Ethical issues in the use of SMS messaging in HIV care and treatment in low- and middle-income countries: case examples from Mozambique

Abstract

The introduction of mobile communication technologies in health care in low- and middle-income countries offers an opportunity for increased efficiencies in provision of care, improved utilization of scarce resources, reductions in workload, and increased reach of services to a larger target population. Short message service (SMS) technologies offer promise, with several large-scale SMS-based implementations already under way. Still largely lacking in the research literature are evaluations of specific ethical issues that arise when SMS programs are implemented and studied in resource-limited settings. In this paper, we examine the ethical issues raised by the deployment of SMS messaging to support patient retention in HIV care and treatment and in the research conducted to evaluate that deployment. We use case studies that are based in Mozambique and ground our discussion in the ethical framework for international research proposed by Emanuel et al., highlighting ethical considerations needed to guide the design and implementation of future SMS-based interventions. Such guidance is increasingly needed in countries such as Mozambique, where the local capacity for ethical study design and oversight is still limited and the scale-up and study of mHealth initiatives are still driven predominantly by international collaborators. These issues can be complex and will need ongoing attention on a case-by-case basis to ensure that appropriate protections are in place, while simultaneously maximizing the potential benefit of new mHealth technologies.

Utility of Short Message Service (SMS) for Remote Data Collection for HIV in Low- and Middle-Income Countries

“…While phones were provided to participants in many early SMS studies, it is increasingly less common to do so as frequency of phone ownership has increased [ 35 ] and due to concerns that phone provision may not increase participation if phones may be sold or used for other purposes [ 55 ]. As a result, phone provision was not determined to be a scalable or sustainable approach to digital health programs [ 39 , 56 ]. However, in areas where mobile phones and SMS literacy are not ubiquitous, SMS engagement may be sub-optimal [ 57 ] and training can result in substantial start-up costs and delays [ 49 ].…”

The telemedical imperative

“…Ossemane and colleagues discuss two SMS interventions in Mozambique that work to improve the retention of HIV+ patients in treatment. 33 Interestingly, given that telemedicine is often implemented to reach those in rural areas, one of these interventions found success in urban patients but not rural patients. 34 It must be noted, however, that just because a telemedical service is effective in general it is not necessarily effective in all situations.…”

Ethics as a Non‐technical Skill for Surgical Education in Sub‐Saharan Africa

“…A recent addition to research effort in SSA is mobile phone usage for collecting and sending research data. How the data are used and other ethical issues are in the early stages of study as reported by Ossemane and colleagues [64]. Also, online data collection and storage methods such as REDCap (which may be institution-based in the West as well as in Africa) [65] focus attention on the issue of data ownership and how data are used.…”