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Patient Age, Sex, Education and Income level determine Mobile Phone use in HIV Care.

Author(s) Naieya Madhvani1, Michele Santacatterina2, Ziad El-Khatib3.
Affiliation(s) 1Project completed at IHCAR Department of Public Health Science., Karolinska Institutet, Widerströmsa Huset, Tomtebodavägen 18A, 171 76 Stockholm, Sweden., Currently Leicester, UK. Previously Stockholm, Sweden., United Kingdom, 2Unit of Biostatistics, Department of Environmental Medicine., Karolinska Institutet, Widerströmsa Huset, Tomtebodavägen 18A, 171 76 Stockholm, Sweden., Stockholm, Sweden., Sweden, 3HCAR Department of Public Health Science., Karolinska Institutet, Widerströmsa Huset, Tomtebodavägen 18A, 171 76 Stockholm, Sweden., Ottawa, Canada., Canada.
Country - ies of focus South Africa
Relevant to the conference tracks Innovation and Technologies
Summary Despite years of goal making and action taking, Human Immunodeficiency Virus (HIV) remains a major global health issue. Challenges include retaining patients in care and optimising adherence to Anti-retroviral Therapy (ART). Mobile phones are one possible solution to these challenges. The main aim of our study was to identify patient demographic groups least likely to use mobile phones as reminder tools in HIV care.
Background During the last thirty years the number of HIV cases in South Africa has dramatically increased. In the 2012 World AIDS Day Report it was reported that 5.6 million people were living with HIV in South Africa – the highest absolute number of HIV cases for any country globally. Despite these bleak statistics, South Africa has one of the highest ART coverage levels in low- and middle-income countries. This underlines the relative success of ART roll out in South Africa.Even with this relative success there are a number of challenges associated with HIV care both worldwide and within South Africa. These include: 1) retaining patients in care and 2) optimising adherence to ART. One possible solution is using mobile phones as reminder tools. Importantly mobile phone use relative to other electronic devices is high in South Africa. According to a study of consumer behaviour by, there are a reported 29 million people mobile phones users relative to a mere 5 million landline users in South Africa. This is a strong reason for choosing South Africa as the setting for fulfilling the general aim of this study.
Objectives The overarching aim of this study was to explore and answer the following question: Which patient demographic groups are least likely to use mobile phones as reminder tools in HIV care, in Soweto, South Africa? Specific objectives included 1) to identify the types of reminders used and the frequency of use of such reminders 2) to assess whether using more reminders improves i) retention in care and ii) adherence to ART, 3) to identify patient demographic groups least likely to use mobile phones as reminders for i) attending clinic appointments relating to appointment reminders (ARs) and ii) taking medication on time relating to medication reminders (MRs).
Methodology The data for this study comes from a cross-sectional study carried out at the Chris Hani Baragwanath Hospital, Soweto, in the outskirts of Johannesburg, South Africa, during March to September 2008. The study was performed at two clinics, one, a Non-Governmental Organisation (NGO) clinic and another a public health clinic. Patients were recruited through posters. An English interview questionnaire was developed and translated into Sesotho and isiZulu. The questionnaire was first piloted and then edited. The final version included 59 questions (210 items). Some questions asked for basic demographic information whilst other questions focused on specific areas of HIV care such as: failure to attend clinic appointments, reminders for attending appointments, ART adherence over the last weekend and reminders for taking medication. Information was collected on demographic characteristics, reminders used for attending clinic appointments, failing to attend appointments, reminders for taking medication and failing to take medication. Firstly, basic descriptive analysis was performed to characterise the study population and obtain frequencies for i) ARs and ii) MRs. Secondly, logistic regression analysis was performed to identify the relationship between a number of variables and the use of ARs and MRs.
Results With regards to ARs: the majority of patients reported using a clinic register card with the appointment date written on it (N=543; 61.5%). Other popular reminder tools were diary/appointment book (N=192; 21.7%) and memory (N=183; 20.7%). A relatively small percentage reported using a mobile phone (N=93; 10.5%) and a similar percentage said they used a close friend/relative (N=86; 9.7%). Few patients reported using a partner (N=36; 4.1%), friend at work (N=2; 0.2%) or other reminder device (N=14; 1.6%). Patient groups significantly associated with being less likely to use mobile phones, as clinic ARs, in the final model were: a) patients 45 years or older (P=0.001), b) women (P=0.015) and c) patients with only primary or no schooling level. (P=0.034).With regards to MRs: the most popular reminder tool was the mobile phone (N=431; 48.8%). A similar percentage of patients reported relying on their memory (N=429; 48.6%). Approximately one fifth of patients used a close friend/relative (N=173; 19.6%) or other reminder device (N=176; 19.9%). A relatively small number of participants used their partner to remember to take medication (N=68; 7.7%). Less than one percent of patients reported using a pill box (N=7; 0.8%), a diary/appointment book (N=5; 0.6%) or a friend at work (N=6; 0.7%).
Conclusion Our study found that people infected with HIV in Soweto, South Africa use a variety of reminder tools in HIV care and that specific demographic groups (those of older age, women, with lower educational attainment and lower income) were less likely to use mobile phones as reminders in HIV care.With the results from this study we highlighted a number of further questions and provided various study suggestions. As per the World Health Organizations (WHO) report on Mobile Health (mHealth) these can be combined into a number of recommendations for the advancement of mHealth in South Africa.1) We suggest exploring further and gaining knowledge on why HIV patients don’t use mobile phones in Soweto, South Africa and then second to investigate additional patient variables associated with using/not using mobile phones.2) Given the high penetration of mobile phones within South Africa and the finding that almost 50% of patients in our study used mobile phones as reminder tools for taking medication, there is a strong argument for making mHealth a bigger priority within South Africa.3) There is still much to be researched but the most conclusive evidence will come from larger scale studies that incorporate a larger sample of the general population and which focus on cost-effectiveness analysis.

4) By combining evidence-based knowledge regarding the clinical and cost-effectiveness of mHealth in HIV care together with prioritising mHealth on the South African health agenda we hope and anticipate that policy makers will have enough to formally prioritise mHealth on the national health agenda and specifically develop mHealth focussed policy.