Use of mHealth for management of hypertension in low and middle-income countries: opportunities and challenges

Opportunities and challenges for the use of mHealth in hypertension management in LMICs

Evidence suggests that mobile technology could be a potential platform to deliver interventions for patients with hypertension in LMICs^[5]. Multiple behaviour change interventions have been tested in these settings using mHealth. This paper is a general overview of the lessons learned from implementation of the pilot randomised controlled trial project using a mHealth (TEXT4BP) intervention to support behaviour change among patients with hypertension in Nepal^[11-12] and qualitative formative study^[13]. The TEXT4BP intervention was tested among a total of 200 patients with hypertension at a tertiary-level hospital outpatient department setting in Kathmandu, Nepal. TEXT4BP study found promising evidence for improving blood pressure control and medication adherence among patients with hypertension. The improvement in blood pressure control was significantly greater among the intervention arm^[12]. The intervention implemented in the TEXT4BP study was informed by formative research, which explored various opportunities and challenges of blood pressure control and mHealth acceptability involving various study participants^[13]. Our previous formative qualitative study explored the perspectives of patients, providers and key informants (focus groups and in-depth interviews using the Technological Acceptance Model)^[13]. The opportunity and challenges expressed in this article are based on our experience and evidence from other LMIC settings [Figure 1]. Along with the opportunities, some challenges must be critically assessed and addressed to maximize the benefit of using technology in hypertension management.

Figure 1. Opportunities and challenges in using mHealth for hypertension management in LMICs.

Bridging gap between the health system and patient

Different studies report communication gaps between providers and patients as one of the significant barriers to hypertension management in LMICs^[14]. In the formative research, we found that the healthcare providers had similar perspectives expressing the staff shortage at health centres as one of the reasons for their inability to have adequate contact with patients^[7]. In such a context, the use of mHealth intervention could prove beneficial by bringing patients closer to the health system^[15]. One simple example includes the delivery of information to patients on hypertension management using various mediums like mobile applications, messages, and phone calls^[16]. By utilizing this approach, one health provider can reach out to multiple patients, thus improving the reach and frequency of contact between patients and providers^[16]. Therefore, mHealth presents an excellent opportunity to address human resource shortages and improve patient care by filling the communication gaps.

Health education and reminders for patients

Like any other chronic disease, taking medication daily is essential to control high blood pressure. In addition, behavioural modifications are also recommended, such as a low salt/fat diet, regular physical activity, and reduction/quitting of smoking and alcoholism. This indicates the complex nature of the disease; therefore, the patients must be constantly reminded and educated. The use of mHealth interventions could be effectively supported by the existing evidence. A systematic review by Hall et al. reports the beneficial impact of mHealth in managing chronic diseases, especially in providing client education and supporting behaviour change^[16]. The WHO Global Observatory for eHealth reports SMS technology as a preferred method to ensure treatment compliance globally^[17,18]. Another systematic review focused on LMICs found a positive impact of mHealth on clinical outcomes, medication adherence, and delivery of effective health education to a patient^[19]. Our formative study in Nepal also reported the benefit of mHealth as a reminder tool for behaviour change among patients with hypertension^[13]. These findings favor the use of mHealth for patient education, including medication and follow-up reminders.

Confidential disclosure of information

Stigma related to disclosure of the information is not commonly reported in the case of hypertension compared to other conditions such as HIV/AIDS^[20].However, in our previous research in Nepal, the need for confidential disclosure of the information was stressed by the patients, especially the young population. Their preferred approach was the delivery of test outcomes and any other related information, such as treatment, via SMS or calls^[7]. It indicates the importance of privacy in managing hypertensive patients. Therefore, a telecommunication platform can be a potential solution to protect patient confidentiality. This stresses the need to prioritise patient privacy in hypertension management, which can be achieved by disseminating patient-related information through digital applications.

Streamlined data management system

Similar to any disease condition requiring longitudinal care delivery, the importance of a streamlined data system in hypertension management cannot be overemphasized. Digital tools, such as mHealth applications, are found to be more cost-effective than a paper-based system and can be utilized to collect patient data at the point of service delivery or for longitudinal patient record management. Such a system also allows an integrated care delivery for hypertension patients; for example, the care delivered by a Community Health Worker can be linked to a health facility and vice versa. Similar systems have already been tested in some LMICs, such as Cambodia, Senegal and Nepal, and have proven effective in patient monitoring and follow-up^[16,21].

