Objective: Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries (LMICs). Mobile health technologies may improve noncommunicable disease outcomes, but LMICs lack resources to provide these services. We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure (BP) monitoring as a strategy for improving systolic BPs (SBPs) and other outcomes of hypertensive patients in two LMICs. Subjects and Methods: This was a randomized trial with a 6-week follow-up. Participants with high SBPs ( ‡140 mm Hg if nondiabetic and ‡130 mm Hg if diabetic) were enrolled from clinics in Honduras and Mexico. Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States, plus a home BP monitor. At baseline, control patients received BP results, hypertension information, and usual healthcare. The primary outcome, SBP, was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs. Secondary outcomes included perceived health status and medicationrelated problems. Results: Of the 200 patients recruited, 181 (90%) completed follow-up, and 117 of 181 had low literacy or high hypertension information needs. The median annual income was $2,900 USD, and average educational attainment was 6.5 years. At follow-up intervention patients' SBPs decreased 4.2 mm Hg relative to controls (95% confidence interval -9.1, 0.7; p = 0.09). In the subgroup with high information needs, intervention patients' average SBPs decreased 8.8 mm Hg ( -14.2, -3.4, p = 0.002). Compared with controls, intervention patients at follow-up reported fewer depressive symptoms (p = 0.004), fewer medication problems (p < 0.0001), better general health (p < 0.0001), and greater satisfaction with care (p £ 0.004). Conclusions: Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs. A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support.
Background
Although interactive voice response (IVR) calls can be an effective tool for chronic disease management, many regions of the world lack the infrastructure to provide these services.
Objective
This study evaluated the feasibility and potential impact of an IVR program using a cloud-computing model to improve diabetes management in Honduras.
Methods
A single group, pre-post study was conducted between June and August 2010. The telecommunications infrastructure was maintained on a U.S. server, and calls were directed to patients’ cell phones using VoIP. Eighty-five diabetes patients in Honduras received weekly IVR disease management calls for six weeks, with automated follow-up emails to clinicians, and voicemail reports to family caregivers. Patients completed interviews at enrollment and a six week follow-up. Other measures included patients’ glycemic control (A1c) and data from the IVR calling system.
Results
55% of participants completed the majority of their IVR calls and 33% completed 80% or more. Higher baseline blood pressures, greater diabetes burden, greater distance from the clinic, and better adherence were related to higher call completion rates. Nearly all participants (98%) reported that because of the program, they improved in aspects of diabetes management such as glycemic control (56%) or foot care (89%). Mean A1c’s decreased from 10.0% at baseline to 8.9% at follow-up (p<.01). Most participants (92%) said that if the service were available in their clinic they would use it again.
Conclusions
Cloud computing is a feasible strategy for providing IVR services globally. IVR self-care support may improve self-care and glycemic control for patients in under-developed countries.
even in this poor region of Honduras, most chronically ill patients have access to mobile technology, and most are willing to participate in automated telephone disease management support. Given barriers to in-person care, new models of mobile healthcare should be developed for chronically ill patients in developing countries.
Both the screening equation and POC-A1c are reasonable alternatives to an FPG test for identifying patients with diabetes. Given the barriers to currently recommended screening procedures, these options could have important public health benefits in Latin America.
The U.S. financial crisis has affected employment opportunities for Latino immigrants, and this could affect their ability to send financial assistance, or "remittances", to chronically ill family members in their home country. In a cross-sectional survey of 624 chronically ill adults conducted in Honduras between June and August 2009, respondents reported their receipt of remittances, health service use, and cost-related access barriers. Fifty-four percent of respondents reported relatives living outside the country, and of this group, 66 percent (37% of the overall sample) received remittances. Seventy-four percent of respondents receiving remittances reported a decrease over the prior year, mostly due to job losses among their relatives abroad. Respondents reporting reductions in remittances received significantly less per month, on average, than those without a reduction (US $170 vs. $234; p = 0.01). In multivariate models, respondents experiencing a reduction in remittances used fewer health services and medications due to cost concerns. Remittance payments from relatives resident in the United States are a major source of income for chronically ill individuals in Latin America. Most recipients of remittances reported a reduction during the financial downturn that affected their access to care.
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