Using mHealth to Prevent and Treat Diarrheal Diseases in Sub-Saharan Africa Diarrhea is responsible for many childhood deaths in Sub-Saharan Africa due to lack of access to clean water and sanitation. [1] Existing solutions include breastfeeding, nutrition, oral rehydration, and antibiotics but are not fully implemented. [2] mHealth initiatives could help by sending reminder texts about handwashing and treatment. Tracking cases through mobile texts could also help prevention. [3] The best potential solution is simple text reminders about hygiene to address the major risk factor in a low-cost way.

1. Using mHealth to Prevent and Treat
Diarrheal Diseases in
Sub-Saharan Africa

2. 1. Introduction and Affected Population
2. Low Hanging Fruit
3. Existing solutions
- Existing non-technological solutions
- Existing mHealth Solutions
4. Effectiveness
5. Best Potential Solution
6. Sources
Overview

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4. 1. Introduction and Affected Population
Over 2 million children a year die from diarrhea and its complications, making in the second leading cause of death in children
under 5 after respiratory infections. Diarrhea and its complications cause more deaths in children under 5 years of age than
malaria and HIV/AIDS combined each year. Addressing diarrheal diseases is not easy, there are many social, economic, and
physical factors that affect access to clean water, proper sanitation practices, etc. In addition to that, new aspects such as the
privatization of water are coming in (IFPRI, 2003) as well as efforts made in the countdown for the fulfillment of the millennium
development goals in 2015 (Countdown to 2015,2013). Lack of access to bathroom facilities, lack of sanitary education and
preventative health education, poor water quality, and close living spaces in urban areas are especially important factors in the
frequency and severity of diarrheal episodes. Diarrheal disease causes and solutions vary greatly from place to place, for example
in monsoon areas too much water, contaminated by open defecation, is the main issue, while in sub-Saharan Africa too little
water is usually an issue, leading to lack of proper sanitation and hygiene practices.
Affected Population and Regionality:
Diarrhea is responsible for 750,000 of the 4.3 million childhood deaths in Sub-Saharan Africa. That is 40% of the cases of diarrhea
worldwide, meaning Sub Saharan Africa has an especially high concentration of diarrheal disease deaths.
“Approximately 50 percent (300 million individuals) of the African population have no access to safe water, and 66 percent (400
million individuals) lack access to hygienic sanitation. It is expected that by the year 2020 these figures will rise to 400 million and
500 million, respectively.”

5. 2. Low Hanging Fruit
The most important risk factors for diarrheal diseases are poor access to safe water and sanitation and poor hygiene and feces
disposal practices at home (Daniels et al. 1990; Haggerty et al. 1994; LaFond 1995; MacDougall and McGahey 2003). Proper
sanitation practices, such as washing hands, which are based mostly in behavior change, are proven to be the most essential
factor in drastically decrease diarrheal disease frequency and severity.
“Other factors, such as poor housing and crowding, are intrinsically associated with poverty. Furthermore, poverty usually limits
access to health care and restricts appropriate and balanced diets. Inequities in exposure and resistance add up to inequities in
coverage of available preventive interventions, access to an appropriate health provider, and care, making poor children more
likely to become sick than the better-off children (Victora et al. 2003). (http://www.ncbi.nlm.nih.gov/books/NBK2302/)
Diarrheal diseases don't just cause death, they greatly diminish a child's physical and mental health, and can lead to poor
development and increases susceptibility to other diseases. Something that is gaining evidence is that proper nutrition can
drastically reduce the number and severity of diarrheal diseases cases.
Both non-technological and mHealth solutions can share and promote proper sanitation practices. Mobile health could play an
enormous role in this issue.

6. 3.1. Existing Non-Technological Solutions
Many interventions are proven effective to prevent and treat diarrheal diseases (Jones et al. 2003). Interventions proven to
prevent and treat diarrheal diseases include: exclusive breastfeeding, complementary feeding, safe water, good sanitation and
hygiene, zinc and vitamin A supplementation, ORT, and antibiotics for dysentery. An estimated 22 percent of deaths due to
diarrhea can be prevented by these interventions (Jones et al. 2003).
“Most of these interventions are feasible for implementation in low-income countries such as those in the African region;
however, the capacity to deliver these important interventions effectively should be strengthened” (Bryce et al. 2003).
(http://www.ncbi.nlm.nih.gov/books/NBK2302/)

