Cell phones as a health care intervention in Peru: The Cell-PREVEN project
Walter H. Curioso, Universidad Peruana Cayetano Heredia
12 October 2006
Dear editor,
In response to the article, “Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries?” (May 23, 2006), our answer is an empirical ‘yes’.
Author Warren Kaplan wrote that “Asides from recent work in South Africa, there is almost no literature on using mobile telephones as a healthcare intervention for chronic, non-communicable diseases such as cardiovascular disease, diabetes, depression, and for chronic, communicable diseases such as HIV and TB (in developing countries). [1]”
We would like to share our experience with Cell-PREVEN [2], a real-time surveillance system using cell phones to collect data from female sex workers in Peru [3]. Cell-PREVEN is part of a large randomized trial in Peru in 20 cities called PREVEN, which seeks to lower sexually transmitted disease rates in Peru. PREVEN is a collaborative effort between the Universidad Peruana Cayetano Heredia in Lima, Imperial College in London, and the University of Washington in Seattle, in collaboration with Peru’s Ministry of Health [3].
Cell-PREVEN allowed health care workers to enter data in cell phones using an interactive voice response application in Spanish designed with the help of Voxiva Inc., a company applying technology in public health. Health care workers interviewed female sex workers in three communities of Peru regarding adverse events from metronizadole, a medication used to treat bacterial vaginosis, and the information was relayed in real-time to a database.
If there was a severe adverse event such as vomiting, a short text message would be sent to a physician by cell phone, and he or she could respond immediately.
Health care workers received an account number, personal identification number and a plastic card with simple instructions and codes for all the symptoms they need to report. Workers could also leave voice messages regarding their cases. Information was stored in a central database with access by phone or Internet.
Both health care interviewers and female sex workers were satisfied with cell phones as a method of data collection, and the system led to much earlier and more complete reports of adverse effects [4]. Voxiva has used a similar system to monitor adverse events and disease outbreaks in Peru [5], Africa, Iraq, and India [6].
While Kaplan said, “The developed world model of personal ownership of a phone may not be appropriate to the developing world in which shared mobile telephone use is important,” we believe that doesn’t hold true in every place and over time. In Peru, sales of cell phones has jumped from 2.5 million in mid-2003 to 6.8 million by June 2006. [7,8]
In the mid-1990s “cholulares,” a nickname for "cholos con celulares" or people who rent cell phones on the streets, was popular in many cities in Peru [9]. But now, more and more people are acquiring cell phones for their own since they have become more affordable [9]. The same situation is happening throughout the developing world, such as in Zambia, Kenya, and several other African countries where mobile phones are used to make cashless payments [10].
Kaplan also stated that “the cost-effectiveness of telephonic interventions (for health) is not known.” We, however, would like to point out that a cost-analysis evaluation of Alerta, a phone-based surveillance system in Peru [5], found that the Alerta system required 40% lower costs of operations than the traditional paper system, resulted in a threefold increase in reporting coverage over a paper-based system, and that the use of voice mail for communications was around 8 times less expensive than written communication [6].
Cell phones are proving themselves to be an important tool in public health in the developing world. Their utility likely will only increase over time, since cell phones leverage existing telecommunications infrastructures in developing countries, without requiring costly standalone system support. We agree with the author that increased research attention to the appropriate use of cell phone and other communication technologies will advance the evidence base.
Walter H. Curioso, MD, MPH
Universidad Peruana Cayetano Heredia, Lima, Peru
Bobbi Nodell, MA
International Training & Education Center on HIV (I-TECH). University of Washington, Seattle, Washington, USA
Ann Kurth, CNM, PhD
University of Washington, Seattle, Washington, USA
Disclaimer
The opinions and assertions made by the authors do not necessarily reflect the official position or opinion of I-TECH.
References
1. Kaplan WA. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Global Health. 2006 May 23;2:9.
2. The Cell-PREVEN Project. Available at: <a href='http://www.cellpreven.org/'>http://www.cellpreven.org/</a> (Accessed: July13, 2006).
