A phone screen showing part of the response to a text sent to 6001

Introduction

There has been a tremendous increase in mobile phone diffusion in developing countries. Statistics from the International Telecommunication Union (2007) suggests that there are now more mobile phone users in the developing world than in the developed world. In countries like Uganda, it is estimated that, there are mobile phone subscriptions have increased by 1700 percent between 2002 and 2008; the mobile phone subscriptions per 100 inhabitants in 2002 was 1.51, and that of 2008 was 27.2 (ITU, 2008). This phenomenal global diffusion of mobile phones in developing countries has sparked debates on how developing countries can effectively harness this innovation for development (Heeks and Jagun, 2008).

It has been argued that mobile phones have a multi-stranded impact on the poor and hence there is a need for a more comprehensive approach to conceptualize the link between mobiles and development (Duncome and Boateng, 2009; Boateng, 2010).

Our attempt to address this imbalance begins with a study on exploring the use of mobiles in health care in a developing country, Uganda. The need for affordable and accessible health care services in sub-Saharan Africa (SSA) and its rural areas is critical. The current health statistics are not encouraging. First, the primary challenge is the lack of well-trained medical health professionals and facilities. Many rural areas are without physicians especially specialists. On an average, most countries in SSA have less than 20 doctors per 100,000 people and a majority of new medical doctors and nurses seek for jobs in richer countries (WHO, 2006; WHO, 2008). Moreover, where accessibility to health care exists, affordability becomes another issue. The inhabitants of SSA only spend an average of US$ 6 per capita compared to US$ 287, US$ 250 and US$ 273 per capita, respectively in the United States, the European Union and Japan (WHO, 2008). Health care services are therefore beyond the reach and means of many rural areas. Second, sub-Saharan Africa’s epidemics vary significantly from country to country in both scale and scope. Recent statistics suggest that diabetes and HIV seem to be the overriding health problem in this sub region of the world. An estimated 1.9 million people were newly infected with HIV in sub-Saharan Africa in 2007. In total, 22 million people are living with HIV in the region, which is two thirds (67%) of the global population of people with HIV (AVERT, 2008). Another killer disease that is plaguing SSA is malaria. Approximately 60% of the population of SSA live in endemic areas and are at risk for malaria. 9 out of 10 of malaria deaths occur in sub-Saharan Africa, the majority being children. Further, the WHO estimates that in every 30 seconds a child dies of malaria in Africa (WHO, 2009a). The socio-economical impact of this situation is felt across sectors of activities – agriculture, education, industry, transport, and human resources.

 

With these resource challenges, a preventive approach to healthcare in sub-Saharan Africa. However, health education, which plays a major role in the prevention of many diseases, is often ineffective or nonexistent. E-medicine has been proposed as a reasonable approach that offers a set of new and innovative health solutions applicable to resource-poor environments (Kifle et al., 2006; Kingue et al. 2008). E-medicine is defined as the use of telecommunication and information technology to provide health care to people who are separated by geography and distance from the provider. In these resource-poor settings, the approach is to examine how low-cost, low-tech and more accessible technologies like telephones and mobile phones can be used to enhance efforts in a preventive approach to healthcare. Such technologies underpin opportunities for health education and monitoring patient compliance. E-medicine opens a new avenue to address and fill the existing gap.

Our study seeks to explore the preliminary lessons in the use of mobiles to promote access to health care information in Uganda. The project under study is the AppLab Uganda Project. The Application Laboratory is an initiative of the Grameen Foundation. AppLab Uganda leverages MTN’s network of over 10,000 Village Phone Operators to test and deliver mobile information services to rural communities. Grameen Foundation, Google, and MTN Uganda have been working together since September, 2007 to build the physical, human, and technological infrastructure needed to support the initiative. In Uganda, the AppLab runs The Health Tips Application which educates users by answering common questions about sexual and reproductive health. It provides users with timely, trusted, accurate, and actionable information. The application also provides information on sexual and reproductive topics pertinent to adolescents, such as body changes and sexual abstinence. The project completed its pilot phase in 2009 and has since been rolled-out nationally.

This study explores the impact or ‘potential impact’ of the Health care Tips Application in health care in Uganda. It details the health care outcomes and the challenges in deploying and managing the application in the developing country. The underpinning research question of this study is, how can mobile phones be used to support health care activities and what is the potential impact?

Research Methods

The study used a mixed methods approach. First, a case study approach to document AppLab project and develop in-depth understanding of the usage and impact of Google SMS Health Tips Application (GSHTA) among a cross-section of users. Data was obtained through 13 semi-structured interviews with the project manager of the AppLab project; two personnel of the MTN Village Phone project; a representative of one of the content developers, Straight Talk; and with nine users comprising of three students, two lecturers, two information technology (IT) journalists, one IT manager and one medical doctor. A focused group discussion was also conducted with six of the users and the project manager of the AppLab project. The objective of the focus group was to create a forum for discussing the project objectives and user perceptions and experiences. Interviews were recorded, transcribed and coded into themes to develop constructs explaining the usage and impact of GSHTA.

