Hani Eskandar, Ict Applications Coordinator, International Telecommunications Union; Mary-Anne Land, Consultant, World Health Organization; Virginia Arnold, Project Officer, Bloomberg Initiative to Reduce Tobacco Use; Sameer Pujari, Joint Who-Itu Initiative On Mhealth; Vinayak M Prasad, Project Manager, Tobacco Control, Who and Susannah Robinson, Consultant, World Health Organization

We live in an age of technology optimists, where innovation has become a byword for facilitation, improvement and success. In the field of development, information and communication technologies – defined broadly as any technologies used to create, disseminate and manage information, and including the internet, broadcasting mediums, and both fixed line and mobile telephony – have repeatedly demonstrated their use value in offering solutions to challenges facing emerging nations. There is a great deal of excitement around the use of mobile technology to overcome infrastructural limitations across all fields – business, health, education, agriculture and governance. Health in particular has seen numerous applications of smartphones and analogue phones being used to improve health coverage and access to services. The technology has been used to promote health and healthy behaviours, raise awareness of health risks, facilitate early diagnosis, manage treatment and adherence, increase surveillance and data collection, and in general improve health systems management and information sharing. There is however the contrasting view that mobile services and mobile technology solutions are not yet validated sufficiently to merit their use in strengthening or replacing existing public health delivery programmes, and have no standard operating systems.

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Noncommunicable diseases (NCDs) are the leading cause of global death and disability (1). Among these, cancers were responsible for some 8.2 million deaths in 2012 (2). Evidence suggests that a comprehensive approach to cancer control and prevention across the life course of an individual will reduce the burden of the disease. The goal of any comprehensive cancer prevention and control programme is typically to reduce the burden of cancer by focusing on three main approaches: 1) health promotion and life style changes such as tobacco control; 2) increasing screening and early-stage treatment of pre-cancers and cancers; and 3) providing timely, appropriate treatment, patient follow-up and palliative care for advanced-stage cancers.

In 2008, over 80% of all NCD-related deaths occurred in low- and middle-income countries (3). Of this, two-thirds of all cancer-related deaths occur in low- and middle-income countries, with some rates even higher (4), such as breast mortality rates (5). The cancer burden in these countries is predicted to worsen over time, with an estimated percentage increase in cancer incidence greater in low- (82%) and lower-middle-income countries (70%) by 2030, compared with the upper-middle- (58%) and high-income (40%) country rates (6). This is often related to problems within the primary health-care infrastructure where challenges relating to issues with awareness, access, appropriate policy and data, all of which contribute to elevated mortality rates. Of over 270,000 women who die from cervical cancer every year, for example, more than 85% of these deaths are in low- and middle- income countries and are linked to systemic problems such as a lack of cervical cancer policies and programmes, insufficient data, insufficient skills for diagnosis and management, high cost of immunization against Human Papilomavirus (HPV), one of the primary causes of cervical cancer, and socio-economic and geographic barriers to care (7). This should serve to highlight the scope of the challenge facing national health systems in managing the disease.

A growing awareness of cancer incidence rates in developing countries is paralleled by another rising rate –mobile phone usage. By the end of 2014 the mobile penetration rate in developing countries reached 90%, with the total number of mobiles accounting for 78% of the global total of 7 billion (8). The ubiquity, popularity and established social acceptability of the mobile makes it a potential delivery channel for communication between public health providers and populations. Mobiles have already been used in multiple small or medium size projects to improve treatment adherence in specific health programmes such as HIV Antiretroviral Therapy (9). They have also been used in several knowledge expansion programmes for different audiences. In Maternal and Child Health, the MAMA Alliance and MOTECH programmes have used SMS and voice messaging to increase knowledge of child care for expectant or new mothers in South Africa and Ghana. They have also been used as confidential hub for youth knowledge access by the U-Report application in countries including Uganda and Zambia, where young people can access medical information and advice on a number of conditions which they might refrain from asking publically, such as sexually transmitted conditions or stigmatized diseases like HIV/AIDS. Nor has activity been restricted to Africa; the MAMA Alliance has also implemented programmes for maternal support in Bangladesh, and the BBC Media Action programme Mobile Kunji has provided similar pregnancy and neonatal support to remote communities in the Indian state of Bihar (10).

