A Comparative Study of the Efficacy of Community Health Clubs in Rural Areas of Vietnam and Zimbabwe to Control Diarrhoeal Disease

*Juliet Waterkeyn, Victor K. Nyamandi and Nguyen Huy Nga*

#### **Abstract**

The Community Health Club (CHC) Model in Makoni District, Zimbabwe operated 265 CHCs with 11,600 members from 1999 to 2001 at a cost of US\$0.63 per beneficiary per annum. A decade later, 48 CHCs were started in three districts in Vietnam with 2,929 members at a cost of US\$1.30. Hygiene behaviour change was compared using a similar survey of observable proxy indicators in both projects, before and after intervention. In Vietnam there was a mean of 36% change in 16 observable proxy indicators (p > 0.001) which compared positively with Makoni where there was a mean of 23% hygiene change in 10 indicators (p > 0.001). In Vietnam, 8 Health Centers reported a reduction of 117 cases of diarrhoeal diseases in CHC communes, compared to only 24 in non-CHC communes in one year; in 8 Health Centers in Makoni, Zimbabwe, a reduction of 1,219 reported cases over a 2–9 year period was reported, demonstrating the efficacy of CHC both in African and Asian context. We suggest that regular government data of reported cases at clinics may be a more reliable method than self-reported diarrhoea by carers in clustered-Randomised Control Trials, which have surprised practitioners by finding negligible impact of WASH interventions on diarrhoea in rural communities.

**Keywords:** community health club, hygiene behaviour change, sanitation, Vietnam, Zimbabwe

#### **1. Introduction**

This study provides a comparison between the first Community Health Club (CHC) pilot project in Makoni District, Zimbabwe in 2000 [1, 2] to the first a pilot project of a 'classic CHC' intervention in Vietnam which was researched and presented in conference proceedings in 2010 but not published [3]. Our interest is to establish if these two interventions can be considered efficacious in the prevention of diarrhoea in Community Health Club households in two very different settings.

#### **1.1 Replication of the community health club approach**

In the past 20 years, over 3,000 Community Health Clubs have been started in 12 countries in Africa reaching over 2.5 million people [4] but in SE Asia, only in Vietnam. Although CHCs have been replicated at a small scale in many countries, only in Zimbabwe and Rwanda have they gone to scale throughout the country [5]. In Zimbabwe most Non Governmental Organisations (NGOs) now use CHC as a standard means of mobilising community in Water and Sanitation Programmes and this method has been endorsed in both the Water Policy and the Sanitation Policy for the country and Ministry of Health is the custodian of this initiative though the Environmental Health Department. In Rwanda the government has taken a lead in coordination of all NGOs into a single National Community Based Environmental Health Promotion Programme (CBEHPP) in which CHCs have been started in all villages throughout the country [6]. A recent systematic review of studies reporting the effect of Community Health Clubs on behaviour relating to drinking water usage, sanitation, hand washing and clean kitchen hygiene [7] demonstrated a strong pattern of community response and a significant change in a wide raft of safe hygiene in virtually all such programmes conducting the 'Classic CHC' training as originally conceived [1]. However, this study is the first to compare CHC in Africa to a similar CHC pilot project in South East Asia.

#### **1.2 Community health clubs in Zimbabwe**

Makoni District in Zimbabwe was the first site internationally to field test the concept of a Community Health Club in 1994, and by 1999 an organisation called Zimbabwe AHEAD had been started to replicate and scale up the approach throughout the country.

Community Health Clubs are defined as a voluntary group of men and women, of all ages, education and income level, who are dedicated to improving the health and hygiene facilities and practices of all members so as to alleviate all preventable diseases and manage public health within the given catchment of the club. CHC are usually supported technically by Environmental Health Technicians (EHTs) responsible for public health who are usually based at Rural Health Centers who supervise voluntary community facilitators in at least 20 health promotion sessions every week for at least six months. The process of training has been well documented in the training manual [8].

