Impact of a mHealth Intervention for Peer Health Workers on AIDS Care in Rural Uganda: A Mixed Methods Evaluation of a Cluster-Randomized Trial
Open accessAbstract
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.
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Health workers perceived direct communication with clients as improving care and trust, while still recognizing that some situations require face-to-face contact.
“Mobile devices facilitated two‐way communication between all categories of health workers and clients (Chang 2011; Garg 2016; Hampshire 2016; Hirsch‐Moverman 2017), and kept health workers informed about the clients' conditions (Barnabee 2014; Huq 2014).”
From Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis (2020) · cites this paper as Chang 2011
The Qualitative Results report that mobile phones improved communication between peer health workers and patients, and that voice calls expedited patient care. They also describe in-person conversations, but do not say that communication improved client trust or that health workers recognized particular situations requiring face-to-face contact. No page numbers are available in our copy. (LLM, conf=0.84)
Experimental — accuracy not yet measuredThe exchange broke the hierarchy between health worker categories, when previously unreachable professionals could more easily be reached.
“The exchange broke the hierarchy between health worker categories, when previously unreachable professionals could more easily be reached (Chang 2011; Huq 2014; Khan 2015).”
From Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis (2020) · cites this paper as Chang 2011
The Results (Qualitative Results; page unavailable) say phones made communication between peer health workers and clinic staff faster and improved their working relationships. They do not establish that the exchange broke a hierarchy between worker categories or that the professionals had previously been unreachable. (LLM, conf=0.86)
Experimental — accuracy not yet measuredHealth workers felt that health promotion and educational messaging directed at clients using mobile health interventions impacted positively on clients' health behaviours.
“Health workers felt that health promotion and educational messaging directed at clients using mobile health interventions, impacted positively on clients' health behaviours”
From Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis (2020) · cites this paper as Chang 2011
In Results > Qualitative Results, a peer health worker said that patients were motivated to take their medication because they knew phone messages reported adherence to clinic staff. This supports the reported perception of a positive effect on client behaviour, but the messages were reports to staff, not health-promotion or educational messages directed at clients. The Discussion also describes the adherence benefit as something only some participants felt occurred; page numbers are unavailable in our copy. (LLM, conf=0.88)
Experimental — accuracy not yet measuredIn the Ugandan peer health worker trial, compared to voice calls, reservations about the lack of immediate response via SMS were noted, privacy concerns were raised, and phone maintenance and charging were problematic.
“As compared to voice calls, reservations about the lack of immediate response via SMS were noted, privacy concerns were raised, and phone maintenance and charging were also problematic.”
From Mobile Health (mHealth) Approaches and Lessons for Increased Performance and Retention of Community Health Workers in Low- and Middle-Income Countries: A Review (2013) · cites this paper as [34]
The Discussion reports that voice calls were the main benefit of the phones and that shared-phone kiosks raised privacy concerns. The Qualitative Results describe phone-maintenance problems, especially charging where electricity was unavailable. The copy does not report reservations specifically about a lack of immediate response via SMS; it gives unclear benefits and difficulty monitoring messages as reasons for dropping the texting component. (LLM, conf=0.86)
Experimental — accuracy not yet measuredIn a randomized controlled trial delivering SMS to community-based peer health workers in rural Uganda supporting antiretroviral treatment for HIV patients, no virological differences in patient outcome over 26 months were observed.
“A randomized controlled trial delivered SMS to community-based peer health workers in rural Uganda supporting antiretroviral treatment for HIV patients [34]. No virological differences in patient outcome over 26 months were observed, but limited qualitative data showed improvements in patient care, logistics, and broad support from health workers and patients.”
From Mobile Health (mHealth) Approaches and Lessons for Increased Performance and Retention of Community Health Workers in Low- and Middle-Income Countries: A Review (2013) · cites this paper as [34]
The Abstract reports that 970 patients were followed for 26 months and that there was no significant difference in virologic failure. But the Methods (Substudy Trial Description) say peer health workers were given phones and asked to send texts with patient data to a central database; the intervention was not simply SMS delivered to the workers. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Chang 2011 and Iversen 2018 reported mortality at 11- to 12-month follow-up (RR 0.82, 95% CI 0.55 to 1.22 and RR 0.94, 95% CI 0.28 to 3.12, respectively; 1157 participants; low-certainty evidence).