Populations in low- and middle-income countries frequently suffer from weak health infrastructure for disease control: minimal clinical resources, infrequent health worker visits, and a general apathy towards preventative measures due to a lack of information. In cancer control this is particularly acute. About 70% of all cancer cases are diagnosed when the disease is already at too advanced a stage to be cured (11). The pro-mobile arguments see mobiles as an “enabler” to improve awareness, facilitate access to timely screening, and ensure proper patient follow-up, overcoming some of the commonest barriers to cancer control.

The questions that require examination are the following. Firstly, the validation of the appropriateness of mobile solutions for wide-scale use in cancer control programmes carried out in low- and middle-income settings (LMICs). This involves looking at how to integrate mobile interventions within the broader framework of existing health systems, since mobile programmes working in isolation will fail to provide these benefits. Secondly, an assessment is needed of the exact value-add of mobile-based solutions in terms of their evidence as effective public health tools.

The third and final question hinges on cost. A similar validation process needs to be undertaken in order to assess the true cost-effectiveness of mobile health (mHealth) programmes. Excluding its return on investment in terms of improved population health, which is difficult to calculate accurately, the technology offers two primary areas of quantifiable cost-effectiveness to national health services. The first reason is that once it is built and embedded into a public health system, the mobile platform infrastructure used for one intervention can be used to target any number of programmes for other diseases. The platform itself is disease-agnostic, making it a solid investment case for governments since the content can be constantly adapted to target the specific health needs of a population or sub-group. This renders the infrastructure investment for a single programme a one-time cost for servicing needs across communicable and noncommunicable diseases alike, as has already been demonstrated in several mobile projects (12). Secondly, the scale at which mobiles are able to reach and engage patients offers a clear opportunity for economies of scale in national programmes, via a low cost per user ratio to render the intervention cost-effective overall. A caveat to this is the need for a strong, sustained promotion campaign for any new mobile-based service, in order to ensure sufficient enrolment and uptake amongst patients and professionals during the initial phase whilst it is normalized as part of basic service provision.

The following article assesses existing evidence on interventions using mobile technology to improve cancer control in emerging health systems. It reviews existing evidence on interventions based around prevention, diagnosis and management of cancer, and draws some broad conclusions on the effectiveness and suitability of incorporating mobile-based solutions into primary health-care services in low-resource settings.

Interventions

In an exploration of opportunities and challenges facing cancer management, the primary challenges were based around four themes: patient-related challenges, health-care providers, health facilities and management (13). These challenges can be extended to apply to the barriers facing the control of other cancers across the continent, and should provide a useful focus for research on how to leverage mobile technology in a way that effectively addresses the needs of the existing health systems and resources. Overall it seems that if mobile technology is to be applied successfully to cancer control, its focus should be on addressing existing health system needs as opposed to adding innovation for innovation’s sake. This is in accordance with conclusions on the general use of mHealth within national health systems (14).

Health promotion

As seen in other mHealth promotion examples from other disease areas – maternal and child health for example – mobile technology can improve access to information. In cancer this could be used to improve awareness of the importance of screening and of how to access the service. This has already been conducted successfully in one trial, carried out in a high-income country setting, where information delivered by SMS saw a 23% increase in female screening rates (15). Another study found significant willingness from users to receive information on cancer prevention and awareness delivered via mobiles; this was conducted among an African diaspora but within a high-income country (16). The challenge will be to test whether these results can be replicated in a low-income setting at scale using sufficiently high-quality evidence. There are numerous examples of SMS-based public awareness campaigns for disease control in developing countries, but the majority of these are based on grey literature and may not hold sufficient scientific validity to be implemented at national scale (17). Another factor key to the success of a cancer prevention programme carried out by SMS will be the suitability of the message tone and content to the intended audience: it is not the SMS delivery channel itself that is successful, but the effect the message it contains has on the recipient. Tailoring the content is therefore a key step in the success of any mobile-based health promotion strategy (18).

