The Journal of mHealth Vol 3 Issue 2 (Apr/May 2016) | Page 6

Transforming Delivery: Learning the Fundamentals...

Transforming Delivery: Learning the Fundamentals...

Transforming Delivery: Learning
the Fundamentals of mHealth
Intervention
mHealth is no longer in its infancy but still faces challenges for
proving its effectiveness and for scaling-up. Understanding the
factors that contribute most to the success or failure of projects and establishing a convincing evidence-base are vital. We
spoke to two experts dedicated to improving training, research
and practice in the area; Dr Claudia Pagliari, Director of the
Masters Programme in Global eHealth at the University of
Edinburgh and Isaac Holeman, co-founder of Medic Mobile,
who leads the programme’s mHealth course, which aims to
equip students with an understanding of key considerations for
the planning, deployment, and assessment of mHealth projects.
For more information visit www.ed.ac.uk
Dr Pagliari has been actively involved in eHealth for many years[1]
and has an extensive research portfolio covering many different
areas, amongst which mobile health is a strong component. Her
work in this area has included early successful mHealth trials, like
the Sweet Talk project[2], which used a text messaging support
system for young people with diabetes and the CYMPLA project
involving cellphone-based peak flow testing and decision support
for patients with uncontrolled asthma[3]. Most recently, her work

has included a systematic review for the World Health Organisation assessing the use of mHealth in maternal and child health in
lower and medium income countries[4]. She is currently investigating the potential of mobile phones for capturing data during
trials and understanding patient reported outcome measures.
Isaac Holeman is a designer-researcher and co-founder of the
social enterprise Medic Mobile. His work aims to understand
complex health systems from the perspective of the poor and
marginalised and respond pragmatically. Medic Mobile received
a Skoll award in 2014, and Isaac has been featured twice in
Forbes Magazine as one of the top 30 social entrepreneurs under
the age of 30. He continues to practice design at Medic Mobile,
while pursuing research projects as a fellow of the University of
Edinburgh’s Global Health Academy and as a Gates Cambridge
Scholar in innovation, strategy and organisation.
Isaac’s involvement with the Masters in Global eHealth programme at Edinburgh underscores some of the complexities
involved in designing effective mHealth interventions. The difficulties and challenges faced in the field mean that to effectively

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4

April/May 2016

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study the intricacies of mHealth requires first-hand knowledge of
the realities that are often faced when deploying specific projects.
“It is an interesting time for the industry in terms of recruiting
people for mHealth projects that can demonstrate the necessary
skills and knowledge to really understand the delivery and use
of these technologies in different settings and scenarios” explains
Holeman. “There are incredible opportunities, and these opportunities aren’t really about introducing medical technologies in
a standalone way, so much as they are about structuring new
delivery systems, and strengthening the way in which we organise and deliver care. For instance, decentralising care, bringing care closer to the patient, or giving people care in a timelier
manner.”
The complex nature of mHealth delivery is something that
Holeman has experienced through his work with Medic Mobile.
“Most of our work has been with community healthcare workers and a lot of those projects have focussed upon antenatal care,
immunisation and proactive management using analytics about
community health worker performance. We have also done
projects that involve disease surveillance, health service statistics
reporting and management. In the last year and a half we have
focussed on some new areas, which include malnutrition and
cervical cancer screening.”
“As our organisation became more established, I recognised that
we needed to do better research if we were to grow to the next
level in terms of the impact that we were having, and the scale
and size of our organisation. Our partnership with the University of Edinburgh has been a great opportunity to advance this
project” explains Holeman.
“One of the things that we were already doing was design
research, understanding user needs and crafting technologies
that would meet those needs in novel ways. Evidence-based support was something that we needed to do more of. When we
first started there was some evidence for the types of interventions that we were developing; today that body of evidence has
grown considerably and we wanted to start making better use
of it. Above all we wanted to be able to document how we were
working, in a way that would allow us to replicate and scale these
approaches. For example, Human-centered design is central to
how we respond to the complexities that arise in practice, seeing
implementation difficulties as opportunities to redesign not only
the technology but also the services and the way that we organise and deliver care. Design is widely embraced in technology
innovation circles but more research is needed to document and
spread its application among global health practitioners.”

tical insight from the activities of Medic Mobile, using case
examples and some of the concerns that frequently do arise at
scale. This is then combined with a sophisticated conceptual
analysis of the field that doesn’t just rely upon the relatively small
body of evidence that has been conducted under the banner of
mHealth. In particular the course draws on the fields of management, human-centered and participatory design, and international development studies for a more thorough conceptual
analysis of mHealth evidence and practice.
“There are a number of challenges in eHealth and they tend to
be somewhat different depending upon the different types of
projects that you undertake, the different settings and sorts of
technology and the types of interventions” explains Pagliari.
“These all influence the sorts of methods you will use and the
sorts of evidence you can gather.”
“Often these are not simple interventions, they can have several components and sometimes those components are not well
specified prior to starting, which can be quite common in realworld projects. Similarly, in academia there is a lot of ‘black
box’ thinking, sometimes without a detailed specification of
how an intervention or technology will lead to some change in
behaviour and then how that will produce an outcome. We have
been advocating a lot more thought about these mechanisms
to improve the clarity about what it is that people are actually
intervening with and what are the objectives they are intending
for those projects.” [Holeman and Pagliari discuss some of these
sociotechnical complexities in a recent paper on mHealth for
Cancer Care[6].
“In certain contexts your interventions may change over time”
continues Pagliari. “For example, we have found from working
on telehealth in the UK that the way a project is initially configured, doesn’t always fit the reality of the context and changes
have to be made. It may become clear that the technology itself
does not represent the key ingredient of the intervention and
that the benefits arise more from the change management processes that go on around it. It therefore becomes quite difficult
to disentangle human and the technological influences, which
presents problems for traditional evaluation.”
The evaluation of mHealth interventions is a significant area of
both Pagliari’s and Holeman’s work. The ability to collect data
in real-time is one of the major advantages of many mHealth
projects and that data is changing the concepts associated with
traditional healthcare/medical evaluation. It also provides a key
component in the delivery of new service models.

“Claudia approached me in 2012 with the question; if you could
have all of your new employees have one solid Masters level
course, so that they would know how to orientate themselves
in this field and work effectively in it, what would it look like?”
says Holeman.

“mHealth is very rich in terms of this innovation but, it can
be challenging to convincingly demonstrate this to healthcare
organisations and sponsors because the evidence is very defuse
and often based on low quality studies” says Pagliari. Many
mHealth projects have been created in order to address a practical
problem and were driven by clinical requirements, not necessarily
as part of a planned research agenda. Where research has happened ‘on top’ of practical implementation projects, evidencebased decision makers may remain skeptical. One of our interests
is in innovating around evaluation methods themselves, finding
new ways to integrate real-world evidence as it is created”.

The result was a co-designed 10-week course that includes prac-

Continued on page 6

The Masters in Global eHealth programme offered by the University of Edinburgh aims to prepare professionals for these
types of challenges that they will face when working in the fields
of eHealth and mHealth.

The Journal of mHealth

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