Part #3 Rough Notes


Case studies: Evaluation of Ehealth projects in Uganda and Zambia, short, long term costs and benefits

What are the roles of actors involved in implementation? And how are programs evaluated? Have current and past programs been successful based on decrease in HIV prevalence and improvement in quality of life?

– Looking at success of current and past projects in Uganda and Zambia



– Despite the rise in global mobile subscriptions there is limited evidence that mhealth technologies are a successful and innovative tool to improve the quality of healthcare in developing countries. (pg 1 limited evidence).




(Chib, Wilkin, Xue Ling, Hoefman, & Van Biejma, 2012)

–       This study looks at the effectiveness of a short message (SMS) based HIV/AIDS information dissemination programs conducted in Uganda.  Past research show that SMS programs have aided the accurate collection of medical records, facilitated mass dissemination of information by health care providers, and served as reminders in order to increase adherence to medical regimens.

–       Mobile technology my be particularly useful in resource constrained settings such as the health care environments found in rural regions of developing countries.

–       Increased affordability and wider network coverage has meant mobile subscriptions have reached 5.3 billion globally with developing countries accounting for 73%.

–       Rural Uganda is struggling with HIV rates which are on the rise with an average of 9.9% prevalence in rural areas and 6.4%  prevalence as the national average, Uganda could benefit from further prevention efforts in rural areas. In addition prevention efforts need to be address to both sexual partners as women have a higher prevalence rate then men at 7.5% vs men at 5%. Although women however are more vulnerable due to the disease because of lower levels of knowledge as compared with men, and have less freedom to make their own sexuality-related decisions.

–       As noted in the previous section (part 2) prevention efforts in Uganda consisted of radio and print media. However these campaigns were an issue as text based campaigns do not reach those who are illiterate and women have a lower literacy rate then men do (57.7% vs 76.8%).


Text To Change Campaign

Text to Change (TTC) is a Dutch NGO that promotes health education specifically HIV/AIDS education via mobile phones through Short Message Service (SMS) quizzes. Included in their objectives are data collection, increasing awareness of HIV/AIDS, advocating testing and counseling behaviors pertaining to HIV/AIDS and testing the efficacy of incentives to participate. The TTC HIV/AIDS campaign was designed to increase knowledge and awareness about HIV/AIDS as well as promoting the regional clinic and testing centers. In conjunction with a local telecommunication company, highly active subscribers were identified. Between January 29 and February 27 2009, text messages with HIV/AIDS multiple choice and true of false questions were distributed via 10 000 identified mobile phone numbers. When participants answered questions correctly, participants received free HIV Counseling and Testing (HCT) services with the Aids information center (AIC) Arua Branch and were entered to win weekly prizes including mobile phones and airtime.


The quiz format is intended to provide a fun way for participants to engage with educational content. TTC works in partnership with other healthcare NGOs in Africa to develop appropriate medical content for the quizzes. The quiz consisted of 13 questions which were sent via SMS to the 10 000 subscribers which fell into three knowledge areas (a) HIV/AIDS disease, (b) testing, and (c) HCT services (Chib et al., 2010). HIV knowledge questions included the following, what causes AIDS? HIV is not present in: sweat, semen, blood or breast milk?, How can you tell whether one has HIV?, HIV weakens an infected person’s immune system (true or false)?, Do you think a healthy looking person can have HIV (true of false)? Other questions centered on testing such as, why is it important to test? Or, if you are exposed to HIV, how long should you wait to get tested?  And finally HCT knowledge including questions such as Where is the AIDS Information Center Uganda (AIC) center in Arua? Is HIV testing at AIC accurate and confidential (Chib et al., 2010)?



–       Van Beijma et al (2010) found that during the TTC campaign 677 people (376 men and 301 women) accessed HCT services at the Aura Clinic which was a 33% increase in the average visitors monthly.  This included 364 people whom presented SMS text messages

–       .

–       1) TTC sends a question to particiapants, participants then answer the question. Next the TTC system checks the answer and responds: if the answer is correct the participants get more information on the topic. If the question is wrong they get the correct answer and an explanation. This is repeated until the quiz is complete.

