Faculty Advisor:George Donohue

Team Members: Kristen Brunngraber, Abdulaziz Attas, Semion Carter, Brandon Tolman

Implementation of mHealth in Nicaragua

SponsorCopyright 2018

What is mHealth ?

“mHealth is the delivery of healthcare services via mobile communication devices" - Foundation for the National Institutes of Health

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Our Motivation

● In developing countries, healthcare faces the challenge of remote access to medical resources and a severe shortage in clinical staff

● However, telecommunications has leapfrogged as populations are adopting cellular phones, including smartphones

● The integration of Mobile Health (mHealth) could yield great results as a response to these factors

● To test this, we looked at the impact of mHealth designs in rural, Puerto Cabezas, Nicaragua

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Healthcare Cycleof a DevelopingCountry

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Vestibulum congue tempus

Vestibulum congue tempus

Vestibulum congue tempus

Vestibulum congue tempus

Developing Healthcare Network

Original Graphic

mHealth as a Building Block

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Healthcare Innovation

mHealth is one building block in the pyramid of innovative healthcare delivery

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Improved Healthcare Delivery

Methods

2

Healthcare Access & Delivery to Patients in Need

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mHealth

Original Graphic

The Missing Piece

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Developing Country● Shortage of trained

clinicians● No remote access

to medical resources

● Slow or delayed information exchange

With mHealth● Aid health

workers in their job

● Serve as remote information tool

● Tool to connect to medical community

● Paper based records to digital based records

Patient Needs● Access to

physicians in reasonable time

● Recent, accurate medical information/advice

● Access to medical community

● Ability to be seen by clinician as needed

Nicaragua

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● 2nd poorest in the Western Hemisphere

● Countrywide 2G Telecommunication

● Nicaragua “Perfect Storm”- Lack of healthcare access- Abundance of Mobile Devices

● Puerto Cabezas- Pilot test city- 3G capabilities

Nicaragua

RAAN

Puerto Cabezas

Healthcare Crisis in Nicaragua

“The World Health Organization estimates that fewer than 2.3 health workers (physicians, nurses, and midwives only) per 1,000 would be insufficient to achieve coverage of primary healthcare needs.”

Statistics from: CIA Factbook, PATH Report, and Nicaraguan Ministry of health (minsa.gob.ni) 8

Only 9% of healthcare workers are located in Caribbean Region (Where Puerto Cabezas is located)

In Puerto Cabezas, per 10,000 people:

- 11 hospitals- 9 Beds- 14 Nurses- 8 Nurse assistants

Major Health Indicator: Diabetes

● Diabetes is becoming a health crisis in developing countries

● It has been on a steady climb in Nicaragua now affecting over 10% of the population

● The increasing trend is due to a lack of education, poor diets, and inefficient healthcare

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Diabetes Causes 6% of total Deaths

Salubrista a Community Health Worker

● Salud means health, Barrio means neighborhood● Salubristas are commonly known around the world as

community health workers● 5 salubristas currently in Network of 2,500 people● Job description:

○ Basic health assessments at community health home

○ Basic health education○ Home visits in remote areas○ Notify health needs of community in time

sensitive manner○ Keep paper records of visits and education

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Image: perspectivasalubrista.blogspot.com

Salubristas

Patient visiting Salubrista home clinic number 1 for care

Salubrista making home visit to house Number 3

Patient House Numbers

Salubrista House Sign

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Community Health Workers in Puerto Cabezas, setting up a care network. Two primary means of care. Patient home visits & visits to Salubristas home clinics

Influence diagram

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Shows stakeholder influence w.r.t mHealth implementation.

● Government has high power & mild interest.

● MITRE has medium power & high interest.

● Salubristas & Diabetic citizens have low power & varied interest.

Tension Diagram Major Tensions:

- Funding

- “Projectitis” - Project Fatigue

- Patient trust in new technology

13Original Graphic

Problem and Need● Salubristas have limited medical

background (if any) and no patient management techniques.

● Diabetes is on a rise and the network is growing.

In order to meet these needs, a system is needed that:

● Provides patient management techniques

● Provides diabetic information through the use of mobile technologies

Growing Network

Increase in Diabetic Indicators

Increase in Diabetics

Increase in Need for Care

Limited # of Salus.