There is also evidence that mHealth can be useful for improving population knowledge of cancer prevention and management. Mobiles have been used to provide a communication channel to promote individual behaviour change in attitudes towards cancer prevention and self-management. A 2014 study reviewed a set of 28 mHealth applications for educating people on cancer prevention and management across income and age groups. The authors identified 28 articles reporting on mobile applications for patients related to cancer, involving direct patient education, patient/professional communication and patient self-management (19). Patients who had mobile contact with health workers demonstrated increased engagement with the knowledge content and treatment processes, showing that mobiles can help increase the understanding of both the importance of self-monitoring, and provide a reliable source of information on how and where to seek medical assistance if needed.

Health access

In cancer screening, mobile technology could play a role if properly designed and applied. Early screening is more cost-effective and has better health outcomes than treatment, yet in the example of cervical cancer the majority of women present themselves at clinics at a late stage (20). Given the complexity of organizing national screening programmes, there is currently a gap in large-scale national cancer screening programmes in the developing world, including the African continent (21). The introduction of basic mHealth services to help address this gap is an area where the technology could have a real and relatively immediate use value, for linking patients to the formal health system as much as expanding health service outreach through health worker training. They can be used for basic preliminary diagnoses of certain cancers such as cervical or skin cancer. In a trial in Botswana, images of suspected cases of cervical cancer were sent to trained gynecologists for preliminary diagnosis, also showing that mobiles can be used to improve patient-provider communication and increase a country’s health workforce (22). The technology however is a stop-gap measure: remote diagnosis should not be relied upon as a full substitute for clinical attendance. This is partly because formal cancer diagnosis is often an activity requiring physical examination as well as ocular; it is also connected to a substantial lack of reliability from the point of view of medical professionals. It has not yet been fully trialed in any setting; yet simple techniques could be used to help health workers reach remote rural patients, expanding health access coverage.

Mobiles could also be incorporated into expanding and strengthening vaccine coverage. For the few cancers where preventative vaccinations are available, these appear effective and should be offered nationally. The vaccine against Hepatitis B, a major cause of liver cancer, has been classified as a “best buy” intervention according to WHO standards, denoting it as a good investment for countries on the grounds of its health impact in relation to cost. Vaccinations against human papillomavirus (HPV), the main cause of cervical cancer, has also been recommended (23). In order for vaccination to be effectively managed, basic data needs to be collected from every recipient (name, age, date of vaccination, dose) – an area where the mobile as data collection unit has a clear use value. Other immunizations programmes such as those for polio have used SMS and Interactive Voice Response Systems (IVRS) to connect with beneficiaries and their families, allowing vaccine uptake and coverage to be tracked (24). There has also been geographical tracking of vaccine supply chains using mobiles which has increased procurement and delivery efficiency (25).

Follow-up

When the focus is not specifically on treatment, which tends to be heavily disease-specific, the contribution of mobile technology to health system strengthening can be considered using examples from other disease areas (26). Cancer researchers and practitioners have an opportunity to leverage the experiences of mHealth in its application to topics such as health system management (appointment tracking and follow-up, patient reminders), health worker training, and health promotion campaigns. The flexibility of mobile technology for achieving this easily is one of its main strengths as a disease support tool in health systems, since it allows replicability and avoids the need to reinvent the wheel for each new disease programme addition. Relevant examples can be seen in appointment reminders for HIV patients and gestational diabetes in low-income settings (27, 28, 29). Reviews of clinical trials of SMS appointment reminders carried out in 2012 and 2013 concluded that the intervention is moderately effective in improving attendance (30).

Replicability

The mHealth technology is a strong example of the benefits of layering multiple programmes: integrating cervical cancer awareness with services for maternal and child health for instance, by adding components from each into a single mHealth platform or by using the same platform to deliver different disease control services to the same users. The mHealth initiative above demonstrated the feasibility of this approach during the recent Ebola outbreak in West Africa, where a 1-way SMS programme providing information to people with diabetes was scaled up to send out 4 million SMS messages on Ebola prevention in Dakar and St Louis. This demonstrates the opportunity mSolutions offer to reinforce the health objectives of multiple disease strategies within a country. For example, given that at present more women in LMICs die from cancer than any other condition in Africa, it would be logical to combine early cancer screening with health check-ups for other issues prevalent amongst women such as pregnancy or post-natal care (31). This could be managed directly through their own phones, by delivering information to increase awareness or registering patients and clinical results through SMS; alternatively it could be managed by local health workers sending data via SMS to centralized databanks to track patient check-up attendance and results, as is currently done in other maternal and child health programmes such as those run by the MAMA Alliance in South Africa and Bangladesh.