“reported mortality at 11‐ to 12‐month follow‐up (RR 0.82, 95% CI 0.55 to 1.22 and RR 0.94, 95% CI 0.28 to 3.12, respectively; 1157 participants; low‐certainty evidence; Analysis 12.1).”
From Mobile technologies to support healthcare provider to healthcare provider communication and management of care (2020) · cites this paper as Chang 2011
The Methods identify mortality as a secondary outcome, and the Discussion says the trial found no significant difference in mortality between arms. Our copy does not give the attributed RR 0.82 (95% CI 0.55–1.22) or establish an 11- to 12-month mortality follow-up; the Results report 970 patients in this trial, while the claim’s 1,157 participants combine two studies. The low-certainty rating is likewise not reported in this paper. (LLM, conf=0.83)
Experimental — accuracy not yet measuredChang 2011 reported healthcare professionals allocated to intervention were not always able to charge the mobile phone, and some mobile phones were stolen.
“reported that healthcare professionals allocated to the intervention were not always able to charge the mobile phone, and that some mobile phones were stolen (Chang 2011; Analysis 15.1).”
From Mobile technologies to support healthcare provider to healthcare provider communication and management of care (2020) · cites this paper as Chang 2011
The Results (Qualitative Results, “Challenges with Phones”; page unavailable) report that peer health workers had difficulty keeping phones charged and that a few reported stolen phones. The claim gets both challenges right, but calls the phone recipients “healthcare professionals”; the paper identifies them as peer health workers, distinct from clinic staff. (LLM, conf=0.86)
Experimental — accuracy not yet measuredCurrent use of mobile technology by frontline healthcare workers in Uganda [21] and other LMICs [20] was also for purposes other than clinical consultation and decision making.
“Current use of mobile technology by frontline healthcare workers in Uganda [21] and other LMICs [20] was also for purposes other than clinical consultation and decision making.”
From Perception of providers on use of the WHO mental health Gap Action Programme-Intervention Guide (mhGAP-IG) electronic version and smartphone-based clinical guidance in Nigerian primary care settings (2022) · cites this paper as [21]
The Results (Qualitative Results; page not provided) describe Ugandan peer health workers using phones for logistics, including requesting supplies, which supports use beyond clinical consultation and decision making. But the same section also describes a call in which clinic staff advised a medication change, so the paper does not support an implication that their phone use excluded clinical consultation or decisions. (LLM, conf=0.86)
Experimental — accuracy not yet measuredSimilar to the present findings, the Uganda study [21] also found phone reliability as a key barrier to mobile application use.
“Similar to our findings, the Uganda study [21] also found phone reliability as a key barrier to mobile application use.”
From Perception of providers on use of the WHO mental health Gap Action Programme-Intervention Guide (mhGAP-IG) electronic version and smartphone-based clinical guidance in Nigerian primary care settings (2022) · cites this paper as [21]
The Qualitative Results (page unavailable) identify keeping phones charged as a maintenance challenge for peer health workers. The Discussion says charging was a logistical challenge but was mostly overcome. This supports a phone-maintenance barrier in the Uganda mHealth intervention, but not the broader claim that phone reliability was a key barrier to mobile application use. (LLM, conf=0.83)
Experimental — accuracy not yet measuredMost studies conducted in LMICs involved the use of short message service (SMS) and voice communication to improve CHWs performance.
“Most studies conducted in LMICs involved the use of short message service (SMS) and voice communication to improve CHWs performance [13, 14].”
From Using mobile phones to improve community health workers performance in low-and-middle-income countries (2020) · cites this paper as [14]
The Results (Qualitative Results) describe text messaging and voice calls in this rural Ugandan intervention, and the Discussion says staff felt the phones improved peer health workers’ communication. But this single study does not establish what *most* LMIC studies used; it also reports no significant quantitative impact and says the benefits of text messaging were unclear. (LLM, conf=0.86)
Experimental — accuracy not yet measuredIn one study, health workers perceived direct contact as improving relationships between lower- and higher-level workers.
“In one study, health workers perceived direct contact as improving relationships between lower‐ and higher‐level workers (Chang 2011).”
From Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis (2020) · cites this paper as Chang 2011
Some health workers felt that mobile devices encouraged truthful reporting.