#### **1.3 Replication in Vietnam**

In 2009, The Ministry of Health in Vietnam was looking for a hygiene behaviour strategy to galvanise communities into changing their high risk behaviour, as several approaches including PHAST [9], Community Led Total Sanitation (CLTS) [10] and Social Marketing [11] had already been tried in some areas but had not succeeded in reaching the last percentile. There was at this time much debate as to the most cost-effective methodology to achieve permanent hygiene and sanitation behaviour change.

As CHCs had not been used in S.E Asia at that time, there was some concern that with higher living standards in Vietnam, the CHC Approach could be too basic for rural Vietnamese. However, the level of literacy in women at 92% and in men at 96.1%, in Vietnam [12] was not much higher than in Zimbabwe which was 87.2% literacy for women and 94.2% for men in 2010 [13]. At the time, the national average for rural water supply household coverage in Vietnam was 83% whilst rural household sanitation was only 55%, of which only 18% of latrines in rural areas met



#### **Table 1.**

*Demographic comparison between CHC intervention in Zimbabwe and Vietnam showing scope of project.*

government standards of hygiene [12, 14]. Again, this compares to Zimbabwe where rural sanitation was estimated at 25% and rural water supply at 79%. Whilst the two cultures of Zimbabwe and Vietnam appear quite different, the demographic level are not dissimilar (**Table 1**)*.*

### **2. The interventions**

#### **2.1 Makoni District, Zimbabwe**

By the year 2000 there were 265 CHCs in 21 out of 35 wards of the district with 11,600 CHC members, involving an estimated 63,700 beneficiaries, calculated by the average of 5.6 family benefitting from improved hygiene in each family. During the period under review there had been 3,731 health promotion sessions held by 14 EHTs. Subsidies for VIP latrine construction at that time resulted in 2,400 VIP latrines being constructed in 2 years, which was considered remarkable given the total for the country was only 8,000 in 1998. No water component was included in the project, but the district was higher than the national average with 676 functional boreholes and 839 family wells [12]. The project was completed in 2000 when most donors withdrew from Zimbabwe for political reasons, and the CHC were largely left to their own resources, except those which continued with income generating activities started in a later programme [2].


*\*Over 100% indicates more than one CHC member per household in the CHC.*

#### **Table 2.**

*Spread of CHC in wards where health centers have provided reported cases of diarrhoea.*

#### **2.2 Adaptation of the CHC approach in Vietnam**

The pilot CHC project was started in three Provinces of Northern Vietnam, Son La, Phu Tho and Ha Tinh with 48 CHCs with 2,393 members. An active health club of committed members was established in every village to manage environmental health and encourage community hygiene through non risk practices. Village Health Workers already part-employed with Ministry of Health were trained to conduct the sessions. The period of intervention was similar in both countries being from 18 months to 2 years with 20–24 sessions completed in a six-month period of weekly training.

#### **2.3 Comparative scope and spread of the two interventions**

The scope of the programme in Zimbabwe was five times larger than the pilot project in Vietnam. However, although the size of each CHC *appears* larger in Vietnam with a mean of 68 members compared to the Zimbabwean CHC with 43 members, those in Vietnam counted *all* members at registration but with no indication if they attended or not, as membership cards were not used. In Zimbabwe, only the *active* members who completed training were counted as members; if all registered members were counted the mean would be around 80 members. Also, the CHC density (spread) is high in Makoni with 21 out of 35 wards in the district with CHC, whereas in Vietnam only in 7 out of 70 communes had CHC. In Vietnam the two communes had a spread of 21% CHC households in Son La and 36% in Ha Tinh, whilst that of Phu Tho was not calculated. The mean coverage in Makoni was 30% but this ranged from 9% coverage in a new area such as Chiduku, to 113% in Nyamidzi where all households were in a CHC, some with more than one per households as a CHC Members. **Table 2** above shows the % spread in the 8 wards where data was collected from local Health Centers.

#### **3. Methods**

#### **3.1 Objectives**

This study seeks to compare outcomes from the Vietnamese pilot project and compare it to the Makoni CHC pilot project, in five measures: improved knowledge, hygiene and sanitation behaviour change, reduction in disease, cost-effectiveness and stakeholder perceptions.