7. 3.2. Existing mHealth solutions
There are many mHealth initatives that are broadly addressing Maternal and Child Health in the world and in Sub Saharan
Africa, an important first step in preventing childhood deaths (http://bit.ly/12bDzVK) . mHealth interventions specific to diarrheal
disease prevention are limited, and very few focus on diarrheal diseases specifically.
• A new pilot study conducted by Alison M. Buttenheim, PhD, MBA of the University of Pennsylvania School of Nurtsing is
investigating is mHealth technologies can encourage more use of Oral Rehydration Therapy to treat diarrheal cases.
“The work of Dr. Buttenheim and colleagues will aim to determine the potential of mHealth to address ORT in Cono Norte, a
community of 30,000 in Arequipa, Peru. Research shows that mHealth can strengthen efforts in disease monitoring, remote
diagnosis, medication adherence, appointment reminders, and health education and promotion. Through cell phones, mothers
will receive timely and targeted text messages about treatment of diarrheal symptoms (including learning the closest retail
location for ORT packets) and then provide information about the health status and treatment outcomes of their children to a
local health clinic.” http://www.newswise.com/articles/the-mobile-health-remedy
• In Laos, health care providers are tracking diarrheal disease cases through mobile phone texts. This can help track and treat
diarrhea, as well as prevent it in the long term once pathways of disease transmission are determined.
(http://geocommons.com/users/blewislao/maps?order=desc&page=1&sort=created) provides maps of the datasets, uploaded by
Barbara Lewis.

8. 4. Effectiveness
The efficacy of existing interventions to prevent or treat diarrheal diseases are proved. Large reductions in child mortality can be
achieved with their implementation if proper planning, implementation and evaluation are completed. As of now, non-technical
solutions are not being implemented enough, perhaps due to financial limitations, social or cultural limitations, or health care
availability.
mHealth solutions could provide the edge needed to more effectively implement diarrheal disease prevention and treatment
initiatives.
Something to keep in mind: in most of these Sub-Sahara African communities, mobile phones are NOT smartphones. They are
very simple phones with few capabilities, especially phones owned by women. However many people to also have 'smartish-
phones', though maybe not capable of having an application, can show videos.
First and foremost, hand washing should be promoted through diarrheal disease prevention. This could be done through text
messaging, or even reminder video downloads to capable phones.
Secondarily, the promotion of ORT, exclusive breastfeeding, proper childhood nutrition, and supplementation programs (e.g.
vitamin A, deworming, etc) should be made a priority. There are several steps to take into account when addressing these
initatives as stated in the later slides.

9. 4. Effectiveness
Birth
• Pre-birth and when-born information to the mother is a key. The mother should understand what she should do in different
situations. This can be e.g. educated by quizzes, information, (non technological) or more technological solutions like videos on
phones or text messages.
Growing-up
•The prevention aspect is still a key. Tools or text messages like regular reminders of basic rules / aspects as well as a possibility to
connect to doctors and have e.g. sms or video exchange on the health of the little one could be helpful
In case of sickness
• It is important to find a low-cost way of having information what to do in case it gets sick
In case it gets severely sick
• In this case, it is important to have a e-health record of the child that can be seen in any hospital you go to. The mother should
also be able to reach a nurse within the region through mobile applications or text messaging in the first parts of the sever
sickness. (Again, important to note that often internet and other more technologically advanced applications and materials are
not available, even to doctors. Important to keep the activities as simple and cost-efficient as possible, especially because in many
of these areas medications are not regularly stocked as they should be, and the infrastructure not necessarily maintained).

10. 4. Effectiveness
In addition, mHealth activities to track diarrheal diseases would be helpful in continuing prevention and treatment. This is a more
difficult solution logistically, since health infrastructure and workers may be unorganized and limited, and community members
cannot afford to send text messages or are not literate and therefore cannot send them. It would be very important to address
local phone use patterns, and do proper monitoring and evaluation in order to ensure effectiveness of the program.

11. 5. Best Potential Solution
Text messages to remind community members to wash their hands could be very effective. It would address the low-hanging
fruit, proper hygiene, in a simple and inexpensive way. In low-income communities where phones are common and at least one
member of the family is literate, such as a son or daughter going to school, this would be the simplest way to incorporate mHealth
in a culturally and economically appropriate way.
In this solution, all community members, after receiving a face-to-face training with a local health worker, receive text messages
to remind them to wash their hand before each meal. Eating with hands is very common and often preferred in Sub Saharan
Africa, both in rural and urban areas. This could lead to positive peer pressure if all members of the community receive the texts
on a regular basis, perhaps weekly.
On capable phones, videos and photos could also be taken or uploaded as reminders. Communities respond to positive peer
pressure, and a doctor can take a photo of a specific person in the community washing their hands, and upload it to another's
phone or print the photo and put it up in the health facility. People respond very well to photos, videos, and calls or text messages
from friends.
It would be essential to do proper monitoring and evaluation, to make sure the initiative is appropriate. If not, the mHealth
solution could go to waste (http://www.fiercemobilehealthcare.com/story/community-health-workers-developing-countries-
have-mixed-results-mhealth/2013-01-28).

12. 6. Sources
• http://www.ncbi.nlm.nih.gov/books/NBK2302/
• http://www.newswise.com/articles/the-mobile-health-remedy
• http://geocommons.com/users/blewislao/maps?order=desc&page=1&sort=created
• https://www.diigo.com/bookmark/http%3A%2F%2Fsites.healthunbound.org%2Fcontent%2Fmhealth-summit-review-
challenges-impacting-maternal-and-child-mhealth?tab=people&uname=maremel
• http://www.fiercemobilehealthcare.com/story/community-health-workers-developing-countries-have-mixed-results-
mhealth/2013-01-28