“and encouraged truthful reporting (Chang 2011)”
From Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis (2020) · cites this paper as Chang 2011
Some health workers felt being contactable via mobile devices during and outside working hours was useful.
“some felt it was useful”
From Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis (2020) · cites this paper as Chang 2011
Some health workers perceived being contactable at all hours as useful in emergency cases.
“Some health workers perceived this as useful in emergency cases (Chang 2011; Hampshire 2016)”
From Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis (2020) · cites this paper as Chang 2011
In one study, health workers thought that clients were motivated to improve their adherence because they were aware that information about their adherence was being relayed to clinic staff by field staff in real time via the mobile devices.
“In one study, health workers thought that clients were motivated to improve their adherence because they were aware that information about their adherence was being relayed to clinic staff by field staff in real time via the mobile devices (Chang 2011).”
From Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis (2020) · cites this paper as Chang 2011
Health workers reported that their access to mobile devices was beneficial to clients and communities who were too poor to own mobile phones.
“Health workers reported that their access to mobile devices was beneficial to clients and communities who were too poor to own mobile phones (very low confidence in the evidence)”
From Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis (2020) · cites this paper as Chang 2011
Challenges included clients not having phones.
“including clients not having phones”
From Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis (2020) · cites this paper as Chang 2011
In the Ugandan peer health worker trial, limited qualitative data showed improvements in patient care, logistics, and broad support from health workers and patients.
“No virological differences in patient outcome over 26 months were observed, but limited qualitative data showed improvements in patient care, logistics, and broad support from health workers and patients.”
Improvements in peer health worker morale and confidence were reported in the Ugandan trial.
“Improvements in peer health worker morale and confidence were reported; peer health worker-patient relationships improved, shifting burdens from staff-patient relationships.”
Peer health worker-patient relationships improved, shifting burdens from staff-patient relationships.
“Improvements in peer health worker morale and confidence were reported; peer health worker-patient relationships improved, shifting burdens from staff-patient relationships.”
This is consistent with our results, especially for settings where constant access to electricity might be an issue (Chang 2011).
“This is consistent with our results, especially for settings where constant access to electricity might be an issue (Chang 2011).”
From Mobile technologies to support healthcare provider to healthcare provider communication and management of care (2020) · cites this paper as Chang 2011
In an exploratory mixed method process evaluation sub-study to a cluster RCT on the impact of mobile phones on HIV/AIDS care in rural Uganda [21], qualitative data suggested broad support by frontline healthcare workers for the use of mobile phone applications to support their work.
“In an exploratory mixed method process evaluation sub-study to a cluster RCT on the impact on mobile phones on HIV/AIDS care in rural Uganda [21], qualitative data suggested broad support by frontline healthcare workers for the use of mobile phone applications to support their work.”
Other LMIC studies on use of digital technology in healthcare [20-22] have tended to focus on health domains other than mental health.
“Other LMICs studies on use of digital technology in healthcare [20–22] have tended to focus on health domains other than mental health.”
In rural Uganda, the mHealth support intervention used by community-based peer health workers resulted in improvements in patient care and logistics.
“The study found out that the mHealth support intervention used by PHWs resulted in improvements in patient care and logistics [14].”
From Using mobile phones to improve community health workers performance in low-and-middle-income countries (2020) · cites this paper as [14]
Impact evaluation of RAFT activities remains an unfinished business.
“Impact evaluation of the RAFT activities remains an “unfinished business” (40–43)”
From The RAFT Telemedicine Network: Lessons Learnt and Perspectives from a Decade of Educational and Clinical Services in Low- and Middle-Incomes Countries (2014) · cites this paper as [42]
The Introduction says this paper reports final outcomes of a peer-health-worker mHealth substudy in Uganda, and the Discussion describes limitations of that evaluation. Our copy does not mention RAFT activities or say whether their impact evaluation remains unfinished (searched: RAFT, impact evaluation, unfinished business). (LLM, conf=0.77)
Experimental — accuracy not yet measuredOther studies have shown that poor network coverage and signal strength are often a major limitation to implementation of mobile technologies.
“Other studies have shown that poor network coverage and signal strength are often a major limitation to implementation of mobile technologies [23, 27, 31, 65, 66].”