*A Comparative Study of the Efficacy of Community Health Clubs in Rural Areas of Vietnam… DOI: http://dx.doi.org/10.5772/intechopen.97142*

#### **3.2 Data collection**

#### *3.2.1. Data Collection in Zimbabwe*

A case/control study was conducted in Zimbabwe in three districts, of which one of the districts was Makoni. The standard indicators used to measure hygiene and sanitation behaviour change included a spot observation of 17 indicators taken in 25 randomly selected CHCs, and within each CHC a random sample of 382 CHC members. These indicators were observed before and after in the CHC intervention villages and in the 113 households of non CHC members, in control villages using similar empirically observable proxy indicators to quantify changes in hygiene facilities and standards of cleanliness. There was no self-reported behaviour. Full details of data collection and analysis are fully described elsewhere [1, 2].

#### *3.2.2. Data collection in Vietnam*

#### *3.2.2.1 Quantitative*


#### *3.2.2.2 Qualitative data*


#### **3.3 Analysis of data**

In Vietnam, analysis of data from each Province of the base line and post line survey was done by Ministry of Health officials and provided to one of the authors in excel for her interpretation. All data was cleaned and in this process it was decided to discard data from two of the districts (Phu Tho and Son La) because the standard household survey had been adapted by each district, which made comparative analysis difficult. Therefore, only data from Ha Tinh is used because it could provide raw data for the full base line and post intervention survey that could be checked. In this district a survey of 7,187 base line respondents, and 1,200 post intervention respondents was undertaken, and used to ascertain levels of knowledge and behaviour change. It was converted into SPSS statistics package and standards test of Chi square used to compare data sets [15].

#### **3.4 Sources of bias and confounding**

Some interviewer bias can be expected, as the data from the household survey in both Zimbabwe and Vietnam was collected by the same Village Health Workers who facilitated the project. However this was triangulated in spot checks using observable indicators which could be verified empirically.

The statistics collected from the Health Centers both in Zimbabwe and Vietnam are considered impartial as reported cases were not influenced by the objective of this research. The data was collected and analysed by each district by Ministry of Health and presented in their annual reports. National statistics also show a gradual trend in improvement of most communities in Vietnam over the previous five years (NTP2) [12]. Therefore, to identify the impact of only the CHC training we compared CHC with non CHCs areas as a control for clinical reported cases.

Ministry of Health statistics in Health Centers were taken to track the pattern of disease in wards or communes where CHCs were operational in both countries despite the fact that these figures may not reflect the true burden of disease, as only the most critical cases will be reported. This is not critical to this research as it is the pattern not the extent we are interested in examining. In Zimbabwe, the two wards where there were large hospitals were not used because the catchment of patients was referred from other areas and therefore could not be attributed to the CHC training.

In Vietnam, the CHC Pilot project was not the only health promotion being done in these districts during this one year period. In Ha Tinh, a Unilever Programme using extensive Social Marketing techniques promoting handwashing with soap was running concurrently for one year in all communes, including the CHC communes. Therefore, to avoid confounding and to measure the impact of *only* the CHC, we have only sited findings from topics which were not included in Unilever Information Education and Communication (IEC) material.

#### **4. Results**

#### **4.1 Vietnam**

The results for Vietnam are provided in five measures: improved knowledge, hygiene and sanitation behaviour change, reduction in disease, cost-effectiveness and stakeholder perceptions**.**

#### *4.1.1 Improved knowledge*

The spot observation done in two CHC per Province provided ample anecdotal evidence of the popularity of the CHCs, with high levels of attendance with an average of 68 people at each session.

The Vietnamese showed a strong interest in health education and although basic knowledge of hygiene was high, it did not seem that the training was pitched too low for their level of education. Two questions were asked to establish difference in health knowledge: the causes and prevention of diarrhoea and how to make Sugar Salt Solution (SSS) a homemade recipe to treat dehydration. Whilst the former was well-known due to Unilever programmes and showed little difference before and after the training (94%), knowledge of how to make SSS, was increased by 42% (**Figure 1**) and is more reliable an indicator as this was not taught in the Unilever programme.

