Innovative solutions: mHealth and contraception use
What is mHealth? In this step Dr Chris Smith explores its definition and how can mobile technologies be used in the context of healthcare. Since the first commercially available handheld mobile phone was officially unveiled in 1983 1, today worldwide mobile phone subscriptions have grown to 92 per 100 people in low- and middle-income countries and 122 per 100 people in high-income countries 2. Mobile phones have additionally evolved from devices to make phone calls and text messages in the 1990s 3 to smartphones in the 21st century, enabling interactivity and exchange of information, text, data and images 4.
The term ‘mHealth’ was defined by the WHO as: ‘medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices’ 5 or to put it more simply, mHealth can be considered as interventions delivered by mobile phone to improve health.
What differentiates mHealth from interventions delivered by landline phones or call centres is the ‘mobile’ aspect. Mobile interventions have a range of advantages over face-to-face or landline phone delivery, such as the ability to deliver support inexpensively wherever the person is located and just as it is needed6. In particular, mHealth interventions have the potential to reach out to youth and rural populations where geographical distances can restrict access to services 7. mHealth interventions can further utilise the varying functions of modern mobile devices and involve different modes of communication, spanning text, voice, and online messaging 8.
Free, et al’s conceptual framework provides an overview of the different ways in which mHealth interventions are being used, for example to improve chronic disease management, medication adherence, appointment attendance, or to change health behaviour.(Figure 1)6.
Evidence for interventions delivered by mobile phone
A number of articles have assessed the evidence for mHealth interventions in high and low-income settings7,9. The txt2stop intervention, comprising personalised text messages, was associated with smoking cessation in the UK and was shown to be cost-effective 10,11, while a trial in Kenya found that a text message and phone counselling intervention increased antiretroviral therapy (ART) medication adherence 12.
mHealth and contraception
mHealth interventions have the potential to support contraceptive use by provision of information and support to women, particularly in rural areas where healthcare services might be less accessible. Several trials have been conducted to evaluate mHealth interventions in this context 13. One trial in the USA reported improved self-reported oral contraceptive pill continuation at six months from an intervention comprising a range of interactive text messages 14. However, simple text message reminders had no effect on missed pills in a small trial in the USA 15.
Another trial in the USA found that text message reminders improved attendance for the first, but not subsequent Depo-Provera contraceptive injection appointments. No change in contraception use was reported among users of an acne medication from a text message and postal mail intervention in Israel 16.
The MObile Technology for Improved Family Planning (MOTIF) trial in Cambodia found that interactive voice messages and phone counsellor support increased use of effective contraception at four months post abortion, but not at 12 months. However, use of long-acting contraception, such as an implant, IUD, or permanent method was increased at both follow-up times 17.
An evaluation of the Mobile for Reproductive Health (m4RH) service in Kenya found that provision of information on contraception methods, a searchable database of clinics offering family planning services, and serial ‘role model’ stories about a person facing a difficult family planning issue via text message increased contraceptive knowledge but not use 18. The m4RH programme also published one of the few articles exploring strategies for mHealth programme sustainability to consider different strategies for cost-recovery 19. There are several ongoing trials of interventions delivered by mobile phone to improve contraception use in Bangladesh, Palestine, Tajikistan, and Bolivia which will add to the evidence base in time 20-23.
In addition to the aforementioned trials, a number of other mHealth contraception initiatives have been launched including FamPlan, a hotline in the Philippines that allows users to ask questions via text message 24, and numerous mobile phone applications such as CycleTel, using the standard days family planning method, and MyPill for oral contraceptive reminders 25-27.
In conclusion, it can be observed that the field of mHealth is a dynamic one with a growing evidence base. The trials of ART adherence and contraception are encouraging in that they demonstrate that mHealth interventions can be delivered to a group in which confidentiality and privacy are important. In general it would seem that more complex and intensive interventions appear to be more effective than more simple ones such as one-way medication reminders, and this is consistent with existing adherence research 7,28.
Most reviews and trials have focused on health outcomes. Whilst evidence for mHealth interventions on health outcomes is increasing, few studies reported on their cost-effectiveness. This may be a contributing factor to why the majority of interventions delivered by mobile phone have not been scaled up 19,29,9. Further research on mHealth interventions to increase contraception use could help to address these research gaps.
© London School of Hygiene & Tropical Medicine 2019