Larry Cheskin, MD, an associate professor of Health, Behavior and Society, and director of the Johns Hopkins Weight Management Center, is hoping to get around the evaluation problem by incorporating mHealth into a randomized study—the gold standard for other health interventions.
He explains that the typical program at the Weight Management Center is a relatively time- and resource-intense affair. On their first visit, patients see a series of health care providers—a dietitian, psychologist, exercise expert and Cheskin himself—and come back frequently for follow-up. This care usually isn’t covered by insurance. Since those of low socioeconomic status are more likely to be obese in the U.S., it places the program out of reach for those who probably need it the most.
“It’s not translatable to the U.S. as a whole,” Cheskin notes.
Seeking a better way, he and his colleagues launched the TRIMM study—short for Tailored Rapid Interactive Mobile Messaging—in 2011. They’re recruiting 150 minority participants from inner city Baltimore who are interested in losing weight. All the participants will receive comprehensive counseling on diet and exercise, but half will receive customized text messages several times a day that address their self-identified problem areas. Cheskin and his colleagues plan to see how the two groups compare after six months—and then after another six months, when the text messages are shut off.
Free phones and airtime for researchers and subjects have been the kiss of death for many mHealth pilot projects as they try to scale up to full-size programs.
“It’s well known in this new field of mHealth that there’s not a lot of control data,” Cheskin says. “Doing a randomized controlled trial is a high quality way of seeing whether the outcome you’re hoping for is really there.”
Evaluation isn’t the only tough problem in mHealth—scalability and sustainability are issues that have doomed many other mHealth projects, notes Patricia Mechael, PhD ’98. She recently became the executive director of the mHealth Alliance, a Washington, D.C.–based organization hosted by the United Nations Foundation that serves as a convener of the mHealth community and provides guidance and support for those using mHealth tools. For example, giving out phones to researchers and subjects alike might be the kiss of death for many mHealth projects, according to Mechael. For a small pilot project, maintaining equipment and airtime might be manageable, but continuing to provide equipment and airtime for a full-scale project is oftentimes financially unsustainable. Unless a country’s government or private sector investor can invest in buying a phone and minutes for the target population, Mechael explains, that model simply won’t work for the long haul.
Similarly, Mechael says, multiple projects have failed because there is no standard for them to integrate with one another. For example, she explains, there’s a missed opportunity if one mHealth intervention evaluates patients for tuberculosis symptoms while another assesses HIV risk, but the two aren’t designed to easily combine their findings. Governments that are seeking a complete picture of these two diseases in the populations they serve will likely discard both programs.
From the outset, Mechael says, programs should examine how mobile technology can be leveraged to strengthen the health system as a whole and interact with other platforms, even if the initial funding is specifically targeting a particular health condition.
“mHealth is a lot more complicated than just giving out phones or developing apps,” Mechael explains. “Technology is only as good as the systems that it supports.”
Alain Labrique shows off a trove of low-cost technological treasures that support research from Kenya to Bangladesh.
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