Technological and financial constraints

Even though a high penetration of mobile technology exists in LMICs, various challenges limit countries from leveraging the full potential of technological advancement in a health system. The WHO Global Observatory Group reports multiple challenges, such as operational costs and underdeveloped infrastructure^[18]. Importantly, internet cost, speed and network coverage remain significant constraints in resource-poor settings^[22]. An underdeveloped health information system was a significant barrier to the continuity of care for hypertensive patients in rural India^[23]. Similarly, studies from Bangladesh^[24], Kenya^[25], and Nepal^[13] have identified information carrying capacity, language, and improper recording of the patient's details as barriers to implementing mHealth interventions. In our previous study in Nepal, though stakeholders expressed enthusiasm regarding using mHealth for hypertension management, the participants also described various resource and technology-related challenges. Such as the requirement of technical departments and experts for software development and program monitoring^[13]. There is also ongoing debate globally around the safety and confidentiality of patient data with the introduction of digital solutions in a health system^[26].

Need for technical manpower

Though we identified that mHealth could address the health human resource gap in delivering health services, it could not overcome the barriers of lack of technical manpower in the health system. Since Health workers are overloaded with other health-related activities, they cannot be involved in the mHealth-related direct technical services, so there should be enough technical expertise or manpower to organise the data-related patients and link with mHealth services and health workers. This issue was highlighted in our previous study, especially through key informants and healthcare providers^[13]. Previous studies from Nepal also reported that the need for good infrastructure and trained human resources is key to the success of the rural-telemedicine program in Nepal^[27]. Therefore until and unless the technical manpower is not integrated into the healthcare system, operationalisation of digital health in the healthcare delivery system of LMICs could be a challenge.

Unclear mHealth policy and guidelines

A clear policy and guidelines are essential for any program’s successful development and implementation^[22]. However, in the case of mHealth/ digital health, this remains a missing piece in many LMICs. This gap of unclarity of policy in privacy and confidentiality of the data implementation strategy was also highlighted by the WHO^[18]. Most LMICs do not have clarity about the data handling, copyright and measures to protect the privacy and confidentiality of the shared information in mHealth policies. In addition, policy and guidelines have not addressed the equity of access to the mHealth program; often, such services are utilized mainly by the accessible (technological and financial) community only^[28]. Further, technological aspects are rapidly evolving, so changes in existing policies are another huge gap in incorporating mHealth into the health system of the LMICs.

Digital literacy and language barrier

Digital literacy is reported as a significant barrier to the implementation of mHealth in LMIC settings^[29]. It is a crucial factor determining the acceptability and usability of mHealth interventions among hypertensive patients. This issue of language and literacy barriers in reading text messages and operating mobile apps are reported barriers in research conducted in South India by Sydney et al. (2012) and Smith et al. (2015)^[20,30]. Language and literacy barriers are also identified in a report focusing on mHealth in LMICs^[26]. These are similar to our study findings in that participants expressed concern about digital illiteracy, as most patients with hypertension were elderly and illiterate^[13], with only 31% of them digitally literate^[31]. Such issues can create significant barriers to implementing mHealth in LMICs.

Based on our experience in Nepal, simple mHealth can work but needs collaboration and cooperation with multiple sectors to make digital friendly health system. In addition, feasibility testing of a simple mHealth intervention could be a starting point, and then gradual scaling up the program could be a practical implementation strategy in LMIC settings. However, the problem we face is that scaling up the program is another big challenge in LMICs settings, even after there is evidence of effectiveness of feasibility study or other generated evidence.

Ways forward

mHealth could be a suitable medium for intervention delivery for a patient with hypertension in an LMIC setting, if designed meticulously. Firstly, there is a need to have a clear guiding policy to inform the implementation process and ensure the protection of the data and privacy of participants. We echo having a mHealth community or a governing body in each health department^[22]. Secondly, Government commitment and multisectoral collaboration, such as with the ICT department and hospital and coordination with the health system, must overcome the identified structural barriers. Concerned stakeholders, including policymakers, should be encouraged to invest more in technological infrastructure^[22]. Additionally, the need and preferences of the participants should be explored while designing the mHealth intervention to be acceptable and sustainable in the local setting^[32,33]. WHO’s mHealth Assessment and Planning for Scale (MAPS) to scale up their mHealth project is an excellent tool to address the usability issue of mHealth^[34]. Further, alternate mediums, such as including family members of illiterate/older groups or using video/voice/symbolic messages, could be instrumental in addressing the digital literacy barriers. Future research should explore how best to implement culturally tailored mHealth intervention in the regular healthcare system to increase the long-term adoption and sustainability of the effectiveness of such innovative approaches in LMIC settings. However, the finding of this paper should be interpreted cautiously as it is not a review paper that summarizes all the existing literature in the field. In addition, future studies should explore the ways of transferring the successfully implemented mHealth strategies for hypertension management at HICs to LMIC settings to address the identified challenges. Ultimately, there should be a practical approach for scaling up the generated evidence and incorporating it into policy and practice.