From these studies, it appears that a good area for future mCancer programmes to consider focusing on is the reduction of existing barriers in areas which are hindering the provision or uptake of basic services. It is anticipated that mHealth will have the greatest impact when programmes are focused on areas such as raising awareness of cancer risks and symptoms, preliminary diagnosis by health workers, clinical appointment management and diagnostic follow-up.

Conclusion

Policy-makers, cancer researchers and practitioners have an opportunity to leverage the experiences of mHealth in other disease areas, avoiding reinventing the wheel (32). The benefits of mobile interventions remain conditional on an understanding of the technology’s use value as a support device for improving existing gaps in a developing country’s health system. This is important in terms of the mobile’s relevance to developing country health support systems because of the mobile phone’s ubiquity and high user trust, especially in Africa where services such as mobile banking originated and are widely used. This trust in the mobile phone is a key factor in the technology’s potential as a public health tool, since it encourages regular use and a willingness to follow behavioural change recommended by mobile-based programmes. It is especially relevant for encouraging the creation of interventions based on feature phones as opposed to smartphones, predominantly SMS or voice messages.

Overall, the focus which is most promising is one that understands the mobile phone primarily not as a solution in and of itself, but as an enabling device for health care. It should not be considered as a conduit for delivery of an intervention which will directly improve the health of the recipient. The mobile remains true to its original use value as an instrument for improving communication. Its most reliable use value, for the time being at least, seems to be facilitating interaction between the population and the health-care system.  The disjuncture between the national health system and populations means that the problem can be phrased as being essentially a breakdown of communication in health systems between user and provider. This reconceptualization of the underlying problem automatically raises the appropriateness of the mobile phone as an instrument to resolve the challenges facing cancer control in low- and middle-income settings – reminding us of the technology’s primary role as the definitive communication tool. •

Hani Eskandar, MBA is the ICT Applications Coordinator at the International Telecommunications Union, where he works on creating and implementing eApplications strategies and policies in developing countries. He has extensive experience in the field of ICT for Development through his work with the International Federation of the Red Cross and Red Crescent, UNDP and other NGOs, working with ICT in health, education, community development and SMEs. He has an educational background in Electrical Engineering (Telecommunications), socioeconomic development and an MBA.

Mary-Anne Land, PhD is a consultant at the World Health Organization, working across population-based surveillance in NCDs and reproductive health. Mary-Anne’s primary responsibility is to coordinate three Bill and Melinda Gates funded projects supporting the prevention and control of cervical cancer. Mary-Anne completed her PhD at the University of Sydney.

Virginia Arnold, MA, MBA is Project Officer for the Bloomberg Initiative to Reduce Tobacco Use, where she is responsible for external relations, global reporting and management of the Bloomberg Initiative. She has experience in development financing, public-private partnerships, and chronic disease control, and has worked for HSBC and the UK Foreign Office in Canada. She holds a BA from Cambridge University in Biological Anthropology, together with a Masters and an MBA.

Sameer Pujari, MBA is the main focal point for the joint WHO-ITU initiative on mHealth for noncommunicable diseases at WHO. Here and in previous roles in surveillance and health systems management, he has provided advice and support to over 35 countries. He has also worked with the United States Government and holds degrees in business and software engineering, a Masters degree in management, and a fellowship in public health informatics.

Dr Vinayak M Prasad, MBA is the Project Manager, Tobacco Control at WHO. His main responsibility is the Africa tobacco control project and coordination of the Tobacco Control Economics unit.  Previously he worked with the Government of India in various senior capacities in health and finance. He holds an MBA from the University of Birmingham, United Kingdom, and a bachelor’s degree in medicine from Maulana Azad Medical College, University of Delhi, India

Susannah Robinson, MA is a consultant at the World Health Organization, working on country implementation of national mHealth strategies for noncommunicable diseases including diabetes, cancer and tobacco cessation. She holds degrees from the University of Cambridge and the London School of Economics, and her research focuses on the use of mobile technology in socioeconomic development

Disclaimer: The authors are staff members of the World Health Organization and International Telecommunications Union. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the World Health Organization or the International Telecommunications Union