Limited Education of Salus.

Unmet Needs

No Patient Manag. System 14

Project Objectives● Create or find an mhealth solution to increase access to healthcare. ● Show effects of mhealth in a developing country.● Choose an mHealth solution that lowers burden of diabetes.

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Mission Requirements

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*Measured by Disability Adjusted Life Year (DALY)

Number Requirement

MR.1 The system shall operate in the Salubrista healthcare network.

MR.2 The system shall provide means for managing patient data.

MR.3* The system shall reduce the burden of diabetes by 2 months per 1000 over 5 years.

Population Statistic: Measure of Diabetes Burden

● MR.3 The system shall reduce the burden of diabetes by 2 months per 1000 people ● Disability Adjusted Life Years (DALY) [1][2]

○ One DALY represents one lost year of “healthy” life in a population○ This is a measure of the burden of living with a disease such as diabetes○ Nicaragua’s DALY due to Diabetes is 12

17Image: Wikipedia DALY Link:https://en.wikipedia.org/wiki/Disability-adjusted_life_year#/media/File:DALY_disability_affected_life_year_infographic.svg [1] Havelaar, A., Prof. (2007). Methodological choices for calculating the disease burden and cost-of-illness of foodborne zoonoses in European countries . Retrieved November, 2017.[2] Metrics: Disability-Adjusted Life Year (DALY). (n.d.). Retrieved February, 2018, from http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/

Salubrista Healthcare Model

18Salubristas

Supervisor Salubrista Home

[3] One Million Community Health Workers(Rep.). (n.d.). Retrieved November, 2017, from ColumbiaUniversity website: http://www.millenniumvillages.org/uploads/ReportPaper/1mCHW_TechnicalTaskForceReport.pdf

● MR.1 The system shall operate in the Salubrista Healthcare Network

mHealth Opportunity in Salubrista Network

mHealth can aid Salubristas with diabetes information and diabetes management

New tool in their toolbox

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Salubrista Center Supervisor

(Emily)

Salubrista

mHealth [3] One Million Community Health Workers(Rep.). (n.d.). Retrieved November, 2017, from ColumbiaUniversity website: http://www.millenniumvillages.org/uploads/ReportPaper/1mCHW_TechnicalTaskForceReport.pdf

Simulation Goal and Requirements

GOAL: Simulate and quantify the impact

of mHealth on diabetic patients.

● The impact is measured by Disability

Adjusted Life Years (DALY)

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Simulation Requirements

Shall estimate DALY within 35% of 12 Nicaragua’s*

Shall track HbA1C of patients

Shall run for more than 20 years per patient

Shall record number of cases for diabetic complications

Shall record the years of life lost due to diabetes

Shall represent a stochastic process of diabetes progression* Diabetes DALY NI = 12.1

(healthdata.org/nicaragua)

Simulation Metrics

● HbA1C - Diabetes indicator○ It shows glucose regulation for past 3-4 months[5]

○ Expressed as a percentage

● Health Utility Index (HUI)[6]

○ A measure of patient health○ Penalties determined through Medical Studies○ Lower HUI is worse ○ Value between 0-1

■ 0 → Death ■ 1 → Perfect Health

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HbA1C Range

Image source: https://www.webmd.com/diabetes/guide/glycated-hemoglobin-test-hba1c[5] Guide to HbA1c. (n.d.). Retrieved from https://www.diabetes.co.uk/what-is-hba1c.html[6] Horsman, J., Furlong, W., Feeny, D., & Torrance, G. (2003). The Health Utilities Index (HUI®): Concepts, measurement properties and applications. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC293474/

Modeling Concepts

1. Randomness associated with the human factors

2. Progression of Diabetes

3. mHealth as an intervention for diabetes

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● Simulation model uses a Monte Carlo method● Why Monte Carlo:

○ Monte Carlo models the randomness of human factors by sampling three attributes

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Randomness of Human Factors Model

Attribute Distribution

HUI ~ N (0.7, 0.05)[2]

HbA1C ~ Unif (6.5,9)

Age ~ Unif (20,40)

[7] Zhou, H., Isaman, D. J., Messinger, S., Brown, M. B., Klein, R., Brandle, M., & Herman, W. H. (2005, December 01). A Computer Simulation Model of Diabetes Progression, Quality of Life, and Cost. Retrieved from http://care.diabetesjournals.org/content/28/12/2856.supplemental

