Defined by the WHO as the use of information and communication technologies (ICTs) for health [37], eHealth evolved in the early 2000s with the significant increase of internet users as well as mobile and fixed-line telephone subscribers worldwide. Through the use of technologies such as computers, internet, satellite receivers, mobile phones, and PDAs, eHealth programs aim to improve healthcare service delivery and health outcomes. The field has great potential to promote healthy lifestyles, improve health decisions by both providers and patients, and facilitate sharing of medical information. Moreover, technology use promises to improve healthcare system efficiency and promote prevention via behavioral change, thus reducing healthcare costs. These benefits also extend to LMICs with the spread of wireless networks, particularly allowing access of eHealth solutions to healthcare providers and patients in remote geographical areas [38].
The initial focus of eHealth initiatives was the use of the internet to provide access to health-related information, introducing benefits to various areas such as health information systems (HIS) development, knowledge management, electronic patient health records, open access to electronic medical journals, and eLearning and training for healthcare professionals. The number of mobile phone users, however, reached a global penetration rate of 49% at the end of 2007 [38], as opposed to only 20% penetration of internet users [39]. Further, the cost of mobile phones began to rapidly decrease, enabling web browsing, global positioning system (GPS) navigation, and email access in relatively inexpensive phones. Though such smartphone features were still relatively sophisticated to LMICs, basic SMS functionality and real-time communication capacity of mobile phones still offered a wide range of potential benefits to their health sectors. The rapid uptake of mobile communication technologies and
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growing interest in mobile telemedicine, in addition to mobile phones allowing LMICs with poor infrastructure to bypass fixed-line technology, drove the WHO to begin a mobile eHealth (mHealth) strategy in 2007 [38].
The field of mHealth had encompassed since 2003 the health‐related uses of mobile telecommunication and multimedia technologies such as mobile phones and PDAs within health service delivery and public health systems [10,22]. However, with the unexpected spread of mobile telecommunications infrastructure and uptake of handsets and services particularly among LMICs, the definition expanded to include public health and well-being as well as patient monitoring devices and other wireless technologies [7,22]. The term
“mobilephone”had also evolved over the years from being used to denote standard voice and SMS to additionally include multimedia messaging (MMS) and in some cases web browsing and email. The earliest version of a mobile phone with web browsing, email, and the ability to write using a pen or a stylus was referred to as a PDA. Smartphones, the most recent technology, combine the functions of a PDA and a mobile phone in addition to enabling internet access and photo and video capturing [22].
Both mHealth and eHealth work in conjunction to improve health outcomes. In addition to stand-alone mHealth programs, the field also presents an opportunity for strengthening existing eHealth initiatives using a variety of mobile phone features such as voice, SMS, general packet radio service (GPRS), 3G and 4G services, GPS, and Bluetooth technology [7,10]; and covering various application areas. For instance, health education and awareness makes use of the popularity of SMS messages by sending SMS alerts directly to users’
mobile phones, offering information about testing and treatment methods, availability of health services, and disease management. Studies indicate that SMS messages have a greater ability to influence people’s behaviors than television and radio campaigns. Further, SMS
alerts offer the advantage of confidentiality when it comes to diseases that are often considered taboo such as HIV/AIDS. In LMICs, SMS alerts have been effective in targeting hard-to-reach populations where the absence of clinics, lack of healthcare workers, and limited access to health-relatedinformationoftenhinderpeople’sabilitytomakeinformed
decisions about their health [10].
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The area of remote data collection emphasizes on the importance of gathering data, particularly in LMICs where many segments of the population are rarely able to visit a hospital. It most commonly uses PDAs to raise the efficiency of traditional data collection methods such as paper-based surveys, which must be submitted in person or manually entered into a database. The area of remote health monitoring opens possibilities to treating patients on an outpatient basis, thus overcoming problems such as shortage of hospital beds or limited access to clinics often found in LMICs. Health monitoring applications generally use one- or two-way communication to monitor health conditions, maintain medical appointments, or ensure adherence to medications, and sometimes include sensors for monitoring multiple conditions. The area of communication and reporting focuses on training CHWs by connecting them with sources of information via mobile technology, and empowering them to perform their duties effectively and self-sufficiently [10]. Mobile telemedicine offers consultation between healthcare professionals which sometimes extends to CHWs as well, overcoming barriers to accessing expertise and relevant information [7,22].
Point of care and decision support applications tend to provide access to patient health records and information at the bedside [7]. Emergency medical response applications in HICs are mainly intended for the aging population, exploring the effects of wearable devices and sensors with integrated alarm systems connected to emergency departments; whereas in LMICs, they target improved transportation in emergency situations [22].
The first WHO report on mHealth identified increasing trends to migrate many pre-existing eHealth systems onto mobile platforms. However, insufficient impact data on how mobile technologies could influence health outcomes created challenges in identifying and replicating best practices. Accordingly, impact evaluation was considered necessary to move beyond discussions of the potential impact of mHealth, and to transition from pilot and case studies to more formal applications and national programs. The report also identified six types of mHealth technologies, namely mobile phones, PDAs and smartphones, patient monitoring devices, mobile telemedicine/telecare devices, MP3 players, and mobile computing. The most significantly documented feature of mobile phones was text messaging, which gained increasing attention as a means of reminding patients of their medical appointments, thus lowering non-attendance and saving healthcare costs. PDAs were generally used for data collection, processing, communication, and reporting; while smartphones were used to provide support to clinicians at the bedside. Mobile telemedicine and patient monitoring devices intended to reduce patient visits to health facilities via
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transmitting patient information using sensors and wired or wireless telecommunications infrastructure. As MP3 players could carry large amounts of audible content in the form of music or speech, there was a growing trend among universities and schools to use iPods to deliver lectures as part of their educational process. Finally, with the booming mobile software development, smartphones were enabled to provide computer basic functions while in motion, hence mobile computing [38].