Commentary on Harder et al. (2020): Ensuring the sustainability of mHealth in low- and middle-income countries-how do we cure 'pilotitis'?

Abstract

In resource-challenged contexts, mobile health interventions have the potential to boost capacity for the prevention and treatment of heavy drinking. To ensure that impacts are sustained, researchers should consider the wider technological, human resource and health system needs. Alcohol is one of the leading global risk factors for disease and premature death, but people in low- and middle-income countries (LMIC) experience a greater burden compared with those in higher-income countries 5. Increasing take-up of mobile phones in LMIC populations, where health-care services face heightened resource, capacity and geographical challenges, could therefore provide new opportunities for alcohol intervention delivery at scale, and at relatively low cost. Although to date most research relates to Europe, North America and Australasia, there is evidence that mHealth interventions for mental health disorders are also feasible, acceptable and efficacious in LMIC settings 6. However, beyond the initial positive trial results, there are few instances where these types of digital health innovations have led to long-term impacts in global health systems. Common factors that have slowed down the sustained adoption of mHealth interventions in low-, middle- and high-income countries alike, include the skills and attitudes of care providers; cost and/or lack of reimbursement for implementation; limited interoperability and scalability of digital technology; and patient-related concerns, particularly around data protection and confidentiality 7, 8. However, in LMIC settings, certain obstacles are likely to be amplified, particularly those concerning access to appropriate technology and infrastructure 9. Evidence from initiatives that appear to have bridged this translation gap more successfully in less developed regions suggests that the following factors need to be taken into account if mHealth initiatives are to avoid ‘pilotisis’. First, where technology is concerned, simplicity is key. Mobile phone access is relatively high in LMICs (recent data suggest around 80% of Kenyans have access to at least one simple device), but only approximately one in four people own a smartphone 10. As such, low-tech alcohol interventions that can work on basic, cheap phones (such as text messaging or telephone-based therapy, as tested here) may be less likely to exclude socio-economically and/or geographically marginalized populations 11. In rural areas, poor internet and electricity access can present additional barriers, meaning that mHealth initiatives also need to take into account the stability of the national power grid in their implementation plans 12. Secondly, while low-tech interventions can extend the reach of care 6, they often still require real-time input from skilled and experienced health providers to deliver appropriate support to patients. There may also be a need for sufficient numbers of trained local technical operators who can manage and service the mobile devices to be used by the health-care practitioners implementing the mHealth intervention in day-to-day practice 11. As such, it is important that researchers work with local training providers from the outset; for example, by incorporating the relevant skill-set within existing medical curricula, as well as offering accreditation and quality assurance to boost practitioner engagement. Thirdly, and importantly, the sustainability of digital and telehealth initiatives ultimately depends upon them being deployed within a supportive and stable health ecosystem. While mHealth has the potential to boost capacity and access to health-care, it is no panacea for a fundamental lack of leadership, resource and political will to prioritize the prevention and treatment of heavy drinking 13. Others have highlighted the need for more effective country-specific alcohol control policies in sub-Saharan Africa in particular 14. Thus, in order to have a long-term, positive impact on LMIC populations, mHealth advocates need to work with policymakers and service commissioners to ensure that implementation is aligned with a broader set of progressive, evidence-based strategies to reduce alcohol harm. None.