Journal of Telemedicine and Telecare http://jtt.sagepub.com/
Design of a community-based mobile phone text message referral intervention in Tanzania John Dusabe, Soori Nnko, John Changalucha, Zaina Mchome, Brenda Kitilya, Gregory Payne, Elisabeth Mapella and Angela Obasi J Telemed Telecare 2013 19: 295 DOI: 10.1177/1357633X13492291 The online version of this article can be found at: http://jtt.sagepub.com/content/19/5/295
Published by: http://www.sagepublications.com
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TAILPIECE
Correspondence
.................................................................................................................................
Design of a community-based mobile phone text message referral intervention in Tanzania
.............................................................. In sub-Saharan Africa, privately-owned drug stores are more accessible than government health facilities and therefore represent the first port of call for many of the poorest people,1 especially for sexual and reproductive health related conditions. Whilst these shops are only licensed to sell non-prescription drugs and are required to be headed by someone with basic medical training, research shows that in Tanzania some drug store attendants have no health related training2 and regularly sell prescription-only medicines without a licence.1,3 We have therefore designed an intervention to facilitate access to prescriptions by patients and drug stores using the mobile phone short-message service (SMS) to improve referral to formal health facilities. Mobile telephony is among the fastest growing resources in Africa. Up to 95% of Tanzania’s population have access to a mobile phone.4 Previous work suggests that mobile phones can improve access to and delivery of health services in sub-Saharan Africa.5,6 Our intervention is designed to improve access to safe prescriptions and uptake of effective reproductive health services.
In addition to sending text messages, we wanted a system in which the data could be accessed by researchers and health workers both within and outside Tanzania. Software was developed by the Minoxsys company to allow access on the software application and the content using an Internet browser. Text messages are received, processed and replies are sent in real time. The data flow in the text messaging system is shown in Figure 1.
Dispensary and drug store selection Dispensaries and health centres were matched with drug stores. Each dispensary or health centre was matched with up to four drug stores in its vicinity. They were matched so that each drug store could only refer its patients to the partner dispensary or health centre. This enables the system to track the patients, drug stores, dispensaries and health centres, ensuring that text-messages from drug stores are only sent to pre-matched facilities and giving patients an opportunity to be referred to dispensaries near them. All dispensaries in the intervention wards were eligible to participate. A total of 15 dispensaries and three health centres in Magu and Sengerema were enrolled. These facilities partnered with three drug stores of their choice each according to the following criteria: (1) located within their catchment areas; (2) trusted, and (3) registered by the Tanzania Food and Drug Authority (TFDA). The TFDA district pharmacists helped the dispensaries to select eligible drug stores.
Study
.............................................................. The intervention is being implemented in two districts (Magu and Sengerema) in the Mwanza Region on the northwest shore of Lake Victoria. It is nested within a larger randomised trial which aims to evaluate the effect of a complex reproductive health intervention on the uptake and integration of reproductive health services in Tanzania and Niger. The SMS intervention is being implemented in one region in Tanzania in a cluster-randomised trial. The study was approved by the appropriate ethics committees.
Text messages The drug store text message includes the patient’s initials, date of birth, sex, symptoms and preferred appointment time at the dispensary. The dispensary text message includes the patient’s ID, clinician’s diagnosis, treatment and advice. Cue cards with disease and treatment codes are used as texting guides. The intervention software matches patient details and creates spreadsheet data which can be exported to a statistical package (STATA).
Evaluation Intervention The SMS intervention was developed in two phases, involving stakeholder consultation followed by the technical design. Twenty-three consultation meetings were held with 78 drug store owners and attendants, 45 dispensary and health centre clinical officers and nurses, and 148 adolescents in communities. These stakeholders prioritised the problems in existing reproductive health provision and suggested strategies to address them. One of the strategies was a managed reproductive health community referral to health facilities using SMS.
The primary outcome measure is the number of patients receiving reproductive health services after referral from drug stores. Secondary outcome measures include the number of patients: (1)
(2)
attending for HIV, sexually transmitted infections (STIs), pregnancy prevention (including numbers of condoms, voluntary counselling and testing, and post-abortion care) and treatment attending for other contraceptives (the pill, intra-uterine devices, injection, female condom and sterilisation where available)
Journal of Telemedicine and Telecare 2013; 19: 295– 297 Downloaded from jtt.sagepub.com at EMORY UNIV on May 24, 2014
J Dusabe et al. SMS intervention in Tanzania
Figure 1 Data flow in the text-messaging referral process
(3) (4)
testing HIV positive (where there is a testing service) diagnosed with STIs (syndromic diagnosis).