3. Curioso WH, Karras BT, Campos PE, Buendia C, Holmes KK, Kimball AM. Design and Implementation of Cell PREVEN: A Real-Time Surveillance System for Adverse Events Using Cell Phones in Peru. AMIA Annu Symp Proc 2005; 176-180. Available at: <a href='http://faculty.washington.edu/wcurioso/cellpreven.pdf'>http://faculty.washington.edu/wcurioso/cellpreven.pdf</a>
4. Curioso WH. Chapter 18. New Technologies and Public Health in Developing Countries: The Cell PREVEN Project. [Book Chapter] In: The Internet and Health Care: Theory, Research and Practice. Monica Murero and Ronald E. Rice [editors]. Lawrence Erlbaum Associates 2006.
5. Lescano A, Ortiz M, Elgegren R, Gozzer E, Saldarriaga E, Soriano I, Martos I, Mundaca C, Kishimoto G, Negrete M, Batsel TM. Alerta DISAMAR: Innovative disease surveillance in Peru. Paper presented at: Annual Meeting of the American Society of Tropical Medicine and Hygiene. Philadelphia, 2003.
6. Prahalad C. The Voxiva Story. The Fortune at the Bottom of the Pyramid: Eradicating Poverty Through Profits. First printing ed. New Jersey: Wharton School Publishing; 2005:361-379. Available at:
<a href='http://www.voxiva.net/resources/Prahalad.asp'>http://www.voxiva.net/resources/Prahalad.asp</a> Accessed: August 7, 2006.
7. ONGEI. Peru: The use of information and communication technologies. Available in Spanish at:
<a href='http://www.pcm.gob.pe/portal_ongei/publica/indicadores/Lib0365/Libro.pdf'>http://www.pcm.gob.pe/portal_ongei/publica/indicadores/Lib0365/Libro.pdf</a> (In Spanish) Accessed: August 7, 2006.
8. OSIPTEL. Telecommunications in Peru (Statistics) Available at: <a href='http://www.osiptel.gob.pe/Index.ASP?T=P&P=2635'>http://www.osiptel.gob.pe/Index.ASP?T=P&P=2635</a> Accessed: August 7, 2006.
9. Cell phones can call good business. La Republica [Newspaper Online edition].
Available in Spanish at: <a href='http://www.larepublica.com.pe/index.php?option=com_content&task=view&id=119017&Itemid=484'>http://www.larepublica.com.pe/index.php?option=com_content&task=view&id=119017&Itemid=484</a> Accessed: August 7, 2006.
10. Economist (2005), The Real Digital Divide: Leader, March 18. Available at: <a href='http://www.economist.com/opinion/displayStory.cfm?story_id=3742817'>http://www.economist.com/opinion/displayStory.cfm?story_id=3742817</a> Accessed: August 7, 2006.
Competing interests
None declared
Mobile phone transcends barriers in health system -NID in India
Rajesh Sood, National Institute of Epidemiology, Chennai, India
9 May 2008
In health programmes with outreach components, we found mobile phone to be a useful asset in overcoming barriers and improving performance.
Supervision in National Immunisation Days is often not easy and is the weakest link. A supervisior is expected to visit ten house to house teams in a day (often in difficult terrain over sparsely populated hamlets). When the supervisor visits the hamlet, the teams may have not arrieved or have already left, thus hampering corodination and timely feedback. Waiting or huting for the team is not practicable as he/she has to move to the next hamlet and oversee the next team with a limited transport support. Moreover, even if both are present in same area they may not be able to establish contact.
During revising microplannings in one block of District Kangra,in the himalayan region of North India, we noticed this problem and included the mobile number of any of the team members and supervisors. This served as a useful tool for improving communication and contact between the grassroot workers and immediate and higher supervisors, leading to improvement in quality of work through immediate rectification of identified problems. We reccommended upscaling of the initiative.
Limitations:
The area has a high per capita income and high mobile phone ownership which enabled the venture. this may not be areplicable in settings with poverty.
Reimbursing communication costs has not been factored into health programmes and many workers amy not be motivated enough to use their personal phones/ list their personal numbers for a health programme.
As the coverage of mobile network is poor in some underserved areas, some areas will still be left uncovered.
However if mobile phones are provided to health care staff and allowance for reccuring costs, (as in Tamil Nadu, a southern state in India), the approach is highly useful.
