[This is a preview of some of the exciting mHealth research being presented at the mHealth Summit on December 3-5, 2012. This abstract and others are candidates for the iMedicalApps-mHealth Summit Research Award]

By: Seneca Perri, RN, PhD candidate, iMedicalApps-mHealth Summit Award Finalist

The Problem

The mortality rate in children under five in sub-Saharan Africa is astounding. Perhaps one of the largest contributing factors for this changeable reality is that heath workers are all too often overburdened, under-supervised, and lack vital resources to effectively care for their patients, especially those serving low resource populations. With better patient counseling and health education, this tragically high mortality rate can dramatically decrease.


Let’s examine the full chain of heath service to understand why health counseling is so essential. Health service delivery begins with finding interventions that work, such as finding ways to diagnose illness and discover medications that can cure disease. Then, resources like medications, know-how, supplies, etc. must be disseminated to front line providers to be implemented. These elements are vital to any public health program. We believe, however, that the key to fundamentally improve high child mortality rates lays one step further, in the realm of health literacy.

Health literacy, or “the degree to which individuals can obtain, process, and understand the basic information and services they need to make appropriate health decisions,” (IOM 2004) may be one of the most essential components of achieving or maintaining good health. Even when effective interventions are available, insufficient counseling has resulted in critically deficient levels of health literacy among the low resource populace. This has consequently produced a large body of disadvantaged individuals who may be unable to fully leverage the already scarce resources that they have.

Health literacy trickles into the clinical interaction between a provider and the caretaker of a child to become the silent doer, and sometimes un-doer, of a successful encounter. Children require their caretakers to act as intermediaries on their behalf; caretakers must interpret and remember the information given to them during clinical visits, and then deliver care as instructed when they return home.

For this to happen, clinical visits must include counseling from providers that empower caretakers with actionable knowledge who will carry out treatment plans. Without this knowledge, caretakers cannot fully know or understand how to apply a treatment plan. The interventions that could cure disease and save lives may fail.

The Solution

With this in mind, we designed a study with the goal of increasing caretaker health literacy. Knowing the advantages that mobile phones can provide, we hoped to leverage optimal caretaker learning and provider communication via the mobile platform. In previous studies in Tanzania, electronic decision support protocols were shown to improve the quality of health service delivery in pediatric patients of low resource populations if appropriately followed. We aimed to build on this improvement by using decision support protocols and mobile technology to further expand the impact of counseling for children’s caretakers, and result in better understanding of what needs to be done at home after the clinical visit.

We designed an intervention that emphasized the counseling prompts of an adapted version of the World Health Organization’s Integrated Management of Childhood Illness (IMCI). Using a randomized cluster design to include 352 participants from six clinics in Dar es Salaam, we allocated clinics to either a test arm using mobile technology, or a control arm using paper. Providers in the test arm used mobile phones with IMCI programmed into a mobile application (eIMCI) to guide clinical encounters with ill children under five. The encounter included a 25-second video formatted for the mobile phone to educate caretakers and cue them to what they should know when the visit was completed.

Providers in the test arm then used the eIMCI application to guide their assessment and treatment plan. Using IMCI protocol content, we embedded communication prompts both within the and at the conclusion of the application that contained the counseling messages for providers to give caretakers. Providers in the control arm used an equivalent protocol in paper format that used the same counseling messages, however were in written text as part of the protocol. An observer who was present during the encounter recorded the type and amount of counseling delivered by providers in each arm. A brief interview was also held with caretakers after the visit to ask them about the information they remembered about their child’s problem and treatment plan.


We found that the providers in the eIMCI group provided statistically significantly more counseling than those in the paper IMCI group in all three key areas. These included the problem of the child, what danger signs to look for that would indicate a need to return to the clinic, and the type of treatment to give and instructions how to give it. Furthermore, caretakers in the eIMCI group reported statistically significantly more than those in the paper IMCI group regarding the diagnoses or problems of their children, more danger signs indicating when to return, and more kinds of correct treatments they would give their children at home.

The knowledge of how many times per day and how many days to give the treatment was not statistically significantly different between the two groups. In summary, our research showed that providers provided more counseling when using the electronic mobile protocol, and caretakers knew more overall and were better able to recall what they were supposed to do when they returned home.


We believe these results are highly valuable to the greater mHealth community which seeks to improve the chain of health service delivery for low resource populations. We know that knowledge and efficiency matter. The mobile platform enables powerful access to both. It is not merely improvement on customer service that we consider; rather it is a matter of human rights.

We insist that the conversation around health literacy must begin and continue until this issue is fully integrated into intervention development. People do not always have access to resources, but they should always have access to knowledge. It can be free and it will save lives.

Seneca Perri, RN, PhD candidate is an experienced electronic medical protocol developer for the mobile platform. She lived and worked in Dar es Salaam, Tanzania serving as the research coordinator on an NIH-funded Harvard School of Public Health study to improve and assess e-IMCI’s impact on provider-caretaker communication. Seneca is currently working on her PhD in Nursing Informatics at the University of Utah with an emphasis on electronic medical decision support for low-resource populations.