Background
The Global Observatory for eHealth defines mobile health (mHealth) as medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices [
1]. The United Nations Joint Program on HIV/AIDS (UNAIDS) encourages the use of mHealth in addressing human immunodeficiency virus (HIV) related illnesses and treatments in resource-limited settings [
2],[
3]. According to the International Telecommunications Union, the number of mobile-broadband subscriptions has reached 2.3 billion worldwide in 2014, with 55% of subscriptions based in developing countries. Africa leads in mobile-broadband growth [
4]. MHealth is increasingly recognized as an effective adjunct to HIV control measures [
5],[
6]. Cameroon, a sub-Saharan African country, has seen the proportion of mobile phone users increase rapidly [
4],[
7] as elsewhere in Africa [
8], with 60% of the Cameroonian population owning a mobile phone in 2012 [
9]. The use of mobile phones has shown effectiveness in health related behavior change, in screening campaigns, and as a supportive tool in treatment, diagnosis, and data collection [
3],[
6],[
10]-[
23]. Challenges to the implementation of mHealth include lack of mobile phone ownership and an inability to communicate in national official languages (NOL) both via mobile phone call (oral) and mobile phone text message (SMS) (written). In 2011, about two-third of the adult population in Cameroon were literate [
8]. An individual’s unwillingness to use a mobile phone for health-related communications represents another barrier to acceptance of mHealth. In certain resource-limited settings adherence to mHealth has been shown to be high, despite potential obstacles [
6],[
24]-[
26].
Notwithstanding the proven benefits of the use of mobile phones in the fight against HIV, challenges to implementation remain. Before adopting mobile technologies into the clinical arena, it is imperative to know exactly what e-health architecture to employ within a health system [
18]. In Cameroon, the challenges that need to be addressed to effectively and efficiently implement SMS and mobile phone calls in pediatric HIV care remain undefined. In the recently reported MORE CARE (Mobile Reminders for Cameroonian children Requiring HIV treatment) study, we investigated the efficacy and efficiency of mobile phone appointment reminders on the attendance of HIV-exposed or infected children at their previously scheduled follow-up medical appointments [
27]. The aim of the present study was to evaluate three factors as potential obstacles to the implementation of using mobile phones (SMS and calls) as medical appointment reminder tools for HIV-exposed and HIV-infected children in Cameroon. More specifically, we sought to investigate the extent of mobile phone non-ownership, the inability to communicate in a NOL, and the refusal to receive mobile phone reminders as variables influencing the acceptance of mobile phones as part of mHealth.
Results
We enrolled 301 subjects: 119, 142, and 40 respectively in rural, semi-urban and urban areas. Table
1 shows the general characteristics of the study population. The mean age of caregivers was 42.9 years (SD 13.4) and 46 caregivers (15.3%) were male. Most of them, 148 (49.2%) had completed a primary level of education.
Table 1
General characteristics and obstacles to the use of mobile phone reminders for mHealth in Cameroon
General characteristics
| | | | |
Children | | | | |
- Mean age, years | 3.6 (3.8) | 2.6 (4.0) | 3.0 (3.7) | 3.1 (3.9) |
- Boys | 46 (38.7) | 70 (49.3) | 27 (67.5) | 143 (47.5) |
Caregivers | | | | |
- Mean age, years | 42.2 (12.9) | 43.1 (13.7) | 43.8 (13.8) | 42.9 (13.4) |
- Men | 22 (18.5) | 19 (13.4) | 5 (12.5) | 46 (15.3) |
Caregivers level of education | | | | |
- No formal | 34 (28.6) | 39 (27.5) | 8 (20.0) | 81 (26.9) |
- Primary | 55 ( 46.2) | 67 (47.2) | 26 (65.0) | 148 (49.2) |
- Secondary | 16 (13.4) | 23 (16.2) | 4 (10.0) | 43 (14.3) |
- University | 14 (11.8) | 13 (9.2) | 2 (5.0) | 29 (9.6) |
Time to scheduled appointment, days | 32.1 (17.7) | 27.7 (12.5) | 27.8 (15.9) | 29.5 (15.3) |
Obstacles
| | | | |
At least one obstacle | 47 (39.5) | 9 (6.3) | 3 (7.5) | 59 (19.6) |
Without mobile phone | 14 (11.8) | 1 (0.7) | 0 | 15 (5.0) |
Unable to communicate via text message in NOL | 41 (34.5) | 5 (3.5) | 1 (2.5) | 47 (15.6) |
Unable to communicate via voice phone call in NOL | 27 (22.7) | 4 (2.8) | 0 | 31 (10.3) |
Declined to receive text message | 3 (2.5) | 5 (3.5) | 3 (7.5) | 11 (3.7) |
Declined to receive voice phone call | 0 | 2 (1.4) | 1 (2.5) | 3 (1.0) |
This study revealed that 80.1% of the study population did not present any of the obstacles to receiving mobile phone reminders. Regarding each study site, the distribution of the absence of obstacles was: 60.5% in rural, 93.7% in semi - urban, and 92.5% in urban settings. The greatest obstacle was the inability to read an SMS message (15.6%) followed by the inability to communicate orally (10.3%) in NOL. Very few caregivers refused to receive a SMS (3.7%) or a phone call (1.0%) to remind them of the child’s upcoming medical appointment. The extent of non-possession of a mobile phone was also low (5.0%) (Table
1).