Globalization and Health
Cell phones as a health care intervention in Peru: The Cell-PREVEN project
12 October 2006
Dear editor,
In response to the article, “Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries?” (May 23, 2006), our answer is an empirical ‘yes’.
Author Warren Kaplan wrote that “Asides from recent work in South Africa, there is almost no literature on using mobile telephones as a healthcare intervention for chronic, non-communicable diseases such as cardiovascular disease, diabetes, depression, and for chronic, communicable diseases such as HIV and TB (in developing countries). [1]”
We would like to share our experience with Cell-PREVEN [2], a real-time surveillance system using cell phones to collect data from female sex workers in Peru [3]. Cell-PREVEN is part of a large randomized trial in Peru in 20 cities called PREVEN, which seeks to lower sexually transmitted disease rates in Peru. PREVEN is a collaborative effort between the Universidad Peruana Cayetano Heredia in Lima, Imperial College in London, and the University of Washington in Seattle, in collaboration with Peru’s Ministry of Health [3].
Cell-PREVEN allowed health care workers to enter data in cell phones using an interactive voice response application in Spanish designed with the help of Voxiva Inc., a company applying technology in public health. Health care workers interviewed female sex workers in three communities of Peru regarding adverse events from metronizadole, a medication used to treat bacterial vaginosis, and the information was relayed in real-time to a database.
If there was a severe adverse event such as vomiting, a short text message would be sent to a physician by cell phone, and he or she could respond immediately.
Health care workers received an account number, personal identification number and a plastic card with simple instructions and codes for all the symptoms they need to report. Workers could also leave voice messages regarding their cases. Information was stored in a central database with access by phone or Internet.
Both health care interviewers and female sex workers were satisfied with cell phones as a method of data collection, and the system led to much earlier and more complete reports of adverse effects [4]. Voxiva has used a similar system to monitor adverse events and disease outbreaks in Peru [5], Africa, Iraq, and India [6].
While Kaplan said, “The developed world model of personal ownership of a phone may not be appropriate to the developing world in which shared mobile telephone use is important,” we believe that doesn’t hold true in every place and over time. In Peru, sales of cell phones has jumped from 2.5 million in mid-2003 to 6.8 million by June 2006. [7,8]
In the mid-1990s “cholulares,” a nickname for "cholos con celulares" or people who rent cell phones on the streets, was popular in many cities in Peru [9]. But now, more and more people are acquiring cell phones for their own since they have become more affordable [9]. The same situation is happening throughout the developing world, such as in Zambia, Kenya, and several other African countries where mobile phones are used to make cashless payments [10].
Kaplan also stated that “the cost-effectiveness of telephonic interventions (for health) is not known.” We, however, would like to point out that a cost-analysis evaluation of Alerta, a phone-based surveillance system in Peru [5], found that the Alerta system required 40% lower costs of operations than the traditional paper system, resulted in a threefold increase in reporting coverage over a paper-based system, and that the use of voice mail for communications was around 8 times less expensive than written communication [6].
Cell phones are proving themselves to be an important tool in public health in the developing world. Their utility likely will only increase over time, since cell phones leverage existing telecommunications infrastructures in developing countries, without requiring costly standalone system support. We agree with the author that increased research attention to the appropriate use of cell phone and other communication technologies will advance the evidence base.
Walter H. Curioso, MD, MPH
Universidad Peruana Cayetano Heredia, Lima, Peru
Bobbi Nodell, MA
International Training & Education Center on HIV (I-TECH). University of Washington, Seattle, Washington, USA
Ann Kurth, CNM, PhD
University of Washington, Seattle, Washington, USA
Disclaimer
The opinions and assertions made by the authors do not necessarily reflect the official position or opinion of I-TECH.
References
1. Kaplan WA. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Global Health. 2006 May 23;2:9.
2. The Cell-PREVEN Project. Available at: <a href='http://www.cellpreven.org/'>http://www.cellpreven.org/</a> (Accessed: July13, 2006).
