Evidence based mHealth for patient engagement in care WelTel International mHealth Society Presenters: Bonface BetI & Antony M. Khaemba

INTRODUCTION WelTel SMS technology is an mHealth intervention that aims to improve health outcomes WelTel is an evidence based intervention, based on evidence to improve HIV treatment adherence and viral suppression (Lancet, 2010) WelTel Kenya 1 study carried out in three facilities in Kenya showed that patients who received SMS support had significantly improved ART adherence and viral load suppression More clients that received WelTel SMS support in the RCT had improved rates of viral load suppression (156/273) as compared to 128/265) who received standard care Mobile health/mHealth is a medical or public health practice supported by mobile devices, such as mobile phones, personal digital assistants and other wireless devices.

Clinic’s Tablet/ Phone Client’s Phone WelTel SMS Platform Mambo? (How are you?) Clinic’s Tablet/ Phone Sawa (am fine)/shida (Not Fine) If shida – clinician calls the patient Point of care WELTEL TECHNOLOGY SMS PROTOCOL

WELTEL KENYA 2 PROJECT WelTel Kenya 2 project is a collaboration AMREF Aphia plus Imarisha, UBC, WelTel International mHealth society. The project is currently implementing the WelTel SMS technology service in various health facilities in NAL Funded by GCC and USAID through Aphia plus Imarisha The project aims To introduce and optimize WelTel SMS service in the HIV CCC and MNCH clinics in northern arid land (NAL) To evaluate the impact of the WelTel service on various HIV and MNCH health indicators in NAL WelTel are involved in the implementation of the project while Aphia plus Imarisha and UBC are involved in the evaluation of the impact of the project

HEALTH CHALLENGES AND BASELINE STUDY IN NAL Social cultural and geographic barriers in NAL limit access to health care There was a low number of HIV CCC and MNCH clients who were retained in care which resulted to poor health outcomes A baseline survey was carried out among MNCH participants in 6 government facilities in NAL and two neighbouring government facilities for comparison in 2014/2015 211(74%) of the participants owned a mobile phone and 39(53%) who did not own a phone shared access to phone 230(92%) of the partipants responded that they would like to receive a weekly SMS from health care provider to inquire about their health Almost all counties in NAL have high maternal mortality rate (MMR)- e.g. Isiolo County has more than 700 MMR/100000 deliveries and Kenya has not yet achieved the set WHO MDG of 147/100000 by 2015. Some counties in NAL like Wajir have MMR of over 1100/100000

A MAP OF KENYA SHOWING NORTHERN ARID LAND NAL occupies more than 60% in Kenya

REGISTRATION IN THE WELTEL PLATFORM CCC HIV and MNCH clients are informed about the existence of the WelTel service during their visits in health care facilities, how the service functions and what the service aims to achieve Clients are registered in the platform either using an offline mode- without internet or an online mode- using internet A client who owns a phone or has access to a shared phone and is willing to participate in the project is registered in the WelTel SMS platform WelTel Kenya 2 project is currently being implemented in Isiolo County Referral Hospital, Kinna Health Center and it will be launched in Maralal Referral Hospital in Samburu in June 2016

HEALTH EDUCATION AND REGISTRATION OF A CLIENT A participant will sign a consent for him/her to participate in the project

PROTOCOL: SMS TEXT MESSAGING Monday If necessary Health Advice <48h SMS response

CLIENTS OFFLINE REGISTRATION Send as a message via SMS type: R+ 254777888999 clinic ID patient name Most of the registration is done on offline mode because it is cheap, accessible and easily available

REGISTRATION USING ONLINE MODE WelTel platform online mode is passcode protected Passcode ensures that patients data is secure

REGISTRATION OF CLIENTS USING ONLINE MODE After delivery the ANC clinic is changed to immunization clinic to help in transition from ANC care to postnatal care

SENDING REMINDERS MNCH It is able to send appointment reminders, immunization reminders and reminders for psychosocial support group monthly meeting for HIV and MNCH clients

WELTEL MNCH PLATFORM Immunization reminders at 6 weeks, 10 weeks, 14 weeks and 9 months

CHALLENGES EXPERIENCED DURING THE IMPLEMENTATION The major challenge experienced in the implementation of the project is poor internet connections in NAL However the WelTel technology is able to register a client on an offline mode and all the responses from the clients are visualized on the phone or tablet as a message A patient registered on the offline mode will be automatically be registered on the online mode

ADVANTAGES OF WELTEL SMS TECHNOLOGY It improves patient health service- it improves patient engagement in care with HCP through: low cost, (basic SMS and voice), SMS bundles discrete SMS (appropriate for HIV clients) valued by patients: weekly “check-in” SMS makes a client feel better cared for strong evidence base (multiple published studies) WelTel Kenya 1 RCT done in three facilities (Editor’s choice, Lancet 2010) proved that WelTel weekly SMS check in model improved HIV treatment outcomes

CONTINUATION OF ADVANTAGES- WELTEL Scalable: Has minimal training requirements, intuitive turnkey project, able to register clients without internet connection, central server (remote support) Accessibility: minimal literacy and a basic phone is required, also sharing of phones is allowed- very appropriate for Manyatas where clients share phones Adaptability: adapted and it is able to support various conditions HIV, MCH, TB, asthma and hypertension Secure: highest international standards, health data not kept on devices Secure server, password protected, encrypted, auditable Stable: minimal down-time Manyatas are common in NAL and most of the people staying in Manyatas share phones and there are community health care volunteer who respond to weekly SMS

IMPROVING ENGAGEMENT TO HIV CARE BY CCC CLIENTS IN ICRH USING WELTEL IN QUARTER 2 2016 Appointment status of non WelTel clients Appointment status of WelTel clients Jan Feb March Met 174 (66.56%) 177 (53.25%) 165 (58.72%) Previously missed 65 (25%) 131 (39. 39%) 88 (31.4%) Missed 22 (8.44%) 25 (7.36%) 28 (9.88%) Total 261 333 281 Jan Feb March Met 160 (70.83%) 145 (64.29%) 163 (86.67%) Previously missed 57 (25.22%) 80 (35.71%) 25 (13.33%) Missed 9 (3.95%) TOTAL 226 225 188 Met- patients who came for their appointment on the scheduled day, previously missed- patients who didn’t come for their appointment on the scheduled day but came within 7 days of their missed appointment and missed- do not appear in the clinic within seven days of their missed appointment

LOST TO FOLLOW CLIENTS IN CCC CLINIC ICRH IN 2014 and 2015 WelTel project was launched in the CCC clinic in April 2015, therefore it has helped to improve engagement and therefore more clients are retained in care and the number of clients who are lost to follow up have reduced

IMPACT IN THE MNCH CLINIC ICRH AS FROM APRIL 2015 to MARCH 2016 Four and more ANC visits usually lead to better maternal and neonatal outcomes

Scale up and sustainability WelTel vision is to provide WelTel mHealth model to support clinical care setting and strive to include most vulnerable and remote population The project aims to scale up to most facilities in Kenya and Africa to help meet Sub Saharan UNAIDS 90-90-90 targets It also aims to improve maternal child health and save lives in Africa- SDG number 3 WelTel will incorporate use of MAPS toolkit to facilitate successful scale of the WelTel mHealth model mHealth Assessment and Planning for Scale- MAPS toolkit

Acknowledgements

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