The occurrence of at least one obstacle to mobile reminders was more frequent in rural than in semi-urban (
p <0.001) and urban (
p <0.001) areas. Caregivers without a mobile phone were more common in rural than in semi-urban (
p <0.001) and urban (
p = 0.03) areas. The inability to use a NOL for text messaging was more prevalent among caregivers living in a rural area as compared to caregivers living in semi-urban (
p <0.001) and urban (
p = 0.002) areas. There were no differences between geographic areas regarding the refusal to receive text messaging reminder and voice phone call reminders. Also, there was no difference between urban and semi-urban areas regarding the mHealth impediments we evaluated (Table
2).
Table 2
Comparison of impediments to mobile phone reminders for mHealth between sites (
p
values) in Cameroon
At least one obstacle | .73 | < .001 | < .001 |
Without mobile phone | 1.0 | .03 | < .001 |
Unable to communicate via text message in NOL | 1.0 | < .001 | < .001 |
Unable to communicate via voice phone call in NOL | .58 | .002 | < .001 |
Reject to receive text message | .57 | .51 | .73 |
Reject to receive voice phone call | .53 | .06 | .75 |
Non-ownership of a mobile phone was associated with geographic areas of residence (
p <0.001), and with the inability to use a NOL for text messaging (
p <0.001) and voice phone calling (
p <0.001) (Table
3). There was no association between caregiver age, sex, level of education attained, or time until the scheduled appointment and the refusal to receive appointment reminder by text message or voice phone call (Table
4). Impediments to using SMS were not significantly different than those to using voice phone calls (Table
5).
Table 3
Comparison of adult caregivers of children requiring follow-up medical care for HIV with and without mobile phone
Sites | | | |
- Rural | 105 (36.7) | 14 (93.3) | < .001 |
- Semi-urban | 141 (49.3) | 1 (6.7) |
- Urban | 40 (14.0) | 0 |
Caregivers mean age, years | 42.6 (13.5) | 46.9 (11.5) | .23 |
Caregivers male | 43 (15.0) | 3 (20.0) | .71 |
Caregivers level of education | | | |
- No formal/Primary | 219 (76.6) | 10 (66.7) | .36 |
- Secondary/University | 67 (23.4) | 5 (33.3) |
Unable to communicate via text message in NOL | 38 (13.3) | 9 (60.0) | < .001 |
Unable to communicate via voice phone call in NOL | 24 (8.4) | 7 (46.7) | < .001 |
Declined to receive text message | 9 (3.1) | 2 (13.3) | .09 |
Declined to receive voice phone call | 3 (1.0) | 0 | 1.0 |
Table 4
Comparison between adult caregivers who rejected or adhered to SMS/voice phone call reminders
Caregivers’ age, years | 50.0 (11.9) | 42.6 (13.4) | .07 | 42.9 (13.4) | 38.3 (11.5) | .557 | 47.5 (12.4) | 42.6 (13.4) | .18 |
Male caregivers | 42 (14.5) | 4 (36.4) | .07 | 46 (15.4) | 0 | 1.0 | 42 (14.6) | 14 (100.0) | .24 |
Caregivers’ level of education | | | | | | | | | |
- No formal/Primary | 221 (76.2) | 8 (72.7) | .73 | 226 (75.8) | 3 (100.0) | 1.0 | 218 (76.0) | 11 (78.6) | 1.0 |
- Secondary/University | 69 (23.8) | 3 (27.3) | 72 (24.2) | 0 | 69 (24.0) | 3 (21.4) |
Time to scheduled appointment | 29.4 (15.4) | 31.8 (14.5) | .60 | 29.5 (15.4) | 28.3 (3.5) | .90 | 29.4 (15.4) | 31.1 (12.9) | .69 |
Table 5
Comparison of impediments to the use of text message and phone call as appointment reminders
Refusal | 11 (3.7) | 3 (1.0) | .054 |
Unable to communicate | 47 (15.6) | 31 (10.3) | .052 |
Discussion
This study reveals that the use of mobile phones for medical follow-up mHealth appointment reminders in pediatric HIV could potentially apply to 80% of the overall population in Cameroon. Considering each study site separately, the potential penetration of such mHealth use would be different, as we captured 60.5% of caregivers in rural, 93.7% of caregivers in semi - urban and 92.5% of caregivers in urban areas. The greatest obstacle to mobile phone reminders was an adult caregiver’s inability to read an SMS message, followed an inability to communicate orally in English or French, which are Cameroon’s two national official languages. Very few subjects refused to receive a SMS or a phone call to remind them of the child’s medical appointment. The rate of mobile phone non-possession was also low. All impediments to mobile reminders were more frequent in the rural setting, except for the refusal to receive SMS or phone call. SMS or phone call showed no difference in their difficulty of use.
