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

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.