HIV-positive patients in Botswana state that mobile teledermatology is an acceptable method for receiving dermatology care
Open accessAbstract
There is a severe shortage of dermatologists in sub-Saharan Africa, with many areas having no dermatologists at all.[1] Furthermore, there is an increased prevalence of skin disease in HIV patients, with many conditions being unique to this population or more severe than in immunocompetent patients.[2] The presence of many of these conditions may affect HIV management.[3,4] Store-and-forward teledermatology offers a method for increasing access to skin specialists. Although many areas have limited computer connectivity, mobile phone networks are more accessible.[5, 9] Mobile teledermatology uses mobile phones to perform store-and-forward teledermatology consultations. Studies evaluating patient acceptability of conventional store-and-forward teledermatology have been conducted in various study populations.[6,7,8] However, it is unknown whether patients, particularly those infected with HIV in resource-limited settings such as southern Africa, find the use of mobile phones acceptable for collecting their health information and would be willing to receive skin care through this method. It is possible that patients with a socially stigmatizing condition such as HIV have additional privacy concerns or that they may feel concerned about transmission of sensitive information by mass telecommunication technologies. While several studies have evaluated patient acceptance of store-and-forward teledermatology in industrialized countries, we were unable to find any studies on patient acceptance in resource poor settings among patients with HIV.[8,9,10,11] We have investigated whether the use of mobile teledermatology technology in a resource-limited setting in Botswana was culturally acceptable to HIV positive patients. Survey We conducted a cross-sectional survey of adult patients with HIV and mucocutaneous complaints in Botswana. Survey questions were developed by physicians in Botswana and the US, and were vetted by dermatologists with clinical experience in Botswana for face and content validity. The survey questions were tested with HIV positive outpatients at the dermatology clinic at the Princess Marina Hospital in Gaborone, Botswana. The study was approved by the appropriate ethics committees and the Botswana Ministry of Health. The study was conducted in consecutively recruited HIV positive patients in Botswana. The patients were at least 18 years old and presented with a skin or mucosal complaint that had not been previously evaluated by a dermatologist. The patients were recruited from the medical and oncology wards, the dermatology clinic, and the Infectious Disease Care Centre at the Princess Marina Hospital; from the Independence Surgery Center, a private primary care clinic in Gaborone; and from the outpatient clinics and medical wards at Athlone Hospital in Lobatse over a 5-week period from August 2009. Enrolled patients received both a face-to-face and mobile teledermatology evaluation and were afterwards asked to complete a questionnaire on their attitudes to mobile teledermatology at the end of the doctor-patient encounter. A Setswana-speaking nurse obtained consent, clarified any patient questions and administered the questionnaire in Setswana to patients unable to read English. Patients who were comfortable reading and writing in English completed the questionnaire on their own if they chose to do so. Enrolled patients received 30 pula (US $4.5) compensation to cover the cost of their travel. We screened 89 patients, of whom 77 (87%) were recruited and 75 completed the survey (97% completion rate), see Table 1. Two patients agreed to participate but could not complete the survey due to nausea from chemotherapy. Most patients (71%) were 31–50 years old. Thirty four (44%) were males. Most patients were single (71%). A significant proportion of patients was unemployed (44%) or received their regular skin care outside Gaborone (39%). The majority of patients stated that time (76%), costs (57%) and distance (41%) were the major barriers in seeking medical care for their skin conditions (Table 2). Forty five percent of patients stated that it took 1–3 h to see a skin specialist, while 53% of patients stated that it took more than 3 h. If privacy was guaranteed, 99% of patients reported that they would be completely comfortable with a mobile teledermatology consultation, while only one patient stated that he or she would have to think about it, and none stated that they would be uncomfortable. When asked what their greatest concern was regarding mobile phone skin consultations, 82% of patients reported none, while 8% reported concerns over not having a face-to-face interaction with the physician and an equal number (n=6) reported concerns over an incomplete representation of their skin or poor photograph quality (Table 2). The majority of patients (91%) believed that they would receive the same treatment and quality of care via mobile teledermatology consultation as with a face-to-face interaction
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Almost all included studies highlighted that mHealth interventions facilitate access to previously unavailable services.
“In fact, almost all included studies highlighted this characteristic feature of mHealth interventions [20, 36–51].”
From A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa (2017) · cites this paper as [20]
In 8 included studies, mHealth interventions connected a patient to a provider, directly facilitating patient access to professional care.
“In 8 studies, mHealth interventions connected a patient to a provider, thus directly facilitating patient access to (professional) care [20, 37, 46, 50, 51, 53–55].”
