AIDS and Behavior

, 15:1776

Impact of a mHealth Intervention for Peer Health Workers on AIDS Care in Rural Uganda: A Mixed Methods Evaluation of a Cluster-Randomized Trial

  • Larry W. Chang
  • Joseph Kagaayi
  • Hannah Arem
  • Gertrude Nakigozi
  • Victor Ssempijja
  • David Serwadda
  • Thomas C. Quinn
  • Ronald H. Gray
  • Robert C. Bollinger
  • Steven J. Reynolds
Original Paper


Mobile phone access in low and middle-income countries is rapidly expanding and offers an opportunity to leverage limited human resources for health. We conducted a mixed methods evaluation of a cluster-randomized trial exploratory substudy on the impact of a mHealth (mobile phone) support intervention used by community-based peer health workers (PHW) on AIDS care in rural Uganda. 29 PHWs at 10 clinics were randomized by clinic to receive the intervention or not. PHWs used phones to call and text higher level providers with patient-specific clinical information. 970 patients cared for by the PHWs were followed over a 26 month period. No significant differences were found in patients’ risk of virologic failure. Qualitative analyses found improvements in patient care and logistics and broad support for the mHealth intervention among patients, clinic staff, and PHWs. Key challenges identified included variable patient phone access, privacy concerns, and phone maintenance.


mHealth Community health workers HIV Cluster-randomized trial Mixed methods research 


