This study illustrates how mobile phones can be utilized as an effective tool for reporting febrile illness and for requesting assistance for malaria testing and treatment. Mobile phones have expanded rapidly even into some of the most remote areas of Bangladesh. In this study site in two remote unions near Bandarban city within the Chittagong Hill Tracts, almost every community had at least a few members with a mobile phone. Although mobile phone coverage is not complete, people are able to climb to the top of the hills to get a signal. Despite low household phone ownership and access to borrowed phones, many who did not claim to have access were able to find a way to call. It is plausible that families that do not own a mobile phone may make a greater effort to find a mobile phone in the context of a medical emergency. Also, some families may have gained access to mobile phones since the time of survey. As most communities had at least a few mobile phone owners, it would be logical that these may have been found and borrowed in this context.
In this study, the mobile phone use was shown to increase communication between the study team and participants allowing more careful follow up. Not only has the use of mobile phones helped increase more potential cases tested and followed, optimizing the research agenda, but also it provided a great service to the community. With access to mobile phones, community members were able to have access to rapid diagnosis and treatment, possibly reducing the likelihood of reliance on local medicine men or drug vendors, and therefore the risk of incorrect results and inappropriate medical advice/treatment . Thus, use of mobile phones, when combined with a strong national health program that provides correct treatment options, could also reduce the threat of drug resistance .
Mobile phones allowed a prompt treatment of patients at home since the call alerted the field workers to visit the patient’s home, leading to an early RDT testing and treatment. This rapid response is especially important for more severe cases who were now able to receive rapid treatment without travelling long distances to reach services. Provision of prompt treatment is likely to improve clinical outcomes. In the future, mobile phones could also be used to provide treatment reminders and follow-up, and current mobile phone owners generally quite open to receiving such reminders. In malaria endemic areas where many are not literate, picture messages could potentially be used for such reminders, but in this survey most preferred a combination of written and picture messages. These strategies have been shown to be successful in robust randomized trials of text messages to improve adherence . A potential constraint to this approach, however, is that many of the phones do not accommodate picture messages.
Although lack of road access did not affect the likelihood of phone use, the proportion of positive cases from these calls was higher from communities without road access and the potential benefit of mobile phone health calls for the communities without road access was likely greater than those with road access in terms of saving time and providing access to services. Furthermore, the ability of the study team to provide these services has improved the quality of communication between communities and the study team staff. An additional benefit to the efficiency of the project is the ability of the research teams to call families prior to routine visits to families living in remote villages to confirm that the family is home.
There are several challenges when using mobile phones: a) When a patient calls in the evening, the patient or field worker may have to wait until the next morning since travel after dark may not be safe; b) Occasionally when responding to a call, the field workers found that the family had already left to seek other help before the team arrived; c) For those without mobile phone coverage, the family member may have climbed to the top of a hill to make the emergency call, but was not able to receive a follow-up call after they returned to their village; d) Sometimes people have little credit on their phone so they cannot speak for a long time. In this case, the missed call mechanism used by the study physician was found to be quite effective; e) Finally, if the physician’s phone is lost or stolen, important phone calls might be missed. This risk was minimized by leaving five different numbers to call with each household.
There are other possible concerns from shared mobile phone use related to stigma and privacy when integrating mobile phones into health programmes in developing countries . Although this study mainly used mobile phones to respond to calls, other studies where text reminders were sent for medication adherence faced difficulties with privacy/confidentiality since these text messages could potentially be seen by other households or community members. In the context of malaria, which has no associated stigma, the advantages of rapid diagnosis and treatment far outweigh these potential concerns. However, if such programmes were expanded to more sensitive issues such as HIV/AIDS or STDs, these concerns would have to be weighed carefully with potential benefits.
Positive impact of mobile phone use in this study is consistent with a few other reports of using mobile phones in malaria programmes, especially to encourage the use of appropriate guidelines by healthcare workers. A study in Kenya showed that health worker adherence to treatment guidelines for outpatient malaria treatment was improved with the use of text message reminders . One study reported monitoring anti-malarial drug use and adverse reactions in Nigeria . Another study in Thailand used mobile phones for case investigation, follow-up for treatment compliance and monitoring patients’ symptoms .
A limitation of this research study is its generalizability. This project field site is one which is intensely monitored by the study’s field staff. The field workers were recruited from the project area so they have detailed knowledge of the area and the people. The health care staff serving other areas may not be as familiar with their catchment area. The key to successful use of mobile phones in similar programmes will depend not only on the mobile phone technology, but on pairing the technology with the on-the-ground knowledge of the area and the people. Nevertheless, this study has demonstrated an effective means for covering remote areas and using mobile phones as a tool to improve project efficiency, as well as quality and timeliness of care as non-governmental organizations and government agencies expand their programmes. As the use of mobile phones is dramatically increasing, the way in which mobile phones are used will continue to change and expand.