In 2010 it was reported that 9% of adolescents (in a sample of 309,291) sought reproductive health services (including HIV, STI, family planning, pregnancy) in 39 health facilities.7 Using the SMS referral intervention, we intend to raise this percentage from 9% to 20%. We estimate that a sample of 136 adolescents seeking reproductive health services after a text message referral would give the study 80% power to detect meaningful changes in access to reproductive health services during a 12-month follow-up period.
Pre-test and training In July and August 2012 we conducted a 7-week test with 16 drug stores, 5 dispensaries and 1 hospital in communities similar to intervention areas. After the successful test, the dispensaries, health centres and drug stores in the intervention communities were trained using a training guide and a toll-free phone number. The intervention began in September 2012.
Discussion
.............................................................. Currently, a total of 44 drug stores, 14 dispensaries and 3 health centres use the system. It takes approximately 50 s to send and receive a text message from the drug store to the dispensary. All participating health facilities have successfully sent or received text messages. The data are exported weekly for analysis in STATA which will be done at the end of implementation. The system also shows
296
maps of all drug stores, dispensaries and health centres in the study. The system has been well received by drug stores and health facilities. The data collection has been efficient, and the information is accessible to the Ministry of Health and the National Institute for Medical Research in Tanzania, the Liverpool School of Tropical Medicine and their partners for monitoring, reporting and process evaluations. The intervention has also been welcomed and accepted by communities. District health authorities have developed ownership of the intervention and participate in follow-up communications with clinical officers in health facilities. Experience to date suggests that health facilities and drug stores work well together. However, our observations suggest that training and orientation of clinical officers and drug store workers, as well as regular follow-ups are necessary for the intervention to work. Its sustainability and cost-effectiveness remain to be established. In conclusion, a managed and intensively implemented text-messaging service can provide rapid access to health data from remote areas in Africa.
John Dusabe , Soori Nnko †, John Changalucha †, Zaina Mchome †, Brenda Kitilya †, Gregory Payne ‡, Elisabeth Mapella § and Angela Obasi Liverpool School of Tropical Medicine, Liverpool, UK; †National Institute for Medical Research, Mwanza, Tanzania; ‡Minoxsys Ltd, London, UK; § Ministry of Health and Social Welfare, Dar es Salaam, Tanzania Correspondence: John Dusabe, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK (Email: [email protected]) DOI: 10.1177/1357633X13492291
Acknowledgements: We thank the researchers, implementers, district officials and health centres, drug Journal of Telemedicine and Telecare Volume 19 Number 5
Downloaded from jtt.sagepub.com at EMORY UNIV on May 24, 2014
2013
J Dusabe et al. SMS intervention in Tanzania
stores and patients involved in this study. Research leading to this paper has received funding from the European Union Seventh Framework Programme and Sainsbury’s Indigo Charitable Trust grant.
References 1 Goodman C, Kachur SP, Abdulla S, Bloland P, Mills A. Drug shop regulation and malaria treatment in Tanzania – why do shops break the rules, and does it matter? Health Policy Plan 2007;22:393 – 403 2 Hetzel MW, Dillip A, Lengeler C, et al. Malaria treatment in the retail sector: knowledge and practices of drug sellers in rural Tanzania. BMC Public Health 2008;8:157
Journal of Telemedicine and Telecare Volume 19 Number 5
3 Viberg N, Mujinja P, Kalala W, et al. STI management in Tanzanian private drugstores: practices and roles of drug sellers. Sexually Transm Infect 2009;85:300 –7 4 Vodafone. Africa: the impact of mobile phones. Available from http://www. vodafone.com/content/index/about/about_us/policy/policy_papers. html (last checked 30 April 2013) 5 Zurovac D, Sudoi RK, Akhwale WS, et al. The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to malaria treatment guidelines: a cluster randomised trial. Lancet 2011;378:795 –803 6 Lemay NV, Sullivan T, Jumbe B, Perry CP. Reaching remote health workers in Malawi: baseline assessment of a pilot mhealth intervention. J Health Commun 2012;17(Suppl. 1):105 –117 7 Obasi AI, Cleophas B, Ross DA, et al. Rationale and design of the MEMA kwa Vijana adolescent sexual and reproductive health intervention in Mwanza Region, Tanzania. AIDS Care 2006;18:311 –322
2013
Downloaded from jtt.sagepub.com at EMORY UNIV on May 24, 2014
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Design of a community-based mobile phone text message referral intervention in Tanzania John Dusabe, Soori Nnko, John Changalucha, Zaina Mchome, Brenda Kitilya, Gregory Payne, Elisabeth Mapella and Angela Obasi J Telemed Telecare 2013 19: 295 DOI: 10.1177/1357633X13492291 The online version of this article can be found at: http://jtt.sagepub.com/content/19/5/295
Published by: http://www.sagepublications.com
Additional services and information for Journal of Telemedicine and Telecare can be found at: Email Alerts: http://jtt.sagepub.com/cgi/alerts Subscriptions: http://jtt.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Sep 5, 2013 What is This?