  1. 1.
    Kaplan WA. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Global Health. 2006;2:9.PubMedCrossRefGoogle Scholar
  2. 2.
    Lester R, Karanja S. Mobile phones: exceptional tools for HIV/AIDS, health, and crisis management. Lancet Infect Dis. 2008;8(12):738–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Vodafone. Africa: The impact of mobile phones. Vodafone Policy Paper Series. 2005; Report No.: 2.Google Scholar
  4. 4.
    International Telecommunication Union. World telecommunication/ICT development report. Geneva; 2010.Google Scholar
  5. 5.
    Catwell L, Sheikh A. Evaluating eHealth interventions: the need for continuous systemic evaluation. PLoS Med. 2009;6(8):e1000126.PubMedCrossRefGoogle Scholar
  6. 6.
    Greenhalgh T, Russell J. Why do evaluations of eHealth programs fail? An alternative set of guiding principles. PLoS Med. 2010;7(11):e1000360.PubMedCrossRefGoogle Scholar
  7. 7.
    Haberer JE, Kiwanuka J, Nansera D, Wilson IB, Bangsberg DR. Challenges in using mobile phones for collection of antiretroviral therapy adherence data in a resource-limited setting. AIDS Behav. 2010;14(6):1294–301.PubMedCrossRefGoogle Scholar
  8. 8.
    Kahn JG, Yang JS, Kahn JS. ‘Mobile’ health needs and opportunities in developing countries. Health Aff (Millwood). 2010;29(2):252–8.CrossRefGoogle Scholar
  9. 9.
    Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball TB, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet. 2010;376(9755):1838–45.PubMedCrossRefGoogle Scholar
  10. 10.
    Pop-Eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, de Walque D, Mackeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS. 2011;25:825–34.PubMedCrossRefGoogle Scholar
  11. 11.
    World Health Organization. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector: progress report 2010. Geneva: World Health Organization; 2010.Google Scholar
  12. 12.
    World Health Organization. Scaling up HIV/AIDS care: service delivery and human resource perspectives. Geneva: World Health Organization; 2004.Google Scholar
  13. 13.
    World Health Organization. Global recommendations and guidelines on task shifting. Geneva: World Health Organization; 2007.Google Scholar
  14. 14.
    Lewin SA, Dick J, Pond P, Zwarenstein M, Aja G, van Wyk B, Bosch-Capblanch X, Patrick M. Lay health workers in primary and community health care. Cochrane Database Syst Rev. 2005; (1):CD004015.Google Scholar
  15. 15.
    Sanders D, Haines A. Implementation research is needed to achieve international health goals. PLoS Med. 2006;3(6):e186.PubMedCrossRefGoogle Scholar
  16. 16.
    Zachariah R, Harries AD, Ishikawa N, Rieder HL, Bissell K, Laserson K, Massaquoi M, Van Herp M, Reid T. Operational research in low-income countries: what, why, and how? Lancet Infect Dis. 2009;9(11):711–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Zwarenstein M, Treweek S, Gagnier JJ, Altman DG, Tunis S, Haynes B, Oxman AD, Moher D. Improving the reporting of pragmatic trials: an extension of the CONSORT statement. BMJ. 2008;337:a2390.PubMedCrossRefGoogle Scholar
  18. 18.
    Chang LW, Kagaayi J, Nakigozi G, Ssempijja V, Packer AH, Serwadda D, Quinn TC, Gray RH, Bollinger RC, Reynolds SJ. Effect of peer health workers on AIDS care in Rakai, Uganda: a cluster-randomized trial. PLoS One. 2010;5(6):e10923.PubMedCrossRefGoogle Scholar
  19. 19.
    Chang LW, Kagaayi J, Nakigozi G, Packer AH, Serwadda D, Quinn TC, Gray RH, Bollinger RC, Reynolds SJ. Responding to the human resource crisis: peer health workers, mobile phones, and HIV care in Rakai, Uganda. AIDS Patient Care STDS. 2008;22(3):173–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. Thousand Oaks: Sage Publications, Inc.; 2007.Google Scholar
  21. 21.
    Oakley A, Strange V, Bonell C, Allen E, Stephenson J. Process evaluation in randomised controlled trials of complex interventions. BMJ. 2006;332(7538):413–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Arem H, Nakyango N, Kagaayi J, Mulamba J, Nakigozi G, Serwadda D, Quinn TC, Gray R, Bollinger RC, Reynolds SJ, Chang LW. Peer health workers and AIDS care in Rakai, Uganda: a mixed methods operations research evaluation of a cluster-randomized trial. AIDS Patient Care STDS. 2011 Mar 10 [Epub ahead of print]. Google Scholar
  23. 23.
    Chang LW, Kagaayi J, Nakigozi G, Galiwango R, Mulamba J, Ludigo J, Ruwangula A, Gray RH, Quinn TC, Bollinger RC, Reynolds SJ. Telecommunications and health care: An HIV/AIDS warmline for communication and consultation in Rakai, Uganda. J Int Assoc Physicians AIDS Care (Chic Ill). 2008;7(3):130–2.CrossRefGoogle Scholar
  24. 24.
    Reynolds SJ, Kagaayi J, Nakigozi G, Makumbi F, Opendi P, Nakamya P, Gray R, Wawer M, Quinn TC, Lutalo T, Serwadda D. Early immunologic and virologic responses to ART in rural Rakai, Uganda [Abstract THPE0181].Toronto: XVI International AIDS Conference; 2006.Google Scholar
  25. 25.
    Todd J, Carpenter L, Li X, Nakiyingi J, Gray R, Hayes R. The effects of alternative study designs on the power of community randomized trials: evidence from three studies of human immunodeficiency virus prevention in East Africa. Int J Epidemiol. 2003;32(5):755–62.PubMedCrossRefGoogle Scholar
  26. 26.
    Hayes RJ, Moulton LH. Cluster randomised trials: a practical approach. Boca Raton: Chapman & Hall/CRC; 2009.Google Scholar
  27. 27.
    Bangsberg DR. Preventing HIV antiretroviral resistance through better monitoring of treatment adherence. J Infect Dis. 2008;197(Suppl 3):S272–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Boguszewska S. Communications markets in Uganda. Cambridge: Pyramid Research, Inc.; 2009.Google Scholar
  29. 29.
    Stanley R. Village phone-a tool for empowerment. Grameen Foundation USA Publication Series; 2005.Google Scholar
  30. 30.
    Mechael P, Batavia H, Kaonga N, Searle S, Kwan A, Goldberger A, Fu L, Ossman J. Barriers and gaps affecting mhealth in low and middle income countries: policy white paper. New York: Center for Global Health and Economic Development Earth Institute, Columbia University; 2010.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Larry W. Chang
    • 1
  • Joseph Kagaayi
    • 2
  • Hannah Arem
    • 3
  • Gertrude Nakigozi
    • 2
  • Victor Ssempijja
    • 2
  • David Serwadda
    • 2
  • Thomas C. Quinn
    • 4
    • 5
  • Ronald H. Gray
    • 3
  • Robert C. Bollinger
    • 4
  • Steven J. Reynolds
    • 4
    • 5
  1. 1.Division of Infectious Diseases, Department of MedicineJohns Hopkins School of MedicineBaltimoreUSA
  2. 2.Rakai Health Sciences ProgramRakaiUganda
  3. 3.Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  4. 4.Division of Infectious Diseases, Department of MedicineJohns Hopkins School of MedicineBaltimoreUSA
  5. 5.Laboratory of Immunoregulation, Division of Intramural ResearchNational Institute for Allergy and Infectious Diseases, National Institutes of HealthBethesdaUSA

Personalised recommendations