Markov Chain Model for Diabetic Progression

Diabetes progression modeled via Markov Chain states:

● Each state represents a diabetic complication● Two complication categories

○ Microvascular and Macrovascular○ 6 Different paths○ 19 possible states

● Complications incur a penalty to the patient’s Health Utility Index (HUI)

● Progression is linear

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Transitional Probability

HUI Penalty HUI Penalty

mHealth Intervention

● 3 month HbA1C change is randomly distributed

○ 3 month HbA1C change ~ N(0.54,0.11) [3]

● mHealth improves the HbA1C change

1. Education improves the change up to 10%[4]

2. Patient Management improves the change up to 8%[5]

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[8]Hirst, J. A., Stevens, R. J., & Farmer, A. J. (n.d.). Changes in HbA1c Level over a 12-Week Follow-up in Patients with Type 2 Diabetes following a Medication Change. Retrieved from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0092458[9] Zareban, I., Karimy, M., Niknami, S., Haidarnia, A., & Rakhshani, F. (2014). The effect of self-care education program on reducing HbA1C levels in patients with type 2 diabetes. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4275624/[10] Cho, J., Chang, S., Kwon, H., Choi, Y., Ko, S., Moon, S., . . . Yoon, K. (2006, December 01). Long-Term Effect of the Internet-Based Glucose Monitoring System on HbA1c Reduction and Glucose Stability. Retrieved from http://care.diabetesjournals.org/content/29/12/2625.short

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Simulation Full Picture

Baseline(no mHealth)

mHealth

Mean DALY

16 years lost Per 1000 healthy and

diabetic people 15 years

Variance 14 13

Student's T Test for DALY-Measure for Impact of Diabetes

Number of Replications for each: 1000Degrees of Freedom: 2000Confidence for Mean: 0.01

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Simulation Requirement

Verification

DALY within 35% of 12

Baseline Daly is 16

Hypothesis Result

DALY with mhealth is significantly better than without

99% confident that simulation shows a ~7% improvement in DALY when mhealth is implemented

Design Alternatives: Approaches to deliver mHealthAlternative Description Hardware Cost (per

5 workers)Similarities Differences

Do Nothing (Baseline)

#1: Base Apps

Provide recommendation of mHealth apps

$5 Same applications as #3 & #4

Requires user to own phone

#2: Tablet Provide tablet with applications downloaded

$330 Same applications as #2 & #4

Provides tablet w/ apps. No service

#3: Radio #2 + device to communicate over radio

$900 Same applications as #3 & #4

Provides method of communication

#4: mHealth Platform

Provides place to host various mHealth Apps.

$560 Uses similar types of apps.

Provides storage of patient info.

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Mobile Apps - The Search

- The team filtered through 100+ applications

- Key Filters: Available in Spanish and Valuable to Caregiver

- Those that passed through the filter were visible inspected

- Awareness and treatment apps were not sufficient

- 20 total, education + patient management, were selected for testing

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Mobile Apps - Testing

- A test for trialling, classifying, and rating the quality of mobile health apps developed by Queensland University of Technology in Brisbane, Australia.

- 4 Sections: Engagement, Functionality, Aesthetics, Information- Mean of 4 sections gives “App Quality Score” which is compared to

another section, “App Subjective Score”- Each member performed the MARs test for 5 apps (20 total)- Each test took approximately 15 minutes- Sample Questions:

- “Is the App enterinatining to use?” - “Does the app come from a legitimate source?”

MARs Rating Scale/Test

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Mobile Apps - Chosen Two

Mini book that aims to transmit the essential aspects of diabetes created in collaboration with the Federation of Spanish Diabetics (FEDE)

Custom Excel Dashboard for tracking patients and their basic information/ medical records. 100+ patient records from sponsor are in the dashboard

Diabetes T2

Excel Mobile

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MARS Rating 4.20/5

MARS Rating 4.15/5

Prototype/ Technologies TestPurpose was to determine the functionality of our proposed solution. 10 Participants. 50% not fluent in spanish, but could understand the application. Many people in Puerto Cabezas speak native languages but understand some spanish.