–       The 160 character limit (which is a technical limit)

–       The user must be literate in the lanuage of the quiz.

–       TTC typically works with a number of stakeholders. TTC works with partner organizations that has a specific population in mind for participation. In 2008 TTC had their first quiz reaching approximitly 60000 people in Uganda, Kenya and Namibia with quizzes targeted to the rural populations.



–       13 questions were sent via SMS and fell into three knowledge areas (a) HIV/AIDS disease, (b) testing, and (c) HCT services. HIV knowledge questions included the following, what casues AIDS?, HIV is not present in: sweat, semen, blood or breast milk?, How can you tell whether one has HIV?, HIV weakens an infected person’s immune system (true or false)?, Do you think a healthy looking person can have HIV (Yes or no)? Other questions centered around testing such as, why is it important to test? Or if you are exposed to HIV, how long should you wait to get tested? Finally HCT knowledge including questions such as Where is the  AIDS Information Center Uganda (AIC) center in Arua? Is HIV testing at AIC accurate and confidential?

–       This study ensured data was cleaned up and as accurate as possible by removing multiple resonses from the same number, late responses,  and answers that were not in specified format.


Statistical Findings

–       Those who answered the quiz question about gender indicated that 421 were male while only 202 were female, however even though males were more likely to answer questions there was no significant difference between the number of questions correct.

–       The age range was 9-65 wit hthe median age 26 and average age 28 years.

–       Of the 10 000 mobile numbers who were sent messages,  2363 numbers responded of which 1954 answered quiz questions (the rest only responded to the age and gender questions).  More then half of the responses replied to at least one question, while only 315 answered 7 or more. More then half (61%) answered at least one HIV testing knowledge question while 45% answered at least one HCT service question.

–       On average 68% of the total questions were answered correctly with only 19% not answering any correctly. The questions that were answered the least also had the lowest number of correct answers.

–       People who answered each question correctly were more likely to answer more questions than those who incorrectly responded.

–       The short term effects of this SMS campaign are an increase in the number of monthly visits for HIV testing. Drawbacks of this SMS campaign include that when an individual answers a question wrong they are less likely to respond on the next question which is problematic as those who answer the questions wrong are the ones who most likely require additional information. All 10 000 subscriptions were to MTN a leading telecomminication provider and thus including other networks might deliver different results.

–       Other challenges to SMS projects include: By only using one telecommnication network leaves out possibly lower or higher literacy levels that may answer the question differently.

–       The SMS campaign may be reinforcing a knowledge gap such as those from certain groups, such as those with higher incomes or men will benefit more from the campaign since they are better able to acquire, process and act upon the information provided.

–       The Quiz provided reinforcing prior knowledge if they got the question right and sending out the right information if they got the question wrong. However the SMS campaign failed to inform those who initially answered questions about gender or sex but failed to answer any quiz questions.

–       More evidence in a long term study would be beneficial.


More suggestions on including those who are not presently in the study.



– see personal statements for this project.
















(Danis, et al., 2010) In another study, TTC was targeted at three factories in central and southeastern Uganda. From January 28 2009 through to April 6th 2009 data was collected to determine the effectiveness of SMS as a user interface by the rates of precipitation. This was a DistrictQuiz


–       Similarly to the previous project the TTC sent a quiz, this time to three different samples referred to as factory1, factory2, factory3.  Factories either processed sugar or cobalt or were located in town in which factories provided housing, schools, and health facilities to their employees and families. This quiz took place from August 13th 2009 through to September 20th 2009 and consisted of 18 true/false questions created by a health care NGO in partnership with TTC. There was a total of 2494 participants enrolled (which consisted of 360 in Factory1, 1294 in Factory2, and 840 in Factory3). For this quiz multiple answer from the same phone number were accepted due to the high volume of phone sharing. Expected results for the true of false quiz were expected to be 50%. An example of a SMS question:

–       TTC Quiz Question: HIV can be prevented by using condoms correctly and consistently (1) true (2) false. Reply with “condom” and the number of your answer


–       Similar to the pervious project, data was processed and entries were eliminated which were blank, incomplete, however response duplicated from the same phone number were accepted due to phone sharing. This study focused on accuracy and participation rates. Accuracy which tested an individuals knowledge of HIV/AIDS.


