Structured Caregiver Feedback Enhances Engagement and Impact of Mobile Health Support: A Randomized Trial in a Lower-Middle-Income Country.
BACKGROUND
Patients' engagement in mobile health (m-health) interventions using interactive voice response (IVR) calls is less in low- and middle-income countries (LMICs) than in industrialized ones. We conducted a study to determine whether automated telephone feedback to informal caregivers ("CarePartners") increased engagement in m-health support among diabetes and hypertension patients in Bolivia.


METHODS
Patients with diabetes and/or hypertension were identified through ambulatory clinics affiliated with four hospitals. All patients enrolled with a CarePartner. Patients were randomized to weekly IVR calls including self-management questions and self-care education either alone ("standard m-health") or with automated feedback about health and self-care needs sent to their CarePartner after each IVR call ("m-health+CP").


RESULTS
The 72 participants included 39 with diabetes and 53 with hypertension, of whom 19 had ≤6 years of education. After 1,225 patient-weeks of attempted IVR assessments, the call completion rate was higher among patients randomized to m-health+CP compared with standard m-health (62.0% versus 44.9%; p < 0.047). CarePartner feedback more than tripled call completion rates among indigenous patients and patients with low literacy (p < 0.001 for both). M-health+CP patients were more likely to report excellent health via IVR (adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI], 1.07, 6.32) and less likely to report days in bed due to illness (AOR = 0.42; 95% CI, 0.19, 0.91).


CONCLUSIONS
In this study we found that caregiver feedback increased engagement in m-health and may improve patients' health status relative to standard approaches. M-health+CP represents a scalable strategy for increasing the reach of self-management support in LMICs.
1 Ann Arbor Department of Veterans Affairs Center for Clinical Management Research , Ann Arbor, Michigan.|2 School of Public Health, University of Michigan , Ann Arbor, Michigan.|3 School of Medicine, University of Michigan , Ann Arbor, Michigan.
John D
JD
Piette
1 Ann Arbor Department of Veterans Affairs Center for Clinical Management Research , Ann Arbor, Michigan.|2 School of Public Health, University of Michigan , Ann Arbor, Michigan.|3 School of Medicine, University of Michigan , Ann Arbor, Michigan.
Nicolle
N
Marinec
2 School of Public Health, University of Michigan , Ann Arbor, Michigan.
Kathryn
K
Janda
3 School of Medicine, University of Michigan , Ann Arbor, Michigan.
Emily
E
Morgan
2 School of Public Health, University of Michigan , Ann Arbor, Michigan.
Karolina
K
Schantz
4 Universidad Católica Bolivìana , La Paz, Bolivia .
Amparo Clara Aruquipa
AC
Yujra
4 Universidad Católica Bolivìana , La Paz, Bolivia .
Bismarck
B
Pinto
5 Universidad Pública de El Alto , El Alto, Bolivia .
José Marecelo Huayta
JM
Soto
2 School of Public Health, University of Michigan , Ann Arbor, Michigan.
Mary
M
Janevic
3 School of Medicine, University of Michigan , Ann Arbor, Michigan.
James E
JE
Aikens
D000368:Aged; D001838:Bolivia; D017028:Caregivers; D003906:Developing Countries; D003920:Diabetes Mellitus / Q000628:therapy*; D005006:Ethnicity; D005260:Female; D000068156:Formative Feedback; D057220:Health Literacy; D006304:Health Status; D006801:Humans; D006973:Hypertension / Q000628:therapy*; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010353:Patient Education as Topic / Q000379:methods; D012648:Self Care; D017216:Telemedicine / Q000379:methods*; D013689:Telephone
behavioral health; cardiology/cardiovascular disease; extreme environments; mobile health; telemedicine