Structured Caregiver Feedback Enhances Engagement and Impact of Mobile Health Support: A Randomized Trial in a Lower-Middle-Income Country.

BACKGROUND: Patients' engagement in mobile health (m-health) interventions using interactive voice response (IVR) calls is less in low- and middle-income countries (LMICs) than in industrialized ones. We conducted a study to determine whether automated telephone feedback to informal caregivers ("CarePartners") increased engagement in m-health support among diabetes and hypertension patients in Bolivia. MATERIALS AND METHODS: Patients with diabetes and/or hypertension were identified through ambulatory clinics affiliated with four hospitals. All patients enrolled with a CarePartner. Patients were randomized to weekly IVR calls including self-management questions and self-care education either alone ("standard m-health") or with automated feedback about health and self-care needs sent to their CarePartner after each IVR call ("m-health+CP"). RESULTS: The 72 participants included 39 with diabetes and 53 with hypertension, of whom 19 had ≤6 years of education. After 1,225 patient-weeks of attempted IVR assessments, the call completion rate was higher among patients randomized to m-health+CP compared with standard m-health (62.0% versus 44.9%; p < 0.047). CarePartner feedback more than tripled call completion rates among indigenous patients and patients with low literacy (p < 0.001 for both). M-health+CP patients were more likely to report excellent health via IVR (adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI], 1.07, 6.32) and less likely to report days in bed due to illness (AOR = 0.42; 95% CI, 0.19, 0.91). CONCLUSIONS: In this study we found that caregiver feedback increased engagement in m-health and may improve patients' health status relative to standard approaches. M-health+CP represents a scalable strategy for increasing the reach of self-management support in LMICs.

A study of mobile phone use among patients with noncommunicable diseases in La Paz, Bolivia: implications for mHealth research and development.

BACKGROUND: While global momentum supporting mobile health (mHealth) research and development is increasing, it is imperative to assess the potential fit of mHealth programs in local settings. We describe the penetration of mobile technologies among Bolivian patients with noncommunicable diseases (NCDs) to inform research on mHealth interventions for the Andean region as well as low- and middle-income countries more generally. METHODS: Five-hundred and fifty-nine NCD patients were identified from outpatient clinics affiliated with four hospitals in the cities of La Paz and El Alto. Respondents completed surveys about their use of standard mobile phones and smartphones. Respondents also provided information about their sociodemographic characteristics, health status, and access to care. We used descriptive statistics and logistic regression to understand the variation in mobile phone use across groups defined by patient characteristics associated with health service access and socioeconomic vulnerability. RESULTS: Respondents were on average 52 years of age, 33% had at most a sixth grade education, and 30% spoke an indigenous language in their home. Eighty-six percent owned a mobile phone and 13% owned a smartphone. Fifty-eight percent of mobile phone users sent or received a text message at least once a week. Some mobile phone owners reported connectivity problems, such as lacking mobile signal (9%) or credit to make a call (17%). Younger age, male gender, high health literacy, more years of education, and having fewer previously diagnosed NCDs were positively related to mobile phone ownership. Among mobile phone users, respondents with lower education and other indicators of vulnerability were less likely than their counterparts to report frequent usage of texting services. CONCLUSIONS: Mobile phones have high penetration among NCD patients in La Paz, Bolivia, including among those who are older, less educated, and who have other socioeconomic risk factors. Smartphone use is still relatively uncommon, even among patients who are younger and more educated. While certain patient characteristics such as age or education impact patients' use of text messaging, mobile phone-based mHealth interventions are feasible strategies for increasing NCD patients' access to self-management support between face-to-face clinical encounters.