Each year more than nine million people die as a result of high blood pressure, 80% of them in low- and middle-income countries. Hypertension is one of the leading causes of cardiovascular diseases such as strokes, heart attacks and heart failure. One of the main problems with treatment is that patients do not take their medication consistently. As a result the disease is not managed and patients become ill. Mobile technology can help. South African Medical Research Council Specialist Scientist Dr Natalie Leon explains how.
Why don't patients adhere to their high blood pressure treatment regimes?
There are several reasons.
The first includes patient-related factors: these are mostly socioeconomic issues. Patients do not have money and transport is poor. It means they are unable to get to the health facility or are late for clinic appointments. And they do not have the money to buy good food. Related to this are lifestyle factors such as eating the wrong foods, not exercising, being obese, smoking and not managing stress.
Then there are also medicine and health service-related problems. Patients may have concerns about taking their medication or be discouraged by its temporary side-effects. Sometimes they have beliefs about alternative medicines that they prefer.
Lastly, there are disease-related factors. Patients don't understand the disease and its consequences and therefore cannot control or manage their condition. As a lifelong disease high blood pressure can be controlled with medication and lifestyle changes, but patients must take medication regularly to prevent complications.
Over and above this, South Africa's public health service is heavily overburdened, resulting in health-care workers being stretched. Our study, which evaluated patients' experiences when the clinic sent them text message reminders, showed that patients are discouraged when they feel unwelcome.
This heavy burden also means that the health system is not geared to treat chronic diseases. Chronic disease management requires that health-care workers track patients for their lifespan. It needs an information system that links individual patient data to health visits. Health-care workers should know when patients need to pick up the next batch of medication, when their six-month check-ups are scheduled for and how to recall the patients when they have missed these dates. It also requires health-care workers and patients to develop a partnership where each side takes seriously their responsibility for improving patient health.
South Africa has only started to recognise the enormity of the chronic disease epidemic. The health-care system has been preoccupied with infectious diseases such as TB and HIV.
How can mobile technology help?
Mobile technology can help in different ways. It can help doctors to access information and patient records to diagnose diseases better. It can help health service providers communicate more effectively and more quickly with patients. And patients themselves can have better access to their health records and to the internet, where they can learn about their disease.
The SMS-text Adherence SuppoRt study focused on increasing the clinical communication between the patients and the clinic to help patients adhere to their hypertension treatment regimes. There is strong evidence that medication helps to contain blood pressure levels.
The study was conducted at a clinic in the City of Cape Town metropole in South Africa's Western Cape province. The health-care facility sent a text message to patients to remind them to:
pick up their monthly medication;
attend their medical appointments;
take their medication regularly, as prescribed; and
encourage them to strive towards and maintain a healthy lifestyle by undergoing dietary changes, avoiding smoking and alcohol, and managing stress. Although lifestyle changes are complicated and require more than text messages, the messages are a useful component to increase awareness and support these changes.
The study found that patients who received the texts had a small reduction in their blood pressure. There was also an improvement in patients collecting medication. Patients found the reminders useful and the polite tone of the messages made them feel cared for.
Where else is it used effectively?
The hypertension study is not the first to use mobile technology in South Africa. The National Department of Health has also initiated one of the largest mobile technology programmes in the world, focusing on maternal and child health through Mom Connnect. Pregnant women and new mothers are reminded of their health appointments and receive useful information about infant health.
There are many examples where mobile health technology has been tested to improve adherence: in HIV, TB, smoking cessation and weight loss. And there has been some evidence of success. But most of these studies were on a small scale and were not implemented in a mainstream health service or on a large scale. Most were in developed countries. This trial shifted the research to make the findings more relevant to health services in South Africa because the study happened within the public-sector health service at a clinic with high rates of hypertensive patients.
Across the developing world, there are many countries that use mobile technology. Kenya, for example, has done the WelTel study for HIV care and several Asian countries have studied mobile technology in health.
What are are the next steps?
The study highlights an important fact. Mobile health should not be seen as an intervention that can solve some of the fundamental problems in health care. It is only a potential tool that can add value when there is a functional health system; where data can be integrated into the health information system and used by health-care workers to monitor and improve the treatment of chronic health conditions.
Although mobile health technology and its potential usefulness for health services is in its infancy, similar research interventions should be developed to improve the ability of health services and systems to apply the evidence on a larger scale.
We have replicated the hypertension study for the study of a different chronic disease - diabetes - which will be conducted in Cape Town and Johannesburg in South Africa, and in Lilongwe in Malawi. It will try to understand whether text messages are effective with different diseases and in different health-care settings and conditions.
Natalie Leon received funding from Wellcome Trust and John Fell Fund and worked in collaboration with Oxford University and University of Cape Town/Groote Schuur Hospital.