3. Curioso WH, Karras BT, Campos PE, Buendia C, Holmes KK, Kimball AM. Design and Implementation of Cell PREVEN: A Real-Time Surveillance System for Adverse Events Using Cell Phones in Peru. AMIA Annu Symp Proc 2005; 176-180. Available at: <a href='http://faculty.washington.edu/wcurioso/cellpreven.pdf'>http://faculty.washington.edu/wcurioso/cellpreven.pdf</a>
4. Curioso WH. Chapter 18. New Technologies and Public Health in Developing Countries: The Cell PREVEN Project. [Book Chapter] In: The Internet and Health Care: Theory, Research and Practice. Monica Murero and Ronald E. Rice [editors]. Lawrence Erlbaum Associates 2006.
5. Lescano A, Ortiz M, Elgegren R, Gozzer E, Saldarriaga E, Soriano I, Martos I, Mundaca C, Kishimoto G, Negrete M, Batsel TM. Alerta DISAMAR: Innovative disease surveillance in Peru. Paper presented at: Annual Meeting of the American Society of Tropical Medicine and Hygiene. Philadelphia, 2003.
6. Prahalad C. The Voxiva Story. The Fortune at the Bottom of the Pyramid: Eradicating Poverty Through Profits. First printing ed. New Jersey: Wharton School Publishing; 2005:361-379. Available at:
<a href='http://www.voxiva.net/resources/Prahalad.asp'>http://www.voxiva.net/resources/Prahalad.asp</a> Accessed: August 7, 2006.
7. ONGEI. Peru: The use of information and communication technologies. Available in Spanish at:
<a href='http://www.pcm.gob.pe/portal_ongei/publica/indicadores/Lib0365/Libro.pdf'>http://www.pcm.gob.pe/portal_ongei/publica/indicadores/Lib0365/Libro.pdf</a> (In Spanish) Accessed: August 7, 2006.
8. OSIPTEL. Telecommunications in Peru (Statistics) Available at: <a href='http://www.osiptel.gob.pe/Index.ASP?T=P&P=2635'>http://www.osiptel.gob.pe/Index.ASP?T=P&P=2635</a> Accessed: August 7, 2006.
9. Cell phones can call good business. La Republica [Newspaper Online edition].
Available in Spanish at: <a href='http://www.larepublica.com.pe/index.php?option=com_content&task=view&id=119017&Itemid=484'>http://www.larepublica.com.pe/index.php?option=com_content&task=view&id=119017&Itemid=484</a> Accessed: August 7, 2006.
10. Economist (2005), The Real Digital Divide: Leader, March 18. Available at: <a href='http://www.economist.com/opinion/displayStory.cfm?story_id=3742817'>http://www.economist.com/opinion/displayStory.cfm?story_id=3742817</a> Accessed: August 7, 2006.
Competing interests
None declared
Mobile phone transcends barriers in health system -NID in India
9 May 2008
In health programmes with outreach components, we found mobile phone to be a useful asset in overcoming barriers and improving performance.
Supervision in National Immunisation Days is often not easy and is the weakest link. A supervisior is expected to visit ten house to house teams in a day (often in difficult terrain over sparsely populated hamlets). When the supervisor visits the hamlet, the teams may have not arrieved or have already left, thus hampering corodination and timely feedback. Waiting or huting for the team is not practicable as he/she has to move to the next hamlet and oversee the next team with a limited transport support. Moreover, even if both are present in same area they may not be able to establish contact.
During revising microplannings in one block of District Kangra,in the himalayan region of North India, we noticed this problem and included the mobile number of any of the team members and supervisors. This served as a useful tool for improving communication and contact between the grassroot workers and immediate and higher supervisors, leading to improvement in quality of work through immediate rectification of identified problems. We reccommended upscaling of the initiative.
Limitations:
The area has a high per capita income and high mobile phone ownership which enabled the venture. this may not be areplicable in settings with poverty.
Reimbursing communication costs has not been factored into health programmes and many workers amy not be motivated enough to use their personal phones/ list their personal numbers for a health programme.
As the coverage of mobile network is poor in some underserved areas, some areas will still be left uncovered.
However if mobile phones are provided to health care staff and allowance for reccuring costs, (as in Tamil Nadu, a southern state in India), the approach is highly useful.
Competing interests
None