Second, in a follow-up to the case study, a survey was conducted on the usage and impact of GSHTA on larger population of potential users. The survey sought to test the strength of the constructs from the case study on a larger population of users. The potential users were randomly selected from two campuses of two leading tertiary educational institutions in Kampala, Uganda. Educational institutions were selected as an appropriate site for study since GSHTA was primarily targeted to young adults. The 20 item questionnaire was administered to 149 users. The response rate was a minimum of 95 percent across all the questions on the questionnaire. Data was analysed through a descriptive statistics – frequency and cross-tabulation – to develop understanding mobile phone usage behaviour of users and the usage and impact of GSHTA.

 

About Uganda

Located at the geographical heart of Africa, Uganda is a cultural melting pot with more than 30 different indigenous languages. This country, known as the “Pearl of Africa,” is appreciated for its scenery, large gorilla populations, and national parks. With a national population of 32 million, its capital Kampala services the diverse cultural mosaic of music, art, and heritage.

Since President Yoweri Museveni’s electoral victory in 1986, Uganda has experienced relative stability and economic growth, shown by its expansion of roads and communications and increase in international tourist arrivals. More than 80% of the workforce is employed through the agriculture sector. However, Uganda’s services industry accounts for more than 50% of the nation’s gross domestic product (GDP). The landlocked country contains natural resources, including fertile soils, regular rainfall, copper, and gold.

Joseph_Munuulo_and_SheilaNearly 50% of the nation’s population is between the ages of 15-64. With an average 53-year life expectancy at birth, Ugandans are faced with healthcare issues deriving from infectious diseases such as, malaria, Hepatitis A, and typhoid fever. Uganda is a successful model for Africa in the fight against the HIV/AIDS epidemic. In the 1990s, the HIV/AIDS prevalence rate was nearly 29% in urban areas. The current HIV/AIDS prevalence in Uganda is estimated at 7%. Government leadership, broad-based partnerships, and effective public education campaigns all contributed to the decline. Despite the remarkable decrease, an estimated 1.1 million people are still living with HIV/AIDS in Uganda, which includes 120,000 children. Devastating consequences, including social and economic, continue to affect the country. In 2008, 61,000 people died from AIDS and 1.2 million children were orphaned.

Uganda has a strong cultural heritage since people from various origins inhabit the region. The residents are hospitable, and each of the native tribes has its own song and dances for various occasions. Traditions also are expressed through a wide range of arts and crafts made from wood and papyrus reeds.

AppLab Uganda’s Health Care Applications

AppLab Uganda is made possible through collaboration between Grameen Foundation, Google and MTN Uganda. This partnership taps into the core expertise of each organization. The Grameen Foundation has extensive experience using technology as an enabler for building sustainable and scalable business models designed to improve the lives and livelihoods of the poor. Google is the worldwide leader in search technology, organizing the world’s information and making it accessible. MTN operates the platform of Village Phone Operators and Shared Phone Operators in Uganda – a unique distribution channel for reaching underserved markets, as well as the communication infrastructure serving the whole country.

 

AppLab Uganda provides a service known as Google SMS. Google SMS is a group of mobile applications that allows users to find information. Google SMS facilitates three applications – Information Tips Application, General Web Search and Google Trader – in Uganda. The information tips application allows users to simply text message a search query to 6001, and the application will text message back the results. Users can use this SMS application to obtain information on health care and agriculture. The General web search application users to search for anything on the worldwide web through Google SMS. Users text queries to 6007. The Google Trader application is a trading platform were users can buy and sell goods and services through SMS. Users register, make submissions and query the trading platform by texting to 6002. Google SMS is currently free from Google but charges from your carrier for usage may apply. Text queries to the Information Tips application (6001) are also currently free.

This study focuses on the use of Google SMS in health care. Google SMS Health Tips and Google SMS Clinic Finder enable users to find a information on sexual and reproductive health care and to locate health care facilities in Uganda respectively. Uganda has a high demand for information on HIV/AIDS, sexually transmitted infections, and reproductive health. Uganda’s Ministry of Health estimates the adult prevalence of HIV/AIDS (15-49 years) in 2005 was 7.0% (Uganda HIV/AIDS Sero-Behavioural Survey, May 2005). The accuracy of information sexual and reproductive health care is essential to dispel local myths and help them make informed decisions. The Health Tips Application educates users by answering common questions about sexual and reproductive health. It is aimed that the information provided should be timely, accurate and actionable. For example, users can text “Health pregnancy” to learn what to do if you are pregnant and how to prepare for a safe labor.

