I recently worked with Medic Mobile @isaacholeman @korir to conduct a randomized control trial (RCT) that adapted the CHT model of nurse to community healthcare worker for direct two-way texting (2wT) between male circumcision (MC) providers and adult patients. This adaption has a lot of potential uses for COVID19 and beyond. For the RCT, the aim was to reduce the need for in-person follow-up visits. For MC, most countries and programs still require in-person follow-up to confirm healing. However, almost all men heal without issue, making these visits largely unnecessary. In our trial, instead of asking the men to return to the clinic to observe how they were healing, we counseled them on warning signs of complication, empowering them to be partners in their own healing. Then, we asked them to monitor their wounds at home. Over the next 13 days after MC, the Medic Mobile hybrid automated/interactive system sent a daily text to check in on the men, requesting a simple response of “0” if well or “1” if not text. If the men responded that they were well, that ended the interaction for the day. If the men reported a concern, a nurse would interact one-on-one with the client to determine if the man should return to the clinic for care. Many men were triaged via SMS, allowing them to remain home and heal after reassurance or additional guidance for wound care. There were no serious complications – the intervention was safe, and we reduced provider workload by 85%. It was cheaper than in-person visits. 2wT was also highly acceptable to patients: over 93% of men responded to at least one daily text. We have a lot of local buy-in for replication and scaling up, including a new model 2wT for MC project in South Africa. You can see more on the Zimbabwe RCT here.
This 2wT-based system has far-reaching potential for expansion to COVID19 or other acute conditions that require brief periods of follow-up (childhood diseases, respiratory infections, post-operative care that could similarly benefit from this type of intensive, direct provider-to-client communication. It has several advantages over other follow-up options. First, 2wT mixed automated and human-to-human messaging that optimized for individualized content, staff efficiency, and rapid follow up for the fraction of cases with that needed in-person care. Second, the short 13-day intervention maximizes client likelihood of response as phone theft, damage, and change of phone numbers are minimal over that brief period. Third, due to the high proportion of unnecessary visits, 2wT realizes immediate efficiency gains.
For COVID 19, the benefits of 2wT could also be quite advantageous. All those with phone numbers in a specific context could easily be enrolled if they’ve signed up for other forms of healthcare worker follow-up. We could use 2wT for contact tracing – sending a daily check in text on symptoms and having them respond (for themselves or their households) with the same “0” or “1”. Those with a 0 end their interaction while a nurse or lay healthcare worker could follow-up with those who have symptoms or concerns. The system could be used to triage patients, allowing those with mild symptoms to remain at home while giving support and directions for sicker patients on where to get care. The simple outgoing message about symptoms is not sensitive health information, reducing the risks to patients if the messages are seen by others. Scale-up and expansion of this system is timely and highly adaptable.