title: An mHealth model to increase clinic attendance for breast symptoms in rural Bangladesh: can bridging the digital divide help close the cancer divide?
abstract: OBJECTIVE
  To demonstrate proof of concept for a smart phone-empowered community health worker (CHW) model of care for breast health promotion, clinical breast examination (CBE), and patient navigation in rural Bangladesh.
  
  
  METHODS
  This study was a randomized controlled trial; July 1 to October 31, 2012, 30 CHWs conducted door-to-door interviews of women aged 25 and older in Khulna Division. Only women who disclosed a breast symptom were offered CBE. Arm A: smart phone with applications to guide interview, report data, show motivational video, and offer appointment for women with an abnormal CBE. Arm B: smart phone/applications identical to Arm A plus CHW had training in "patient navigation" to address potential barriers to seeking care. Arm C: control arm (no smart phone; same interview recorded on paper). Outcomes are presented as the "adherence" (to advice regarding a clinic appointment) for women with an abnormal CBE. This study was approved by Women's College Hospital Research Ethics Board (Toronto, Ontario, Canada) and district government officials (Khulna, Bangladesh). Funded by Grand Challenges Canada.
  
  
  RESULTS
  In 4 months, 22,337 women were interviewed; <1% declined participation, and 556 women had an abnormal CBE. Control group CHWs completed fewer interviews, had inferior data quality, and identified significantly fewer women with abnormal breast exams compared with CHWs in arms A and B. Arm B had the highest adherence.
  
  
  CONCLUSIONS
  CHWs guided by our smart phone applications were more efficient and effective in breast health promotion compared with the control group. CHW "navigators" were most effective in encouraging women with an abnormal breast examination to adhere to advice regarding clinic attendance.
authors.affiliation: Women's College Research Institute, Faculty of Medicine and Dalla Lana Faculty of Public Health, University of Toronto, Toronto, Ontario, Canada; mPower Social Enterprises, Dhaka, Bangladesh; Amader Gram, Khulna, Bangladesh; International Breast Cancer Research Foundation, Madison, Wisconsin, USA.
authors.forename: Ophira M
authors.initials: OM
authors.lastname: Ginsburg
authors.forename: Mridul
authors.initials: M
authors.lastname: Chowdhury
authors.forename: Wei
authors.initials: W
authors.lastname: Wu
authors.forename: Md Touhidul Imran
authors.initials: MT
authors.lastname: Chowdhury
authors.forename: Bidhan Chandra
authors.initials: BC
authors.lastname: Pal
authors.forename: Rifat
authors.initials: R
authors.lastname: Hasan
authors.forename: Zahid H
authors.initials: ZH
authors.lastname: Khan
authors.forename: Dali
authors.initials: D
authors.lastname: Dutta
authors.forename: Arif Abu
authors.initials: AA
authors.lastname: Saeem
authors.forename: Raiyan
authors.initials: R
authors.lastname: Al-Mansur
authors.forename: Sahin
authors.initials: S
authors.lastname: Mahmud
authors.forename: James H
authors.initials: JH
authors.lastname: Woods
authors.forename: Heather H
authors.initials: HH
authors.lastname: Story
authors.forename: Reza
authors.initials: R
authors.lastname: Salim
mesh_terms: D000328:Adult; D001459:Bangladesh / Q000453:epidemiology; D001941:Breast Diseases / Q000175:diagnosis* / Q000453:epidemiology; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D040421:Cell Phone; D003150:Community Health Workers; D005260:Female; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D015397:Program Evaluation; D012424:Rural Population; D055815:Young Adult
keywords: Breast cancer; Community health workers; Health promotion; Patient navigation