abstract: 'Background: The burden of non-communicable diseases (NCDs) is increasing

  in low-and middle-income countries (LMICs) where NCDs cause 4:5 deaths,

  disproportionately affect poorer populations, and carry a large economic

  burden. Digital interventions can improve NCD management for these

  hard-to-reach populations with inadequate health systems and high

  cell-phone coverage; however, there is limited research on whether

  digital health is reaching this potential. We conducted a process

  evaluation to understand challenges and successes from a digital health

  intervention trial to support Cambodians living with NCDs in a peer

  educator (PE) program. Methods: MoPoTsyo, a Cambodian non-governmental

  organization (NGO), trains people living with diabetes and/or

  hypertension as PEs to provide self-management education, support, and

  healthcare linkages for better care management among underserved

  populations. We partnered with MoPoTsyo and InSTEDD in 2016-2018 to test

  tailored and targeted mHealth mobile voice messages and eHealth tablets

  to facilitate NCD management and clinical-community linkages. This

  cluster randomized controlled trial (RCT) engaged 3,948 people and 75

  PEs across rural and urban areas. Our mixed methods process evaluation

  was guided by RE-AIM to understand impact and real-world implications of

  digital health. Data included patient (20) and PE interviews (6),

  meeting notes, and administrative datasets. We triangulated and analyzed

  data using thematic analysis, and descriptive and complier average

  causal effects statistics (CACE). Results: Reach: intervention

  participants were more urban (66\% vs. 44\%), had more PE visits (39 vs.

  29), and lower uncontrolled hypertension {[}12\% and 7\% vs. 23\% and

  16\% uncontrolled systolic blood pressure (SBP) and diastolic blood

  pressure (DBP)]. Adoption: patients were sent mean {[}standard deviation

  (SD)] 30 {[}14] and received 14 {[}8] messages; 40\% received no

  messages due to frequent phone number changes. Effectiveness: CACE found

  clinically but not statistically significant improvements in blood

  pressure and sugar for mHealth participants who received at least one

  message vs. no messages. Implementation: main barriers were limited

  cellular access and that mHealth/eHealth could not solve structural

  barriers to NCD control faced by people in poverty. Maintenance: had the

  intervention been universally effective, it could be paid for from

  additional revolving drug fund revenue, new agreements with mobile

  networks, or the government. Conclusions: Evidence for digital health to

  improve NCD outcomes in LMICs are limited. This study suggests digital

  health alone is insufficient in countries with low resource health

  systems and that high cell phone coverage did not translate to access.

  Adding digital health to an NCD peer network may not significantly

  benefit an already effective program; mHealth may be better for

  hard-to-reach populations not connected to other supports. As long as

  mHealth remains an individual-level intervention, it will not address

  social determinants of health that drive outcomes. Future digital health

  research and practice to improve NCD management in LMICs requires

  engaging government, NGOs, and technology providers to work together to

  address barriers.'
affiliation: 'Steinman, L (Corresponding Author), Univ Washington, Hlth Promot Res
  Ctr, UW Box 354804, Seattle, WA 98105 USA.

  Steinman, Lesley, Univ Washington, Sch Publ Hlth, Dept Hlth Serv, Seattle, WA 98105
  USA.

  van Pelt, Maurits; Hen, Heang, MoPoTsyo Patient Informat Ctr, Phnom Penh, Cambodia.

  Chhorvann, Chhea; Te, Vannarath, Natl Inst Publ Hlth, Phnom Penh, Cambodia.

  Lan, Channe Suy, InSTEDD, Phnom Penh, Cambodia.

  LoGerfo, James; Fitzpatrick, Annette L., Univ Washington, Sch Publ Hlth, Dept Global
  Hlth, Seattle, WA 98105 USA.

  LoGerfo, James, Univ Washington, Dept Med, Seattle, WA 98105 USA.

  Fitzpatrick, Annette L., Univ Washington, Sch Med, Dept Family Med, Seattle, WA
  98105 USA.

  Fitzpatrick, Annette L., Univ Washington, Sch Publ Hlth, Dept Epidemiol, Seattle,
  WA 98105 USA.'
article-number: '40'
author: Steinman, Lesley and van Pelt, Maurits and Hen, Heang and Chhorvann, Chhea
  and Lan, Channe Suy and Te, Vannarath and LoGerfo, James and Fitzpatrick, Annette
  L.
author-email: lesles@uw.edu
author_list:
- family: Steinman
  given: Lesley
- family: van Pelt
  given: Maurits
- family: Hen
  given: Heang
- family: Chhorvann
  given: Chhea
- family: Lan
  given: Channe Suy
- family: Te
  given: Vannarath
- family: LoGerfo
  given: James
- family: Fitzpatrick
  given: Annette L.
da: '2023-09-28'
doi: 10.21037/mhealth-19-249
eissn: 2306-9740
files: []
journal: MHEALTH
keywords: Diabetes; hypertension; mHealth; Cambodia; implementation science
keywords-plus: 'NONCOMMUNICABLE DISEASE; PREVENTION; INTERVENTION; TECHNOLOGY;

  ADHERENCE; PROGRAM; SERVICE; BURDEN; IMPACT'
language: English
month: OCT
number: '4'
number-of-cited-references: '82'
papis_id: 50b3f52055b82213f72fbc7bb57feeb5
ref: Steinman2020canmhealth
times-cited: '7'
title: Can mHealth and eHealth improve management of diabetes and hypertension in
  a hard-to-reach population? -lessons learned from a process evaluation of digital
  health to support a peer educator model in Cambodia using the RE-AIM framework br
type: Article
unique-id: WOS:000850208600007
usage-count-last-180-days: '2'
usage-count-since-2013: '6'
volume: '6'
web-of-science-categories: Health Care Sciences \& Services; Medical Informatics
year: '2020'