–       Challenges: Formatting of the text messages due to technical requirements and limitations in the Factory1,2,3 samples formatting issues either they gave conversational responses or their were mechanical formatting errors resulted in 5.97%, 14.10% and 8.53% of the responses (even if correct) were not usable. However over the course of the question formatting issues significantly decreased by 90% from the first to last question. SMS messages can be used effectively, although their may be a learning that needs to take place. A new system as () suggest could directly formulate conversational answers into correct form so they too can be counted.





– (Seidenberg, et al., 2012)


2 article on infant diagnosis for HIV prevention


In Zambia mother-to-child transmission accounts for 21% of all HIV infections.





Donald Thea


#1) I was looking at some of the publications you are part of and noticed your very involved with breastfeeding as a preventive measure for mother to child transmission. Is there any sort of technology used to educate communities (either mobile, or internet?) or do any of the local clinics use any forms of ehealth?


#2) (Thea, Donald. Phone Interview: Aug 7th 2012) 617 414 1271


Interview with Donald Thea: Professor of International Health at Boston University. Thea purses a full time career in both domestic and international clinical and epidemiological research in infectious diseases. He is currently the program director of the Boston University preventing mother-to-child transmission of HIV (PMTCT) integration project, which seeks to improve the implementation of PMTCT services and early infant diagnosis services in Southern Zambia.


Background: Thea has spent 25 years in Africa starting in 1989 when he was first went to Congo. He was been working in Zambia since 1999 mostly on HIV and PMTCT. Thea (2012) mentions that this is really the first study that he knows of using mobile technology to improve the health of rural communities and prevent HIV.

–       1st phase is article he wrote.

–       2ned phase will be community health agent who live in the community have an interest in health and doing some work for some pay and volunteer and a lot of them have cell phones. (5 years increase in cell phones). We are these communities with cell phones to register pregnancies and births and maternal and infant deaths. Once the pregnancy is entered and expected date of delivery is entered into the database. The community health workers then get text messages to remind women to come in for visits to the local clinic. This encourages mothers to come in for their first, second and third trimester visits whom may be coming from long distances away. During these visits to the clinic the mother is reminded about the impotence of taking her ARVs for her and her child to encourage a healthy pregnancy and childbirth with the help of prophlaxisis.  The community health workers are also using cell phone for maternal morbidity using community counselors in setting up trios center to text health related questions to the clinic to determine if an ambulance is needed for further medical attention.

–       Started implementing it and getting (5 health centers) impressive results. 800 pregnancies, deliveries registered in 2 months.

–       System was failing from mother to bring in child to get tested for HIV and often mothers would not come back, now women get child tested and get the results quickly which is import as children’s HIV progresses much quicker then adults ARVs are essential.


Although Zambia has one of the highest cell phone usages per 100 inhabitants in Africa, programs dedicated to HIV prevention within Zambia are minimal. According to Donald Thea (2012) of the Boston University School of Public Health Mwana is virtually the only project of its kind in Zambia that contains some sort of prevention effort using mobile technology. Elin Murless works for UNICEF on project Mwana and although she agrees with Thea, she has seen some new innovative ideas by partners of UNICEF nothing has yet to be implemented.