Language illiteracy was the major barrier in our study, as in others [
24], and was more pronounced in rural areas in our study. In Uganda, in a region where 80% of people live in rural areas, most persons speak a local language different than NOL [
30]. Before SMS and phone calls can be widely implemented as medical appointment reminders, it will be necessary to assess the feasibility of a particular linguistic communication program specific to each health care setting. The literacy rate will need to be improved, especially in rural areas, to help achieve gains in globalization and automation of medical appointment reminders via SMS and phone calls. Health care providers could also adapt and use local languages and dialects to deliver messages about upcoming medical appointments. We suggest that medical assistants in each HIV care center be trained to communicate in the most widely spoken local language (or dialect) in their catchment area in order to reach and include patients and caregivers who communicate exclusively in their local language. The challenge lies in the great number of ethno-linguistic groups in Cameroon, recently assessed at 286 [
31]. It will be therefore necessary to target the most widely spoken local languages in each health district.
In our study, 95% of subjects owned a mobile phone. The rate of ownership is higher than that found in Durban, South Africa in 2010 where 81% of people living with HIV had a mobile phone [
26] and in Nigeria where 68% of a diabetes population owned a mobile phone [
32]. The finding is explained by the exponential increase in the number of subscriptions to mobile phone companies each year [
7],[
8],[
24]. Mobile phone ownership in our 2013 study is however greater than that found in Kenya in the same year (61.2%) [
33]. The difference may reflect the greater proportion of the population living below the national poverty line in Kenya (45.9% in 2005) as compared to Cameroon (39.9% in 2007), and by Cameroon’s higher per capita Gross National Income as compared to Kenya’s [
34],[
35]. In our study, subjects in urban and semi-urban areas owned more mobile phones compared to Kenya’s rural areas [
33], due to the fact that the socioeconomic level is lower in rural areas [
36]. The observed regional and socioeconomic heterogeneity of mobile phone ownership was also demonstrated in Kenya [
37] where factors like gender, educational level, literacy and income are also thought to have an influence on mobile phone ownership [
37]. The present study also reveals that people unable to communicate in NOL by text message or orally are most likely not to own a mobile phone. In contrast to another study from sub-Saharan Africa, we found that neither gender nor educational level was a factor in mobile phone ownership [
37]. This implies that increasing the NOL literacy rate could lead to an increase in the rate of mobile phone ownership. Although it might be of interest to assess the feasibility and acceptability of using a shared or borrowed mobile phone for appointment reminders and delivery of other healthcare related information for caregivers not owning a mobile phone, we believe that such a ‘solution’ carries significant ethical concerns, especially in regards to privacy and confidentiality.
The acceptability of mobile phones for our mHealth reminder intervention is high (95%) in our study, as it is in other studies in sub-Saharan Africa [
24]-[
26],[
30],[
38]. In our study, age, sex, and educational level of the caregivers did not influence acceptability. Also, the interval of time until the scheduled follow-up appointment did not influence acceptability. The adult caregivers were agreeable to receiving an appointment reminder by mobile phone independently of how close or far away the upcoming appointment was in time. The willingness of an adult caregiver to receive mobile phone reminders for a child’s follow-up HIV care likely reflects an interest in the well-being and continued optimal care of the child and incorporates the perception that a reminder helps ensure better monitoring and delivery of required ongoing care. It will thus be informative and relevant in future studies to investigate the motivations of caregivers of children exposed to or infected with HIV who refuse to receive mobile phone reminders.
Our study found no significant differences in the rates of refusal between SMS and voice phone calls. Crankshaw et al. found a 99% acceptability for phone calls and 96% for SMS [
26]. Their result is very similar to ours; we achieved 99% acceptability for calls and 96.3% for SMS. This suggests that we could freely choose to use SMS or phone calls in sub-Saharan Africa in terms of communication difficulty.
Our study has some limitations. Barriers in addition to those we assessed may impede the use of mobile phones as a medical appointment reminder aid. Examples of obstacles that we did not examine include the timing of sending messages, the unavailability and fluctuations of the wireless network, the phone being powered off, low motivation of medical assistants, and privacy concerns about health [
19],[
24],[
26],[
39].
Authors’ contributions
JJRB conceived and designed the study, collected, analyzed and interpreted data, and drafted the manuscript. JJNN designed the study and drafted the manuscript. CK, and SKS designed the study and critically reviewed the manuscript. CSP critically reviewed, revised, and edited, the manuscript. All authors approved the final version to publish.
Competing interests
The authors declare that they have no competing interest.