*A Comparative Study of the Efficacy of Community Health Clubs in Rural Areas of Vietnam… DOI: http://dx.doi.org/10.5772/intechopen.97142*

#### **Figure 1.**

#### *4.1.2 Hygiene and sanitation behaviour change*

#### *4.1.2.1 Hygiene in the home*

Of the three provinces we chose to use Ha Tinh with 12 CHC and almost 900 CHC members as it provided the most reliable information on levels of hygiene behaviour change as summarised in **Figure 2** below. Across 17 indicators, only one indicator, the use of bednets, i.e. 'protection from mosquito' showed no significance at all, as it was 100% in both pre and post intervention survey. In the other 16 indicators, all practices showed compositive behaviour change of 36% (the mean of all 16 indicators) after one year: 'safe water source' and 'drinking water treated', which had

#### **Figure 2.**

*Prevalence of observed proxy indicators of safe hygiene in CHC members after one year of health promotion, in 2 communes Ha Tinh District, Vietnam. (2009–2010).*

*Improved knowledge in Ha Tinh, Vietnam, after one year of health promotion using two indicators (2009–2010).*

been advocated by previous WASH projects were significant at p > 0.05; the other 14 indicators, not used in previous projects, were highly significant (p > 0.001).


#### *4.1.2.2 Speed of sanitation behaviour change*

Community Health Club records were used to analyse the speed of adoption by the CHC members*.* At base line there was 99% open defecation in Ha Tinh (**Figure 3**)*.* When a survey was taken only one month into the training when CHC members had attended 1–4 sessions, open defecation had decreased to 84%, with 13% now practicing cat sanitation and 3% having constructed a permanent latrine.

By the second and third month when between 5 and 12 sessions had been attended, open defecation had plummeted to only 2% with a massive uptake of 87% practicing cat sanitation, with 10% constructing permanent latrines and 1% having a temporary latrine.

By the time more than 20 sessions had been done, it was found that 49% had constructed a permanent latrine and 50% were still using cat sanitation with 1% having a temporary latrine.

Thus in 5 months Zero Open Defecation (ZOD) had been achieved.

#### *4.1.3 Reported cases of diarrhoea, dystentry and food poisoning*

Diarrhoea, Dysentery and Food Poisoning (DD & FP) are listed together as one category in reported cases in Health Centers in Vietnam. The communes selected

*A Comparative Study of the Efficacy of Community Health Clubs in Rural Areas of Vietnam… DOI: http://dx.doi.org/10.5772/intechopen.97142*

#### **Figure 3.**

*Uptake of safe sanitation correlated with number of health sessions attended in community health clubs in one year in Ha Tinh District, Vietnam, (2009–2010).*

for CHC were in most cases, the more challenging areas as shown by higher DD & FP at baseline (**Figure 3***, above*)*.* The data from all three provinces showed the same pattern of reduction in areas where Community Health Clubs were fully operational, all with a downward trend in reported cases. In total there were an estimated 459 saved cases in CHC Communes.

The Community Health Club communes showed a sharp decline in reported cases of DD & FP from a total of 171 cases to 17 cases in one year, saving an estimated 154 cases, a mean reduction of 61 cases in each commune from 2010 to 2011. By contrast, control communes with no CHC, reduced in DD & FP reported cases from 99 to 75, only 24 down from the previous year (**Figure 4**).

Of the non-CHC Control communes, only Pi Toong in Son La decreased in DD &FP, whilst in the two other non-CHC Communes Thach Vinh and Thach Dai reported cases of DD & FP *increased* in reported cases, despite the fact that in the latter a Social Marketing campaign was being conducted. In Son La Province, with a

#### **Figure 4.**

*Reduction of reported cases of diarrhoea, dysentery and food poisoning (DD & FP) in 7 CHC communes in Vietnam after one year of health promotion activity (2009–2010).*

higher density of 12 CHC in 55 villages in the catchment of the Health Centre, there were no other public health programmes, therefore we attribute the decrease in DD & FP to the CHC intervention.