Feedback from Initial Prototype test, the patient management (excel) app will not work for the phone. Result: Changed the alternatives to using tablets.

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Image: Amazon.com

Diabetes T2: “ Will recommend this application to my family in Peru, it’s so easy to use and actually really helpful” - Participant 3

Alt #1 - Base Apps

- This alternative recommends the use of Diabetes T2 and gives the Excel Dashboard. It is expected the Salubrista use their own computer/phone

- Hardware Cost: $5 for five Salubristas

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Pros:- Cheap & Simple- Quick to implement- Highly trainable

Cons:- Limited in impact- Not all Salubristas have

phones- Only one computer in

among 5 Salubristas

Alt #2 - Tablets

- This alternative provides a tablet with the Excel dashboard and Diabetes T2 app downloaded to each Salubrista

- The tablet that would be used is the Amazon Fire 7- Hardware Cost: $330 for 5 Salubristas

Amazon34

Pros:- Allows each Salubristas to

have access to the applications

- Increased impact potential

Cons:- Lacks communication

ability among Salubristas

Alt #3 - Radio Communication

- Provides a ‘smart walkie talkie’, along with the tablet and apps that, that connects to the tablet via bluetooth allowing communication through radio signals

- Walkie talkie device is called Beartooth- Hardware Cost: $900 for five Salubristas

beartooth35

Pros:- Allows Salubristas to

communicate with one another

- Calling up to 10 miles- Texting up to 5 miles

Cons:- Expensive- Communication may

not be significant factor

Alt. #4 - mHealth Platform

● Uses SMS texting to:- Send Diabetes information to patients - Provide Diabetes Decision Support- Store Patient Data

● Hardware Cost: $260 for five Salubristas● Data Costs: $170 per year

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Pros:- Adaptability- Scalability- Interoperability

Cons:- Maintainability- Data Cost

Image: Samsung J1 mini Image: Best Buy LG B470 cost 20$

Platform Capabilities

Text “Wiki diabetes” to dedicated phone #

Demonstration upon request during Q&A.

37Original Graphic

Total System Costs (Beta Test- Generation 1)

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Alt #1 - Mobile Apps

Alt #2 - Tablet

Alt #3 - Radio

Alt #4 - Health System

Developmental Cost* $75,000 $75,000 $75,000 $75,000

Hardware Cost $5 $330 $900 $260

Recurring (yearly) Cost $0.00 $0.00 $0.00 $170Implementation Cost $1,300 $2,500 $3,800 $5,000

Total Cost $77,000 $78,000 $80,000 $81,000

Development Cost represents this project’s total cost:

50 $ x 1,500 hours for a 36 Week Project.

Utility FunctionFunction: 0.70 I + 0 .05 T + 0.05 C + 0.20 M

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Patient Management

Education

Decision Support

CommunicateTime to Implement

MTBFMeantime

Between failure

IMPACT

Semi-subjectively Based on Research

BinaryRanked & normalized

Researched& normalized

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Utility vs. Cost

Factor (weight)Alt #2 - Tablet

Impact (0.7) 0.67

Time (0.05) 0.66Communication (0.05) 0Meantime between failure (0.1) 0.25

Utility 0.55

Chosen Alternative

● Alternative 2 - providing the Salubristas with an Amazon Fire tablet, the excel patient management dashboard, and recommending the use of the app, Diabetes T2

● This will provide the Salubristas with the necessary tools to care for more patients and increase the quality of care provided

● Total cost (minus the $75,000 developmental cost) is $2,900 to provide this for the 5 Salubristas

● We believe this has the ability to be impactful now, but also have the ability to be expanded on and integrated into more areas

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Implementation Strategy

Our strategy is designed to maximize impact of the Tablets & Apps alternative.

● Training salubristas on tablets & apps.● Evaluate system performance.

Two phases of implementation over 10 year lifecycle

● Phase 1: Salubrista Network Beta Test (5 salubristas)- Helps 2,500 people in years 1 - 5.

● Phase 2: Puerto Cabezas (50 salubristas)- Helps 25,000 people in years 5 - 10.

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Expanding into Puerto Cabezas

Google maps43https://en.wikipedia.org/wiki/North_Caribbean_Coast_Autonomous_Region

● Blue circle is Salubrista network.