In Zambia it is estimated that 21% of new HIV infections are transmitted via mother-to-child. Antiretroviral’s (ARVs) are critical to help prevent the transmission from mother to child but when this fails it is essential to ensure the infant is tested immediately for HIV. There is strong evidence that if an infant is diagnosed early for HIV that morbidity and mortality can be significantly decreased. The main goal of Mwana is to reduce the time between blood sampling for the detection of infant HIV infection and notification of the test results to the relevant point-of-care facility by using an SMS based system (Seidenberg, et al., 2012).  Clinic are widely dispersed and laboratories where blood samples are tested can be 10 to 600km away from a district clinic making it difficult to quickly transport samples and get results. In April 2009, at Nameembo Rural Health Clinic an infant’s blood was collected for an HIV test. It took 66 days for the same to travel to the lab and the results to be returned to the caregiver. In February 2011, a similar sample took 29 days to make the same trip; Mwana is the project, which facilitated this decrease in travel time using mhealth technology (Republic of Zambia Ministry of Health [RZMoH], 2011).  The Ministry of Health in Zambia, UNICEF, Boston University and the Zambia Center supported this project in Zambia’s Southern Province where 10 public health facilities (five in Mazabuka district and five in Monze district) for Applied Health Research and Development, which is a local NGO, also affiliated with Boston University (Seidenberg, et al., 2012).


Although the main purpose of this project initially was to speed up diagnosis times, preventive HIV measures are also an important part of this project during the second phase. The second phase, which involves the community care workers who register pregnancies, births and maternal and infant deaths. Once the pregnancy is entered into the database the expected date of delivery is established. The community health workers then gets text messages to remind women to come in for visits to the local clinic. This encourages mothers to come in for their first, second and third trimester visits who may be coming from long distances away (Thea, 2012). During these visits a mother has access to many benefits to prevent HIV transmission to her child but at which point basic HIV education is also available to prevent the risk to the rest of her family. In Zambia more then 90% of women attending antenatal care (ANC) services are tested for HIV, thus the community health care work can get notifications from the local clinic as to when the pageant women should be visiting the clinic for visits (RZHoH, 2010). Women are encouraged to visit the clinic within the first 14 weeks of her pregnancy. During the first visit to the ANC clinic woman and their partners are encouraged to find out their HIV status if unknown (Or if previously negative are retested). Second women can attend group health education to obtain information about child health, and preventing mother-to-child transmission as well as a wide range of other topics such as the importance of couple testing and disclosing results to the partner, HIV testing for the baby and information about family planning as well. If a woman discovers she is HIV positive she is recommended to begin ART treatment immediately. Visits are encouraged two weeks after first visit, then again within four weeks for the third visit and a visit in the third trimester. Follow up visit after the infant is born is critical as well for HIV testing (RZHoH, 2010). Community health care workers also keep women accountable who are HIV positive by reminding them of their visits to the clinic which are important for HIV positive women to receive does of Co-trimoxazole which is recommend for HIV positive pregnant women after the first trimester. Comprehensive HIV care is required at minimum every four weeks during the pregnancy.  If the mother lives far from the clinic she is recommend to utilize waiting homes until the birth to ensure a safe delivery (RZHoH, 2010).  Results of this program according to Thea (2012) are impressive. During the first two months in 5 clinics, more then 800 pregnancies were registered. There is future plans to expand this project to all ten clinics as well as include additional 200 health facilities in the next year (Murless, 2012).


Initial costs of this program were training two people from each health facility, usually a nurse and a manager. The training consisted a half-day seminar instructing individuals how to use the SMS-based system to retrieve test results. Local Zambian software developers developed the SMS-based system entitled Results160. The software securely and quickly delivers infant HIV results from lab to facilities using SMS is sent through a server was centrally placed at the Ministry of Health. Ten mobile phones were distributed, one to each health clinic and used on the SMS-based system between health clinic and laboratories to retrieve results. Support visits were made to each facility after two months of the program being launched to workout any outstanding issues that might have arise.


Currently the MoH is playing supportive role at both the district level as well as national level with the support of UNICEF and partners. After the pilot projected was introduced the Government of Zambia committed to a scale up of the project which would entail 587 health facilities to include HIV testing to infants which as both Thea (2012) and Murless (2012) acknowledged would be room to further growth ANC services and ensure mothers to be have the proper access to care to prevent the transmission of HIV. The National Government is currently seeking non-governmental organizations that are willing to help. The project has moved slowly with the integration of the governments involvement with pilot project but their support is seen my UNICIEF to create what has so far been a successful initiative (Murless, 2012).