Are Mobile Health Tools a Panacea for Global Health Challenges?

Innovative, evidence-based strategies are needed to tackle the global burden of hypertension. The ubiquity of mobile phones in emerging economies, such as Ghana, provides a new health care delivery paradigm to improve hypertension health outcomes.

Valencia Koomson, an associate professor in the Department of Electrical and Computer Engineering at Tufts School of Engineering and at the Tisch College of Civic Life, believes this rapidly expanding telecommunications structure has the potential to improve access to health care around the world, especially in low- and middle-income countries. She’s launching a five-year project with the University of Ghana, which has a long history of collaborating with both Koomson and Tufts, to test that theory in a clinical trial focused on hypertension.

According to the World Health Organization, 7.5 million deaths globally each year are associated with uncontrolled high blood pressure, which can lead to heart attack, stroke, renal or cardiac failure, and blindness. Over 80% of the deaths occurred in low- and middle-income countries.

“Ghana is faced with the growing need to expand resource-constrained health systems beyond traditional services focused on communicable diseases to now include noncommunicable diseases, such as hypertension,” says Koomson, whose work has long focused on cost-effective solutions for medical devices in low-resource settings and digital health.

Digital health is a growing field that includes mobile health(mHealth), health information technology, wearable devices, telehealth, and personalized medicine. Studies have shown that a user-centered design based on the local culture, diet, and language can encourage patients to use digital health tools. Still, there’s a knowledge gap on the effectiveness of mHealth interventions, says Koomson.

It’s a gap she hopes to fill with a clinical trial using an evidence-based mHealth platform designed to help clinicians manage hypertension in patients who live in urban and rural areas of Ghana. Funded by a $1.2 million grant from the National Institutes of Health, the AHOMKA platform allows for patient-to-provider communication over a mobile application and text messaging, so even patients without a data plan can participate. 

Over the next five years, researchers will follow about 200 patients at two medical clinics affiliated with the University of Ghana: Korle Bu Teaching Hospital in the capital city of Accra and Ho Teaching Hospital in the rural Volta region. Patients will be given a blood pressure cuff to take their blood pressure daily, and they’ll enter their numbers into the app, which sends the data to one of the clinics. A nurse or doctor will periodically review all data received from patients and correspond with them if necessary, such as to prescribe medicine or offer nutritional advice.

The team conducting this project is a multi-national, multi-disciplinary group with expertise in mobile technology development, hypertension, cardiology, population studies, and public health. Both Tufts and the University of Ghana are members of the Talloires Network of Engaged Universities, a global coalition of 417 university leaders across 79 countries who have committed to strengthening the civic and social responsibilities of their institutions. The Secretariat of the Network is based at Tufts University’s Tisch College and it is the largest international network focused on university civic engagement. The project involves other institutions, as well, including Beth Israel Deaconess Medical Center and Medtronic Labs, the tech company developing the mHealth platform.

“The point of this project is to leverage digital health technology and empower patients to self-manage their hypertension through well laid-out guidelines,” says Jacques Kpodonu, a cardiac surgeon at Beth Israel Deaconess Medical Center who is originally from Ghana, and a co-principal investigator on the grant with Koomson. “We will gather a tremendous amount of granular data from these patients, and we hope that, over time, we will be able to better control blood pressure and decrease it by a certain amount.”

Kpodonu will work closely with Medtronic Labs to build clinical workflows into the platform, such as determining the baseline measurements they need to collect and the clinical endpoints to watch for. He’ll also help build predictive analytical tools on the backend, including the ability to leverage the data for machine learning in the future.

“We hope the learnings will be scalable and replicable beyond the project size and can be adopted in other sub-Saharan countries,” he said. “We also have an education portion of our project, so in addition, we will be training community health workers in better identifying and managing hypertension.”

That goal is shared by Ruchika Singhal, vice president at Medtronic Labs, who says the company’s approach, which consists of “digital technologies coupled with field-based teams integrated with local health systems, drives sustainable system-level transformation and enables access to health care for patients, families and communities.”