Downloaded from jtt.sagepub.com at EMORY UNIV on May 24, 2014
TAILPIECE
Correspondence
.................................................................................................................................
Design of a community-based mobile phone text message referral intervention in Tanzania
.............................................................. In sub-Saharan Africa, privately-owned drug stores are more accessible than government health facilities and therefore represent the first port of call for many of the poorest people,1 especially for sexual and reproductive health related conditions. Whilst these shops are only licensed to sell non-prescription drugs and are required to be headed by someone with basic medical training, research shows that in Tanzania some drug store attendants have no health related training2 and regularly sell prescription-only medicines without a licence.1,3 We have therefore designed an intervention to facilitate access to prescriptions by patients and drug stores using the mobile phone short-message service (SMS) to improve referral to formal health facilities. Mobile telephony is among the fastest growing resources in Africa. Up to 95% of Tanzania’s population have access to a mobile phone.4 Previous work suggests that mobile phones can improve access to and delivery of health services in sub-Saharan Africa.5,6 Our intervention is designed to improve access to safe prescriptions and uptake of effective reproductive health services.
In addition to sending text messages, we wanted a system in which the data could be accessed by researchers and health workers both within and outside Tanzania. Software was developed by the Minoxsys company to allow access on the software application and the content using an Internet browser. Text messages are received, processed and replies are sent in real time. The data flow in the text messaging system is shown in Figure 1.
Dispensary and drug store selection Dispensaries and health centres were matched with drug stores. Each dispensary or health centre was matched with up to four drug stores in its vicinity. They were matched so that each drug store could only refer its patients to the partner dispensary or health centre. This enables the system to track the patients, drug stores, dispensaries and health centres, ensuring that text-messages from drug stores are only sent to pre-matched facilities and giving patients an opportunity to be referred to dispensaries near them. All dispensaries in the intervention wards were eligible to participate. A total of 15 dispensaries and three health centres in Magu and Sengerema were enrolled. These facilities partnered with three drug stores of their choice each according to the following criteria: (1) located within their catchment areas; (2) trusted, and (3) registered by the Tanzania Food and Drug Authority (TFDA). The TFDA district pharmacists helped the dispensaries to select eligible drug stores.
Study
.............................................................. The intervention is being implemented in two districts (Magu and Sengerema) in the Mwanza Region on the northwest shore of Lake Victoria. It is nested within a larger randomised trial which aims to evaluate the effect of a complex reproductive health intervention on the uptake and integration of reproductive health services in Tanzania and Niger. The SMS intervention is being implemented in one region in Tanzania in a cluster-randomised trial. The study was approved by the appropriate ethics committees.
Text messages The drug store text message includes the patient’s initials, date of birth, sex, symptoms and preferred appointment time at the dispensary. The dispensary text message includes the patient’s ID, clinician’s diagnosis, treatment and advice. Cue cards with disease and treatment codes are used as texting guides. The intervention software matches patient details and creates spreadsheet data which can be exported to a statistical package (STATA).
Evaluation Intervention The SMS intervention was developed in two phases, involving stakeholder consultation followed by the technical design. Twenty-three consultation meetings were held with 78 drug store owners and attendants, 45 dispensary and health centre clinical officers and nurses, and 148 adolescents in communities. These stakeholders prioritised the problems in existing reproductive health provision and suggested strategies to address them. One of the strategies was a managed reproductive health community referral to health facilities using SMS.
The primary outcome measure is the number of patients receiving reproductive health services after referral from drug stores. Secondary outcome measures include the number of patients: (1)
(2)
attending for HIV, sexually transmitted infections (STIs), pregnancy prevention (including numbers of condoms, voluntary counselling and testing, and post-abortion care) and treatment attending for other contraceptives (the pill, intra-uterine devices, injection, female condom and sterilisation where available)
Journal of Telemedicine and Telecare 2013; 19: 295– 297 Downloaded from jtt.sagepub.com at EMORY UNIV on May 24, 2014
J Dusabe et al. SMS intervention in Tanzania
Figure 1 Data flow in the text-messaging referral process
(3) (4)
testing HIV positive (where there is a testing service) diagnosed with STIs (syndromic diagnosis).