However, the data could not determine if there were fewer reported cases at Health Centres due to successful prevention of DD & FP by safe hygiene, or due treatment at home using SSS, but either way these numbers show some positive effect. Nurses interviewed from the Health Centres attributed the decrease in cases to the CHC training and maintain that patients were more able to distinguish between when it is necessary to come to the clinic for treatment and when they can treat dehydration at home. This clear pattern in six well matched communes, provides some indication of the potential of hygiene and sanitation training in CHC to affect health outcomes.

#### *4.1.4 Cost effectiveness of the CHC intervention*

We apply the same method of assessing cost-effectiveness in Vietnam as we did when estimating cost per beneficiary in two districts of Zimbabwe [1]. In Makoni District in two years for 68,700 beneficiaries we estimated a cost per beneficiary of US\$ 0.61: this included in addition to training and running costs, support in terms of allowances and fuel and motorbikes for 14 government field workers [3]. Whilst this method of dividing the cost of operation of the project by number of beneficiaries is a fairly rough approximation, it can give some comparative data to enable assessment of cost-effectiveness in Vietnam using the same equation.

The 48 CHC in Vietnam were run by Village Health Workers, who were given a nominal incentive, but no transport or fuel allowance as they were stationed in the village. The only costs in Vietnam were for the initial training in the District, which was done in 2009. The running costs for two years was estimated in one Province at US\$45,045. Taking the national average of 4.5 family members per household with 2,929 CHC member, there were **13,258** beneficiaries. Thus, cost per beneficiary can be roughly estimated at US\$1.30 per annum for two years (2009–2010) per district [3].

Cost-effectiveness is determined by the number of beneficiaries and the CHC approach is a methodology which can work at scale. The Zimbabwe programme was almost 5 times larger than the Vietnam pilot project and was therefore a third of the cost per beneficiary. Generally pilot projects are not expected to be cost-effective as they tend to be small scale with large start-up costs which make them more costly per person. However, as with the pilot Community Health Club project in Vietnam, this rough calculation may provide some indication of the cost-saving that could be achieved at scale.

#### *4.1.5 Perceptions of stakeholders of the community response*

Perception of project success can be ascertained from the stakeholders and for this reason we conducted a structured interview with health officials in each province in Vietnam [16] and asked them to rate the 'popularity' of Community Health Clubs from 1 to 10.

Community Response in Phu Tho, was rated at 7 out of 10, with officials saying, 'the *CHCs are very popular because people do it voluntarily, they vote for the committee and they organise it all themselves…more focus on the practical and more participation. They do not rely on the facilitator, so it is a two-way teamwork and promotes a good spirit.'.*

In Son La officials gave a score of 8 out of 10 and reported: **'***We are very satisfied with the changes and expect that it can be replicated to other districts. With experience* 

*A Comparative Study of the Efficacy of Community Health Clubs in Rural Areas of Vietnam… DOI: http://dx.doi.org/10.5772/intechopen.97142*

*it has improved knowledge and skills, not only for district but also for provincial staff. Before we had to deal with health promotion but not in a professional way, no materials, so after CHC training we know how to do it.'*

The highest score was given by officials in Ha Tinh with 9/10, who said that community '*have better relationships with each other, and exchange information, do village clean ups, have better coordination and help improve knowledge and awareness.'* One official declared that the CHC Model is *'low cost- high impact'*.

#### **4.2 Results from Zimbabwe**

The impact on behaviour change found in Makoni [1] are now summarized. Clinical data is now provided to assess if there was an impact on health in CHC areas in Zimbabwe. By 1999 there were 42 Health Centres throughout the 20 communal wards of Makoni, of which 12 had resident Environment Health Technicians (EHTs). A communal ward consisted of five or six scattered villages and between 1,000–2,000 households of mostly subsistence farmers.