From A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa (2017) · cites this paper as [20]
If patients faced access barriers such as long travel times, waiting times, and high travel costs, mHealth interventions were perceived to be useful.
“If patients faced access barriers such as long travel times, waiting times, and high travel costs, mHealth interventions were perceived to be useful [20, 42, 45, 46, 48–50, 52, 53, 55].”
From A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa (2017) · cites this paper as [20]
For both patients and specialized healthcare providers, another important predisposing characteristic associated with the perception that mHealth was useful was source confidentiality.
“For both patients and (specialized) healthcare providers another important predisposing characteristic associated with the perception that mHealth was useful was source confidentiality [20, 39, 40, 49, 51]: Healthcare providers have to be confident that the information received via the mobile phone is accurate, and patients have to trust the (specialized) provider on the line in order to perceive”
From A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa (2017) · cites this paper as [20]
In three studies, sicker patients were more likely to use mHealth interventions.
“Furthermore, three studies found that sicker patients were more likely to use the interventions, possibly because they found it easier to use the mHealth interventions rather than, for instance, walk to a provider [20, 51, 55].”
From A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa (2017) · cites this paper as [20]
Over-burdening workload contributed to specialized providers' perceived usefulness of mHealth.
“Also for (specialized) providers, several need factors contributed to the perceived usefulness of the intervention, including, for example, an over-burdening workload [20, 36, 38–41, 43, 45, 47, 50] and a lack of adequate referral and transport systems [38, 46, 47].”
From A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa (2017) · cites this paper as [20]
For patients, availability of a functioning stable telecommunications network was one of the two most important enabling resources necessary for a mHealth intervention to be perceived useful.
“For patients, unsurprisingly, the two most important enabling resources necessary for a mHealth intervention to be (perceived to be) useful were access to mobile phones [37, 45, 46, 50, 53–55] (also possible through borrowing [46, 50]) and the availability of a functioning stable telecommunications network [20, 36, 39, 42, 45, 47, 48, 52, 55].”
From A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa (2017) · cites this paper as [20]
In Botswana, 91% of HIV-positive patients felt that a mobile teledermatology visit would provide the same level of care as a face-to-face visit.
“A cross-sectional survey of HIV positive patients in Botswana found that 91% of patients felt that a mobile teledermatology visit would provide the same level of care as a face-to-face visit”
From Global Burden of Skin Disease: Inequities and Innovations (2017) · cites this paper as [41]
The screening alternatives and attribute levels were chosen based on results of three previous surveys in the target group, a literature review, and included important screening outcome, financial and convenience considerations.
“These alternatives, and the different attribute levels over which they vary, were chosen based on the results of three previous surveys undertaken in the target group [11], as well as a literature review [14, 16-22, 27, 28] and included important screening outcome, financial and convenience considerations.”
From Consumer preferences for teledermoscopy screening to detect melanoma early (2016) · cites this paper as [16]
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- Authors
- Azfar, R. S., Weinberg, J. L., Cavric, G., Lee-Keltner, I. A., Bilker, W. B., Gelfand, J. M., & Kovarik, C. L.
- Affiliations
- University of Pennsylvania (US)
- Christiana Care Health System (US)
- University of Botswana (BW)
- University of California, San Francisco (US)
- Corresponding author
- Azfar, Rahat S
- Venue
- Journal of Telemedicine and Telecare
- Publisher
- SAGE Publications
- Published
- 2011-08-15
- Volume
- 17
- Issue
- 6
- Pages
- 338-340
- ISSN
- 1357-633X (ISSN-L)
- 1758-1109
- PMC
- PMC3163714
- OpenAlex
- W2057435526
- Cited by
- 51
- References
- 13
- Citations by year
- 2026: 1 · 2025: 2 · 2023: 2 · 2022: 2 · 2021: 3 · 2020: 5 · 2019: 4 · 2018: 4 · 2017: 6 · 2016: 1 · 2015: 5 · 2014: 9 · 2013: 7
- FWCI
- 5.03
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Telemedicine and Telecare (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- ScholarlyCommons (University of Pennsylvania) (submittedVersion)
- Funders
- National Institute of Allergy and Infectious Diseases (P30AI045008)
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (F32AR056799)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Digital Imaging in Medicine
- Keywords
- store-and-forward telemedicine, people living with HIV, patient acceptability, resource-limited settings, privacy concerns, stigma, mobile phone networks, Botswana, sub-Saharan Africa, dermatologist shortage
- MeSH terms
- Adult, Aged, Botswana, Cross-Sectional Studies, Dermatology, Female, HIV Seropositivity, Humans, Male, Middle Aged, Skin Diseases, Patient Satisfaction, Telemedicine
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