Since 2017, we’ve worked to build, evaluate, improve, and optimize effective mobile health (mHealth) interventions in Malawi, Zimbabwe, and South Africa. We partner with leading providers of HIV-related care in each setting, learning, and listening to the needs and priorities of local leaders. Our mHealth approaches use the open-source Community Health Toolkit (CHT), a global digital good used by over 41,000 healthcare workers (HCWs) over 1.8 million care encounters every month. Each innovation applies a human centered design (HCD) process to optimize for the local context and uses implementation science (IS) to guide rigorous evaluation for high-quality evidence of impact.

  • For healthcare providers, 2wT uses a simple, user-friendly, web-based interface.
  • For clients, 2wT does not require an app: clients communicate using any basic phone’s text capability.
  • Strong evidence of success in post-operative care quality improvement in routine LMIC settings
  • Proactive engagement via daily reminders to monitor and assess wound healing and validate and verify follow-up visits to ensure swift and successful referral
  • Optimized for routine LMIC settings — maximizing human and financial resources
  • Integration of interoperability with existing health information systems

This is the smartphone interface, in English (left) and Setswana (right), showing messages between a provider and client.

 

Applications of 2wT

Zimbabwe: Our first CHT app established a hybrid, two-way text-based telehealth (2wT) system to provide direct patient to provider communication for voluntary medical male circumcision (VMMC) clients in Zimbabwe.

  • 2wT improved follow-up care, increased early detection of complications, engaged clients in their healing process and reduced unnecessary visits to the clinic by almost 90%.
  • Clients and providers liked the 2wT approach. 2wT lowered the costs of post-operative care without decreasing quality.
  • By 2023, 2wT reached over 33,000 males in Zimbabwe, affected policy change, and is scaling up nationally.

 

South Africa: 2wT for VMMC expanded to rural and urban South Africa in 2021, providing similar improvements in care quality, user satisfaction, and efficiency gains across contexts and clinic settings.

 

Malawi: In Malawi, the 2wT approach is being used to improve retention in antiretroviral therapy (ART) during the first year in care when drop-out rates are highest. 

  • 2wT for ART sends weekly motivational messages and specific visit reminders to clients for their individual appointments, letting clients report transfers or request visit changes.

  • 2wT improved early retention in care by 10%, setting new ART clients up for long-term success.

  • Again, both clients and healthcare workers liked the simple, effective approach.

We also adapted CHT to extend an HIV-focused electronic medical records system (EMRS) to community-based settings via our Community-based ART REtention and Suppression (CARES) App.

  • CARES is a tablet-based, battery-operated, mobile, point-of-care (POC) App for real-time, EMRs-guided care, providing high-quality, integrated care in community settings, improving care quality.

 

Future Implementation: We are currently translating 2wT for 1) out-patient follow-up; 2) post caesarean delivery surgical site infection prevention.

Example of Message Flow Between Clients and Providers in South Africa

Starting on the day of circumcision, automated prompts ask about healing. Those who respond with potential complications are followed by a “hub nurse,” or a nurse who monitors the entire system. If they need to be seen in person, the hub refers to a nurse at the client’s facility where a “site nurse,” follows up with the client to ensure completion of the referral. The system generates no response “tasks” for health care providers when a client does not respond to any messages, triggering tracing. 2wT: 2-way texting; VMMC: voluntary medical male circumcision. Published by Fabens et al.