In 2010 it was reported that 9% of adolescents (in a sample of 309,291) sought reproductive health services (including HIV, STI, family planning, pregnancy) in 39 health facilities.7 Using the SMS referral intervention, we intend to raise this percentage from 9% to 20%. We estimate that a sample of 136 adolescents seeking reproductive health services after a text message referral would give the study 80% power to detect meaningful changes in access to reproductive health services during a 12-month follow-up period.
Pre-test and training In July and August 2012 we conducted a 7-week test with 16 drug stores, 5 dispensaries and 1 hospital in communities similar to intervention areas. After the successful test, the dispensaries, health centres and drug stores in the intervention communities were trained using a training guide and a toll-free phone number. The intervention began in September 2012.
Discussion
.............................................................. Currently, a total of 44 drug stores, 14 dispensaries and 3 health centres use the system. It takes approximately 50 s to send and receive a text message from the drug store to the dispensary. All participating health facilities have successfully sent or received text messages. The data are exported weekly for analysis in STATA which will be done at the end of implementation. The system also shows
296
maps of all drug stores, dispensaries and health centres in the study. The system has been well received by drug stores and health facilities. The data collection has been efficient, and the information is accessible to the Ministry of Health and the National Institute for Medical Research in Tanzania, the Liverpool School of Tropical Medicine and their partners for monitoring, reporting and process evaluations. The intervention has also been welcomed and accepted by communities. District health authorities have developed ownership of the intervention and participate in follow-up communications with clinical officers in health facilities. Experience to date suggests that health facilities and drug stores work well together. However, our observations suggest that training and orientation of clinical officers and drug store workers, as well as regular follow-ups are necessary for the intervention to work. Its sustainability and cost-effectiveness remain to be established. In conclusion, a managed and intensively implemented text-messaging service can provide rapid access to health data from remote areas in Africa.
John Dusabe , Soori Nnko †, John Changalucha †, Zaina Mchome †, Brenda Kitilya †, Gregory Payne ‡, Elisabeth Mapella § and Angela Obasi Liverpool School of Tropical Medicine, Liverpool, UK; †National Institute for Medical Research, Mwanza, Tanzania; ‡Minoxsys Ltd, London, UK; § Ministry of Health and Social Welfare, Dar es Salaam, Tanzania Correspondence: John Dusabe, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK (Email: [email protected]) DOI: 10.1177/1357633X13492291
Acknowledgements: We thank the researchers, implementers, district officials and health centres, drug Journal of Telemedicine and Telecare Volume 19 Number 5
Downloaded from jtt.sagepub.com at EMORY UNIV on May 24, 2014
2013
J Dusabe et al. SMS intervention in Tanzania
stores and patients involved in this study. Research leading to this paper has received funding from the European Union Seventh Framework Programme and Sainsbury’s Indigo Charitable Trust grant.
References 1 Goodman C, Kachur SP, Abdulla S, Bloland P, Mills A. Drug shop regulation and malaria treatment in Tanzania – why do shops break the rules, and does it matter? Health Policy Plan 2007;22:393 – 403 2 Hetzel MW, Dillip A, Lengeler C, et al. Malaria treatment in the retail sector: knowledge and practices of drug sellers in rural Tanzania. BMC Public Health 2008;8:157
Journal of Telemedicine and Telecare Volume 19 Number 5
3 Viberg N, Mujinja P, Kalala W, et al. STI management in Tanzanian private drugstores: practices and roles of drug sellers. Sexually Transm Infect 2009;85:300 –7 4 Vodafone. Africa: the impact of mobile phones. Available from http://www. vodafone.com/content/index/about/about_us/policy/policy_papers. html (last checked 30 April 2013) 5 Zurovac D, Sudoi RK, Akhwale WS, et al. The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to malaria treatment guidelines: a cluster randomised trial. Lancet 2011;378:795 –803 6 Lemay NV, Sullivan T, Jumbe B, Perry CP. Reaching remote health workers in Malawi: baseline assessment of a pilot mhealth intervention. J Health Commun 2012;17(Suppl. 1):105 –117 7 Obasi AI, Cleophas B, Ross DA, et al. Rationale and design of the MEMA kwa Vijana adolescent sexual and reproductive health intervention in Mwanza Region, Tanzania. AIDS Care 2006;18:311 –322
2013
Downloaded from jtt.sagepub.com at EMORY UNIV on May 24, 2014
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