● Dotted line shows expansion through Capital.

Generation1

Generation 2

RAAN

Nicaragua

Implementation Timeline

Recommendation:Technicians - Check system performance yearly.Surveyors - Administer satisfaction surveys and education test for the first and fourth year.

Measures of Success:15% increase in education over 5 years[11].76% satisfaction among users[12].

44[11] Collins, N., 2015, ‘Why does education improve health? It’s complicated’, Pacific StandardMagazine, from: https://psmag.com/education/why-does-education-improve-health[12] Benchmarks By Sector. (n.d.). Retrieved from http://www.theacsi.org/acsi-benchmarks/benchmarks-by-sector

Thank You ! Dr. Danny Moore (Sponsor)

Dr. Danny Moore, point of contact within MITRE

- Taken three trips to Nicaragua (Two in Puerto Cabezas) non-profit work.

- MS Health Service Administration Internship Requirements (120 hrs/3 trips) helped expand a Community Health Network, Salubrista network, in Puerto Cabezas.

- Brought Systems Engineering to the Salubrista Network by creating an inventory management and reorder system.

Dr. Moore Creating Inventory System45

Research Links

[1] Sequeira, M., Espinoza, H., Amador, J., Domingo, G., Quintanilla, M., de los Santos, T. (February 2011).“The Nicaraguan Health System: An overview of critical challenges and opportunities”. Program for Appropriate Technology in Health. Retrieved from PATH.org, [2] Mechael, P. mHealth interview (personal communication, April 11, 2017).

[3] Mechael, P. mHealth interview (personal communication, July 10, 2017).

[4] Donner, J., Mechael, P. (2013). mHealth in Practice: Mobile technology for health promotion in the developing world, 1st Edition. Bloomsbury, NY.

[5] Werner, D. (2010). Where There Is No Doctor: a village health care handbook, Hesperian, Berkeley, CA.

[6] Premier Research (2016). “Mobile Clinical Research. There’s an App for that”. Retrieved from https://premier-research.com/perspectivemobile-clinical-research-theres-app/

[7] (n.d.). Retrieved November 15, 2017, from http://images.huffingtonpost.com/2016-01-28-1454013075-7132532-shutterstock_143005036.jpg

[8] "Noticias y Eventos News and Events Nouvelles et Événements." Caribbean Studies 37, no. 1 (2009): 327-35. doi:10.1353/crb.0.0100.

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Research Links Cont.

[9] Projects & Operations. (n.d.). Retrieved November 15, 2017, from http://projects.worldbank.org/P152136/?lang=en&tab=procurement&subTab=contractdata

[10] Strengthening the Public Healthcare System. (n.d.). Retrieved November 15, 2017, from http://documents.worldbank.org/curated/en/735091506684947024/pdf/Plan-Archive-2.pdf

[11] Nohair, S. A. (2013). Effectiveness of Levels of Health Education on HbA1c in Al-Qassim Region , Saudi Arabia. International Journal of Health Sciences,7(3), 301-308. doi:10.12816/0006058

[12] Kaplan, W. A. (2006, May 23). Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Retrieved November 15, 2017, from https://globalizationandhealth.biomedcentral.com/articles/10.1186/1744-8603-2-9

[13] Niknami, S., Haidarnia, A., Rakhshani, F., Zareban, I., & Karimy, M. (2014). The effect of self-care education program on reducing HbA1c levels in patients with type 2 diabetes. Journal of Education and Health Promotion,3(1), 123. doi:10.4103/2277-9531.145935

[14] One Million Community Health Workers(Rep.). (n.d.). Retrieved November, 2017, from Columbia University website: http://www.millenniumvillages.org/uploads/ReportPaper/1mCHW_TechnicalTaskForceReport.pdf

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Research Link Cont.

[15] Chib, A. (2010). The Aceh Besar midwives with mobile phones project: Design and evaluation perspectives using the information and communication technologies for healthcare development model. Journal of Computer-Mediated Communication, 15(3), 500-525. doi:10.1111/j.1083-6101.2010.01515.x

[16] One Million Community Health Workers(Rep.). (n.d.). Retrieved November, 2017, from Columbia University website: http://www.millenniumvillages.org/uploads/ReportPaper/1mCHW_TechnicalTaskForceReport.pdf

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