The Clinic Finder offers a directory providing the details of local clinics, including the types of services offered as well as the hours of operation. This searchable directory makes it easier for users to find appropriate medical assistance. For example, users can text “Clinic Kampala” to locate health facilities in Kampala. The application also enables patients to find answers to questions that arise after treatment.

The content for the health care tips application is provided through two local partners; Marie Stopes Foundation Uganda and Straight Talk. Marie Stopes Uganda is a leader in Sexual and Reproductive Health and provides content for the Health Tips and Clinic Finder Service. Straight Talk is a leader in health communication in Uganda and provides content for the Health Tips and Clinic Finder Service.

 

How Mobile Phones Support Health Care

Figure 1 Conceptual Model of Mobile Phones in Health Care in Uganda

The above model proposes that through applications mobiles phones can be used to support preventive and curative health care activities. Preventive health care activities cover health education and promotion to prevent the occurrence of illness or curb and control the outbreak of illness. Curative care activities cover treatment and post-treatment activities. Curative care also includes information and communication strategies which will enhance compliance to medical regimens and recommendations. We conceptualize mobile phones to have two effects – incremental and transformative – on compliance intervention strategies. Incremental effects characterize the effects from using mobile phones to enhance current preventive and curative health care activities. For example, mobile phones may enhance activities such as telephone education, feedback, scheduled appointments, monitoring, and reminders. In the case of the Google SMS it is primarily used to educate and provide information to access health facilities.

Transformative effects characterize effects from using mobile phones to create something new – new forms of compliance intervention strategies. Transformative effects may include developing new mobile-driven multi-media education strategies, goals and means to change the schemes of thought. For example, “Text to Change,”- is a health non-profit organization running a project in Uganda, where the focus is on HIV/AIDs education as well as the promotion of HIV Counseling and Testing (HCT) services (TextToChange, 2008). In a six week pilot project targeted at 15,000 participants, a total of 255 participants came for HCT services and the response rate for the pilot quiz was on average 17.4% per question. The mobile-enabled HIV/AIDs education contributed to behavior to access HCT services among 255 participants. These examples demonstrate the transformative effects mobile phones may have on health care activities.

Based on the model the underpinning research question of this study is,
How can mobile phones be used to support health care activities and what is the potential impact?

Then as a follow up we also ask that,
What are inherent barriers (individual and environmental) to access to health care information and how mobile phones help to address these barriers?

 

Key Field Notes

We will investigate

  • The motivations behind the project and roles of the partners in Uganda
  • How the AppLab works?
  • What has been the impact – how has the target audience responded to it? Do Ugandan’s know about it and how often do they use it? Do Ugandan’s find it useful?
  • What are challenges in implementing it?
  • What have been the health care outcomes? What is the perspective of medical doctors and other health professionals concerning the project?
  • Are there any privacy concerns when people access the service through the MTN village phone project?

The AppLab project also focuses on trading and weather information, however, our focus is health care.
To read more about the project, visit –

Interview subjects and Institutions we may need to visit and interview:
a) MTN Village Phone Project Office

  • Interviews and purchase one of the village phone for documentation and exhibit in our research office.

b) Grameen Foundation Uganda – AppLab Team

  • Interviews and demonstrations

c) Marie Stopes Uganda

  • Interviews and follow-ups on their contribution to the project

d) Medical Professionals – nurses, doctors and medical students

  • Interviews (5) on the views and perspectives concerning the project and also case stories of how it helped in emergency situations

e) MTN Village Phone Operators

  • Observe and Interview (10) on the views and perspectives concerning the village phone project, its impact on their livelihoods and use of the Village phone for health care tips (enquiries)

e) Different members of general public – lecturers, students, workers, taxi drivers and et cetera

  • Interviews on the use of mobile phones for medical information, and emergencies; their knowledge of the Health care Tips short code (6001) and the frequency of usage and how it is has helped.

PROJECT COORDINATORS

Richard Boateng, PhD, ICITD, Southern University, USA
Victor Mbarika, PhD, ICITD, Southern University, USA
Waswa Balunywa, PhD, Makerere University Business School, Uganda
Stephen Robert Isabalija, ICITD, Southern University, USA
Carlos Thomas, ICITD, Southern University, USA

RESEARCH TEAM

Southern University, USA
LaKenya Simpson, Brenda Wu and Shayla Price

Makerere University Business School, Uganda
Charles Olupot, Joseph Munuulo, Mariam Naku, and Nulu Naluyombya

PC Tech Magazine, Uganda
Albert Mucunguzi and Sandra Kukundakwe

DISCLAIMER

This material is based upon work supported by the National Science Foundation under Grant No. 0927688. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.