobile phone can be used by health care workers to send SMS with real-time data on symptoms experienced by clinical trial participants, so that immediate care can be provided in case of adverse circumstances. Frontline-SMS-a bulk SMS solution and OpenRosa are the commonly available applications for bulk messaging. These applications can be used in various health domains such as volunteering support, monitoring of patients and control of diseases [9]. In a past study in India, there was a significant increase of women performing breast self-examination after 2 months when receiving breast cancer prevention messages through SMS reminders [13,20]. However only highly educated women working in the private sector and having mobile phones were included [13,20]. However, there are some issues related to use of m-health technology and include lack of timely responses, mobile network fluctuation, and lack of financial incentives, maintenance and SMS costs, high mobile turnover and potential misuse or private use of SMS [13,21,22]. A study reported language as one of the barrier to this technology [13,21,22]. High maintenance and SMS costs, high mobile phone turnover and security of the system are also few challenges to this technology [13,21,22]. Whether the message has been delivered and received by the concerned person or not is also an important issue. Data protection and confidentiality is an important concern in this regard [13,21,22]. The objective of this pilot study is to assess the perceptions of receiving health messages through SMS among individuals living in rural Indian settings. 2. Methods A convenient sample of 100 individuals aged 18 years and above and living in rural settings of Kuthampakkam village in Chennai, a Southern part of India were enrolled during September 2013. Individuals were enrolled using simple random technique. The total population covered in the village is 5,150. 39% (n = 2000) of them were age 18 years and above and of which 60% (n = 1,200) were having mobile phones. A random number was assigned to all eligible numbers and a random selection was done. Individuals agreeing to participate were enrolled in the study. Individuals with physical and mental challenges or involved in other clinical trials were excluded from the study. The study was approved by Institutional Review Board at Foundation of Healthcare Technologies Society, New Delhi, India (IRB#FHTS/027/2013). 2.1. Data collection instruments – Socio-demographic characteristics: Variables gathered included age (years), gender, family type (joint/nuclear/extended), number of household members, educational status (primary/middle/high school/intermediate/no college/some college/graduate or postgraduate/no schooling) and occupational status. – Familiarity with technology: Variables gathered included familiarity with using computers, whether individuals had computers or internet at work or home, and frequency of usage of computer and internet.
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S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information
– Mobile phone usage: Information was also gathered on the variables including having mobile phone in a household or with an individual, average time that an individual spends on mobile phone calls and text messaging. Additional information gathered from the study participants included information about the various features of the mobile phones that the users commonly use such as internet, camera and gaming. Information was also gathered to gather feedback about the main benefits and challenges of using internet on the mobile phone. Information was also gathered about the costs that individuals are spending on making mobile enabled phone calls, text messaging and internet. – Perceptions of using SMS for health information: Information was also gathered about current sources that individuals utilized to obtain health information. Health information topics included information about disease condition, prevention, treatment, monitoring and obtaining health advice from healthcare professionals. Further information was also gathered if individuals were currently receiving health information through mobile phones, and their perceptions about future use of mobile phones as means for obtaining health information. Information about the current and future costs that individuals spend to receive health information through mobile phones was also recorded. 2.2. Statistical analysis Descriptive analysis was performed to report means and standard deviations for the continuous variables and frequency analysis was reported for the categorical variables. Analysis of variance (ANOVA) was used to compare the means of the various continuous variables as compared to the chi-square analysis that was performed to compare the frequency distribution for the categorical variables. All analysis was performed using SAS v9.1. 3. Results 3.1. Socio-demographics The average of the study participants was 34 years (SD = 17), with more than half of them being males (54%; n = 54), and 47% (n = 47) of them had education less than high school. More than half of the study participants were married (54%; n = 54) and lived in a nuclear family structure (61%; n = 61) (Table 1). 3.2. Access to technology Results showed that more than half of the individuals had no computers either at home (61%; n = 61) or work (68%; n = 68). 100% of them had mobile phones in their household. However, less than half of them had internet access on their mobile phones. Text messaging was most common in more than half of the study participants (Fig. 1). 3.3. Familiarity with use of technology Results showed that 47% of the individuals were not at all familiar with using computers. Majority of them had never used a computer before (45%: n = 45) and more than half of them had never used internet (58%; n = 58) (Table 2)
S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information
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Table 1 Socio-demographic characteristics Variables Age, years 20 21–40 41–60 61 and above Gender, Males Education Less than high school High school some college Graduate or Postgraduate Marital status Married Single Family structure Nuclear Joint Household members 1–3 4–5 6 and above Annual Household Income, INR 100,000
Results N = 100 Mean = 34; SD = 17 30 40 20 10 54% (n = 54) 47% 36% 17% 54% 44% 61% 38% Mean=4; SD=1 29% 58% 13% Mean = 1,03,404; SD = 1,54,376 38 35 27
Fig. 1. Frequency distribution of access to technology. (Colours are visible in the online version of the article; http://dx.doi.org/ 10.3233/THC-130766)
3.4. Sources of health information The most common sources of health information were doctors (42%; n = 42), family members (11%; n = 11) and friends (9%; n = 9) (Table 2). Internet was the least used source of health information (Table 3).