Benefits for the Patients

Koomson and Kpodonu are managing the project from the Boston area, and they’re collaborating with a third principal investigator, Mark Tettey, a cardiothoracic surgeon and head of the Department of Surgery at University of Ghana Medical School. Tettey said patients who visit these clinics stand to benefit a lot from this project.

“During the COVID-19 pandemic, when most patients hesitated to come to the hospital for their regular visits, a successful mobile platform technology will reduce these visits considerably,” Tettey says. “Patients will be able to take their own blood pressure regularly and communicate with the caregiver without physical contact. This will enhance blood pressure control within the acceptable levels, and in the end, there will be a reduction of complications and death from uncontrolled hypertension.”

The five-year project has two phases; the goal of the first phase is to adapt the app based on feedback from local patients and practitioners. Phase two aims to conduct a year-long study to assess changes in blood pressure among patients.

To help gather stakeholder feedback and make the platform culturally appropriate, Koomson brought in Alice Tang, an epidemiologist and professor of public health and community medicine at Tufts University School of Medicine. Tang, a co-investigator on the grant, has experience working in global health, most recently in Namibia but also in Vietnam and India.

“This project is not only about technology development, but also about culturally adapting this intervention in Ghana. My role is to help develop surveys and qualitative interview guides to collect information from different stakeholder groups—patients, nurses, doctors—to see how feasible the mobile health application is,” says Tang. “For example, can patients understand the app, and do they know how to use it for its intended purpose? Does it work on their mobile phones? Do they know how to take their blood pressure using the provided cuff?”

The team also will examine the management process for health care providers at the clinics, Tang says. Key questions include: Do doctors have time to look at the data and respond to patients, or should that responsibility go to nurses or other clinicians? Is the data coming in from remote patients too burdensome on clinic staff? Answers will inform how the app is implemented for the clinic, says Tang.

The Path to the Present

Koomson’s AHOMKA project builds on a long-standing partnership with the University of Ghana, one that goes back more than a decade. She was teaching a remote course to computer engineering students about the design of micro-scale electrical systems—a course very similar to one she teaches at Tufts. After a few semesters, the department chair at the University of Ghana asked her to co-advise students working on their capstone design projects related to her interest in cost-effective medical devices.

Around that time, Koomson received a grant from the National Science Foundation and began to work remotely with University of Ghana engineering students each year on device development, including a weight-management app.

Obesity, like hypertension, is a noncommunicative disease that heightens the risk factors of potentially fatal conditions like stroke, diabetes, heart disease, and certain types of cancer. Koomson launched a study to help 30 Ghanaian participants use an artificial intelligence-based mobile app driven by a genetic algorithm. The app tracked calories taken in and macronutrients, and provided a personalized weight loss solution. The results of that two-year endeavor were recently published in the International Journal of Telemedicine and Applications.

“A lot of the popular fitness apps used in the United States are preloaded with a database of foods that people normally eat. We built an app that was adapted to Ghana using the local foods people normally eat in that part of the world,” says Koomson. “For example, if you're a diabetic and you're trying to restrict carbohydrates, we added macronutrient tracking for that in the app, which displays your macronutrient targets per day. You input what you have for breakfast and lunch, and it could predict what you should eat for dinner to stay within your targets.”

Future Tech Possibilities

For now, Koomson wants to explore how mHealth can be used to strengthen a fragile health care system where the doctor to patient ratio is large and there aren’t enough primary care doctors, let alone specialists like cardiologists, to manage care for chronic illnesses like diabetes and hypertension.

Ultimately, she envisions a future opportunity where internet-connected, wearable medical devices could capture multiple vital signs on patients for remote monitoring by a clinician, and machine learning models can be trained to track disease progression and send alerts before a life-threatening event occurs.

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Angela Nelson can be reached at angela.nelson@tufts.edu.