From Qualitative Assessment of the Feasibility, Usability, and Acceptability of a Mobile Client Data App for Community-Based Maternal, Neonatal, and Child Care in Rural Ghana (2016) · cites this paper as [66]
The Results (Qualitative Results; page unavailable) describe charging and theft as challenges, while the Discussion (page unavailable) identifies phone access, privacy, cost, and maintenance. Searches for network coverage, signal strength, and reception found no passage saying these were major implementation limitations. (LLM, conf=0.72)
Experimental — accuracy not yet measuredA similar advantage of m-health interventions was reported in a study conducted in Uganda and in a systematic review of the feasibility and effectiveness of m-health strategies in LMICs.
“A similar advantage of m-health interventions was also reported in a study conducted in Uganda [27], and in a systematic review of the feasibility and effectiveness of m-health strategies in LMICs [45].”
Mobile app-based clinical guidelines can increase health workers morale.
“and can facilitate task-shifting, and increase health workers morale [25, 27].”
Mobile app-based clinical guidelines can facilitate task-shifting.
“and can facilitate task-shifting, and increase health workers morale [25, 27].”
In rural Uganda, quantitative results from 970 patients in a cluster-randomised trial of mHealth support for HIV CHWs failed to show any statistical difference between intervention and control in virological failure (19.4% vs 16.4%).
“Quantitative results from the 970 patients managed (446 in intervention arm, 524 in control), however, failed to show any statistical difference between the intervention and the control arm in terms of the primary outcome (virological failure) (19.4% vs. 16.4% in the intervention and control arms, respectively).”
From Assessing the impact of mHealth interventions in low- and middle-income countries – what has been shown to work? (2014) · cites this paper as [39]
In rural Uganda, qualitative results of an mHealth support intervention for HIV CHWs suggest improved communication and patient care.
“Qualitative results suggest improved communication and patient care, because patients could now contact CHWs who would work to treat the patient (if possible), whereas previously their needs would have gone unmet or be borne by clinic staff.”
From Assessing the impact of mHealth interventions in low- and middle-income countries – what has been shown to work? (2014) · cites this paper as [39]
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- Authors
- Chang, L. W., Kagaayi, J., Arem, H., Nakigozi, G., Ssempijja, V., Serwadda, D., Quinn, T. C., Gray, R. H., Bollinger, R. C., & Reynolds, S. J.
- Affiliations
- Johns Hopkins University (US)
- Rakai Health Sciences Program (UG)
- National Institutes of Health (US)
- Corresponding author
- Chang, Larry W.
- ORCID
- Venue
- AIDS and Behavior
- Published
- 2011-07-08
- Volume
- 15
- Issue
- 8
- Pages
- 1776-1784
- ISSN
- 1090-7165 (ISSN-L)
- 1573-3254
- PMC
- PMC3265752
- OpenAlex
- W2042543641
- Cited by
- 184
- References
- 26
- Citations by year
- 2026: 4 · 2025: 2 · 2024: 8 · 2023: 11 · 2022: 20 · 2021: 10 · 2020: 23 · 2019: 7 · 2018: 10 · 2017: 17 · 2016: 15 · 2015: 16 · 2014: 18 · 2013: 12 · 2012: 10
- FWCI
- 24.38
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- www.springer.com/tdm (tdm)
- Locations
- AIDS and Behavior (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Pure Amsterdam UMC (submittedVersion)
- Funders
- Doris Duke Charitable Foundation
- U.S. President’s Emergency Plan for AIDS Relief
- National Institutes of Health
- National Institute of Mental Health (K23MH086338)
- National Institute of Allergy and Infectious Diseases (2T32-AI07291, T32AI007291, ZIAAI000361)
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (R24HD042854)
- Topics
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
- Physical Sciences › Computer Science › Information Systems › ICT in Developing Communities
- Keywords
- mobile health, HIV care, mobile telephony, community health workers, virological failure, rural health care, privacy concerns, health worker support, Uganda
- MeSH terms
- Acquired Immunodeficiency Syndrome, Communication, Community Health Services, Female, Health Personnel, Humans, Male, Middle Aged, Peer Group, Rural Population, Uganda, Cluster Analysis, Randomized Controlled Trials as Topic, Telemedicine, Anti-HIV Agents, Cell Phone
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