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S. Priyaa et al. / A pilot study to assess perceptions of using SMS as a medium for health information Table 2 Level of familiarity with the use of technology Variables How familiar are you with using computer? How comfortable do you feel using computers? How often do use a computer? How often do you use Internet? How often do you use your computer at work? How often do you use the internet at work?
Variables Consult a doctor Use a search engine Consult friends Consult family Go to library Through books Consult Wikipedia
Always 42 1 9 11 3 5 3
Not at all familiar 47 Not at all comfortable 44 Daily 23 Daily 24 Daily 16 Daily 14
Responses Somewhat familiar 30 Somewhat comfortable 36 Sometimes 18 Sometimes 17 Sometimes 51 Sometimes 31
Very familiar 23 Very comfortable 20 Never 45 Never 58 Never 3 Never 5
Table 3 Sources of health information Sources of health information Often Sometimes Rarely or never 9 20 24 4 7 36 12 23 39 13 25 37 8 4 43 10 15 44 2 2 31
I don’t know 4 40 16 14 32 23 50
Table 4 Percentage distribution of the individuals spending time spent on mobile phone and its various features Time spent on mobile phone Average in a day Internet/browser/applications Camera Games Text messaging
I do not use 68 59 67 59
3 hours 11
2 8
Results showed that the majority of the study participants agreed that receiving calls on the mobile phones for receiving health messages would be the most preferred method (Fig. 2). Games (23%) and text messaging (21%) were the most common mobile phone related features that were utilized by the study participants. More than half of them (66%; n = 66) were spending high school some college Graduate or Postgraduate less than high school Annual Household Income (INR) 0–50000 50001–100000 above 100000 Familiarity with computer use Not at all comfortable Somewhat comfortable Very comfortable Frequency of computer use Daily Never sometimes Frequency of internet use Daily Never sometimes Internet Access at work Don’t Know No Yes
Would you find it useful to receive SMS based health information or not? Not useful N = 27 Useful N = 73 p value N % N % p = 0.140 10 33.3% 20 66.7% 6 15.0% 34 85.0% 7 35.0% 13 65.0% 4 40.0% 6 60.0% p = 0.244 15 32.6% 31 67.4% 12 22.2% 42 77.8% p = 0.293 16 23.2% 53 76.8% 5 29.4% 12 70.6% 6 42.9% 8 57.1% p = 0.696 12 31.6% 26 68.4% 8 22.9% 27 77.1% 7 25.9% 20 74.1% p = 0.399 13 29.5% 31 70.5% 11 30.6% 25 69.4% 3 15.0% 17 85.0% p = 0.576 7 30.4% 16 69.6% 17 28.8% 31 71.2% 3 16.7% 15 83.3% p = 0.561 5 20.8% 19 79.2% 21 30.4% 40 69.6% 1 14.3% 6 85.7% p = 0.021 7 63.6% 4 36.4% 15 21.7% 54 78.3% 5 25% 15 75.0%
compared to those who did not feel it useful. Results found internet access at work (p = 0.02) as the only significant variable necessary to facilitate receiving health messages. None of the other variables were significant (Table 6). 4. Discussion Our study aimed to understand people’s perception regarding the use of SMS services as an intervention in a rural setting of India. Since mobile phone subscription is increasing at a faster rate with around 4.6 billion subscription globally [6], we found that all the participants have a mobile phone in their household but only 76% of them actually own it. People have mostly used it for text messaging while very few of them have used internet on their phone. Results of our study showed that there was a limited access and usage of technology for obtaining health messages. Majority of the individuals agreed to receive phone calls on the mobile rather than SMS. However more than half of the study participants agreed that SMS based health messages will be useful. One of the reasons of having calls over the mobile phones being preferred than receiving SMS
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based health messages could attribute to high cost of the text messages that still exists in developing countries including India. To the best of our knowledge, this is the first pilot study aimed to explore the role of SMS based health messages in rural population in India. This raises an important challenge that despite the growing rise of mobile phones in rural settings, SMS based health messages might still not be used in practice despite being considered useful. There was limited number of individuals that were inclined to pay for the SMS based health messages. Results also showed that people like to receive health information by consulting their doctors and their family members. There were a growing numbers of individuals who were aware about how technology can be utilized to improve their healthcare. This shows that there is an urgent need to create more awareness about the usefulness and effectiveness of SMS based health messages especially among individuals living in rural settings. Games and text messaging are the most common mobile phone features that are being used by the people. Results of our study are similar to a previous study where games were used to increase participation and promote disease prevention behaviours [12]. Participants were ready to receive health information on their mobile phones in the form of calling messages rather than through internet or any other form. These findings are similar to an earlier study where pregnant women living in rural settings agreed that they would like to receive health information through phone calls rather than through messages [16]. There are several limitations to the current pilot study. One of the limitations is the small sample size, cross sectional nature of the study design, localized to rural settings. These results might not be applicable to individuals living in the urban settings and it would be interesting to explore the impact of the digital divide in adoption of SMS based health messages. The study suggests that individualized ICT based health programs need to be established so that the audience receives the optimal technological platform program necessary to obtain health messages. This also suggests that future research is needed to determine the population that would actually adopt the use of SMS based health interventions rather than using SMS as a tool for delivery of health information to all. Further, there is a need to integrate delivering health messages through use of games and interactive communication strategies as it can be a great mean for potential social change. References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10]
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