We developed the content for a diabetes self-management support program delivered via cell phones with input from more than 50 physicians, nurses, and behavior change experts. The content was translated into Spanish and pilot tested with Spanish-speaking immigrants in Western Michigan, USA. The technologic infrastructure was developed with specialists in open-source telecommunications programming for low-cost international calling. Prior to implementing the program in rural Honduras, we surveyed more 600+ patients in the target community to identify their mobile phone resources, interests, and needs. We also have met regularly in person and via frequent Skype calls with community leaders in Honduras, local clinicians, and international experts in chronic illness telehealth to get their input on program development. In 2010, we successfully piloted the program in Honduras with 90 patients. That study showed very positive outcomes as measured by patient interviews, physiologic tests, quantitative surveys, and electronic tracking of patients' responses to the automated calls.
We have found that despite these Honduran patients' very low incomes and limited educational attainment, roughly 80% have access to mobile phones. More than 80% reported interest in receiving automated telehealth support for their disease self-management. In our system testing, Honduran clinicians were able to enroll patients via the website, generate patients' weekly automated diabetes support calls, and generate automatic feedback via email, fax, and voicemail for clinicians and patients' family caregivers. Patients were very enthusiastic about using the system and completed roughly four assessments over their six weeks of participation in the study. At follow-up, many patients reported significant improvements in their health and diabetes self-care, and many experienced a substantial improvement in their blood glucose levels. Clinicians used the feedback reports to identify patients needing additional follow-up, health education, and medication changes. Family caregivers reported that the system was easy to use and that they were able to provide more effective support for their patient-partner.
What will it take for your project to be successful over the next three years? Please address each year separately, if possible.
In the next year, we hope to conduct a larger community-based trial in Honduras to evaluate the service's longer-term impacts on diabetes patients' glycemic control, self-care behaviors, and use of health services. To do that, we need to identify funding from NIH global health initiatives, international foundations, or private businesses (multiple applications are in process).
Over the next two years, we need to make further advances in understanding how to provide this service on a large international scale using robust telecommunications approaches and a sustainable business model. A huge advantage of cloud-computing is that the content for disease management programs can be developed by experts anywhere in the world. Low-income communities can share telecommunication resources – dramatically decreasing their costs. With this service, healthcare workers can increase patients’ access to health information between face-to-face visits without managing the infrastructure making the service possible. Ultimately the provider of the service should be outside of the University of Michigan, e.g., in a non-profit organization dedicated to the program, an international relief organization, a national governmental agency, or a telecommunication provider with a strong commitment to improving community health. We also need to develop and test options for transfering the communication platform to smaller, portable hardware environments such as a laptop or even an iPhone. All of these challenges are highly addressable, but will require even closer collaborations with telecommunication experts than we have established to date, including large telecommunication companies in Central America.
In year 3 and beyond, we need to establish a strong business model for the program, and broaden the content-base so that we can address other high-priority conditions such as asthma, neonatal complications, and mosquito-borne diseases. We need to establish an advisory council with expertise in social entrepreneurship, and market the results of our work to national governments and other potential sources of financial support. Working groups will be required to develop the content for messaging to patients, family caregivers, and clinical teams that is linguistically appropriate and improves patients' care without further burdenening already scarce clinical resources.
What would prevent your project from being a success?
Funding for international projects such as this one tends to be fragmented, short-term, and scarce. To date, we have been very successful leveraging in-kind personnel support from our excellent partner organization in Honduras (Yojoa International Medical Center), as well as the support of students from our university School of Public Health, and small amounts of discretionary funding available to the applicant. We are actively pursuing a very broad approach to seeking funding for the next phases of work, including support from: (1) US National Institutes of Health grants for global initiatives; (2) grants from relevant private foundations and businesses such as from Cisco Systems, Vodafone, and the Gates Foundation, (3) national government funders in Mexico, and (4) partnerships with private companies that have a social service arm and serve the geographic area where our projects take place, such as TIGO, the large telecommunication company in Central America.
Developing a creative telecommunication program for disease management will have limited impact on health outcomes if patients have no access to resources such as medications or glucose monitoring supplies. We are continuing discussions with local clinical leaders, patients, and groups such as the International Diabetes Federation so that the services we develop give realistic advice to patients for practical ways they can improve their health status given the very real shortages of health care resources in under-developed countries.