Kronis, Nadine

South Africa

Analysis of characteristics associate with mobile phone usage among patient populations in South Africa

With a growing number of mobile phone subscriptions and access to smart-phone technology in low- and middle-income countries (LMIC), mHealth strategies are increasingly being proposed as useful tools for integration into health service delivery. The potential for integrating mHealth technologies into health service systems in South Africa is promising, as a large proportion of South Africans use mobile phones. While pilot studies in LMICs provide evidence for potential positive impact of mHealth programs, few have gone to scale not only due to lack of funding, but also due to a lack of information to effectively guide the design and implementation of interventions. Context-specific implementation studies and behavioral research are required to ensure these potentially beneficial services are best suited for the population in need. Needs assessments are also necessary to make sure programs reach all populations equitably. Further, each health care setting and program may vary in important ways regarding successful implementation of mHealth strategies. Population dynamics, sensitivity or stigma of health condition, and clinic setting may play important roles in implementation and scale-up. Understanding the landscape of access to mobile technology, which may vary based on income, literacy, sex, or other socio-demographic indicators, is important to understand prior to implementation of mHealth interventions. The objective of this study is to describe the characteristics associated with mobile phone access and use among individuals attending diabetes, maternal and child health, TB, and HIV clinics in South Africa. The results of this study will provide important baseline information for development of future mHealth intitiatives in these clinics.   

Global Health Mentor: Jonathan E. Golub, PhD

This summer, I had the opportunity to work as part of an interdisciplinary team in the Matlosana sub-district of South Africa’s Northwest Province. I had never been anywhere in Africa before, nor did I have any prior experience in public health research, so I was grateful to be placed with a group of people who had a lot of experience doing both. Our project was to conduct the formative research for a patient-centered mHealth platform, intended to improve the HIV continuum of care by reducing the number of patients lost-to-follow-up, or who test positive for HIV and don’t return to the clinic for further test results or treatment initiation. We interviewed patients and healthcare workers at public clinics about their thoughts on the state of HIV care at their clinic and about what could make a mobile phone health intervention successful.

Although we thought our survey was straightforward, it yielded some less than straightforward results, and many were both receptive and critical of mobile phone health interventions over the course of the same interview, revealing a complex network of social and structural inequalities embedded in the provision of healthcare and the HIV epidemic itself. The nurses, counselors, and research staff at the clinic in the township where we stayed generously let me shadow them at work in the tiny space that they already shared between five or more people on any given day, and gave a variety of explanations for why so many patients discontinue their HIV treatment. High unemployment and HIV rates are densely spatially concentrated in urban and peri-urban townships. Despite the advent of democracy, the end of forced residential segregation, and the modest growth of a black middle class within townships, the legacy of apartheid is the confinement of the majority of the African population to impoverished areas with little opportunity for geographical, social, or economic mobility. One adherence counselor noted that many of her patients who defaulted on their HIV treatment were single mothers informally employed as domestic workers who could not ask their employers for days off to visit the clinic or pick up medications because of the risk of losing their jobs.

Other clinicians and patients cited hunger, which Oxfam International estimates affects 25% of South Africans, as another reason patients may experience difficulty adhering to antiretroviral treatment, which must be taken with food. While the medications are free, food is not, creating a complex set of trade-offs that patients must negotiate to ensure their bare subsistence and daily survival. In the context of extremely high unemployment, many South Africans living with HIV and their families depend on a temporary disability grant that pays about $108 US dollars monthly, however, the grant is terminated when the recipient’s CD4 count rises above 350, the point at which someone with a suppressed viral load is considered healthy enough to work. As a result, many patients find themselves in a situation where they have to choose between their continuing their treatment and having enough to eat. Over the course of shadowing the nurses at this clinic, I found myself constantly impressed by their optimistic and life-affirming attitudes when they interacted with their patients, teasing the younger ones about how many children they wanted and asking elderly patients with problems adhering to treatment about when they planned to remarry. These conversations illuminated a side of the South African HIV epidemic that I wasn’t used to reading about or seeing in news coverage: the remarkable success that resource-poor clinics and communities have had normalizing life in a crisis situation, despite the stigma and access problems that still affect people living with HIV.

Since I was on the team as an anthropology student, most of the information I collected and the conclusions that I came to were the product of informal interviews and conversations that were not part of the formal dataset. However, I learned a lot by working on a public health project and believe that global health and anthropology ultimately share a commitment to equitable and sustainable development as well as to social justice, and thus could work in mutually reinforcing ways. 

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October 2020

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