Whilst the Health Centres cater only to the local population of up to 3,000 people (usually within a 10 km radius), the district hospitals are referral centres for all the surrounding health centres, often over 50 kms away. District hospitals, therefore, did not reflect the same pattern of decrease, presumably because many patients are likely to be referred by Health Centres from areas where there may be no Community Health Clubs. Most Health Centres, on the other hand, situated within a CHC catchment area, did register some downward trend, not only in diarrhoea, but also in skin and eye diseases, ARIs, schistosomiasis and some malaria during the intervention period [15]. Bilharzia was almost eliminated from 1,310 to only one case; Acute Respiratory Diseases decreased from 2,136 to 159 and skin diseases fell from 685 to 41 reported cases.

For the purpose of this paper, we examine only diarrhoea reported cases for comparative analysis with Vietnam. We took the data collected in 8 Health Centres, between 1995 and 2003, which was two years after the end of the project in 2001 [16]. Most notable is the pattern that *in all wards* reported cases of diarrhoea start to fall in the same year that CHCs start in each ward even though the start-up year may be different in each Health Centre, as shown by the shaded areas in **Table 3**. Furthermore, cases in all 8 wards *continue to decline* until 2001 when there is a *rise or a spike* in all but two wards: the two oldest wards of Ruombwe remains low (38 cases) and never climb back to its original level of 404 as in 1995 and Mutanda maintains the fall but starts to rise the following year 2003, when the highly effective EHT left the area. Tikwiri by contrast, without an EHT after the project ended in 2001, climbed straight back to previous levels of diarrhoea in two years (437) with 124 more cases than in 1995 (**Table 3** below)*.* The effect of the charisma of different EHTs is a variable which should be correlated more closely with behaviour change.

This lack of sustainable reduction of diarrhoea maybe attributed to the circumstances in Zimbabwe where in 2001, political change and economic inflation started to affect the country. However, if these circumstances caused the decrease in reported cases, it stands to reason that all wards would have been equally affected. The question to be asked is 'Why is it that one ward, the one which was the most diarrhoea-affected of all wards in 1995, continued to decrease in reported cases across all diseases over nine years, despite the economy and other constraints shared by all other wards?' Our explanation for this is that only in Ruombwe ward was there a dedicated EHT and active CHCs for nine years, and only in this ward was the coverage of CHC members of all households sufficiently high (80%) with 18 CHCs and 1,777 members out of 2224 households in


*Shaded area indicates the span of the CHC in each of the wards. Underlining represents a decrease from previous year.*

#### **Table 3.**

*Number of reported cases of Diarrhoea in 8 health Centres in Makoni District, Zimbabwe 1995–2003 [17] LINK Excel.Sheet.12 "Book1" "Sheet1!R17C2:R26C11" \a \f 4 \h \\* MERGEFORMATX.*

the ward participating in the programme, all of which were accessing one Health Centre (**Table 2** *above*). Furthermore, Ruombwe being the first ever CHC project received high visibility externally [15]. This finding reinforces the need for CHC activity to continue for many years to ensure that a sufficient number of people in the area are converted to good hygiene and that this standard is taken as a norm in all households. This take more than a couple of years which is the normal length of a WASH project.

In wards which had been going for five years there was a higher number of CHCs and *(See* **Table 2***)*, the downward trend of reported cases remains low. In wards where CHC had been active for one or two years (Inyati and Chiduku) downward trend was reversed the moment the project officially ended in 2001.

The total number of diarrhoea cases from all wards decrease from 1,787 to 568 between 1995 and 2000 which were the years of intervention. Although the number of cases mounts again to 1,168 two years after the end of the project, the same level is not regained in six out of eight wards by 2003.

To understand which variables affects these differences we would have needed more contextual information from that period: it could be the effectiveness of the EHT, the local leadership, the proximity of the ward to urban areas and the impact of rising HIV/AIDS infections which at the time were 30% of the population. Our sense is that the *length* of the intervention, which also affects the *spread* of CHC members is probably the most important variable, but more contextual information is needed to interpret this data.

#### *4.2.1 Intermediate outcomes of hygiene behaviour change in Makoni District*

The most significant intermediate outcomes of hygiene behaviour change were found in 10 proxy indicators showing a mean improvement of 24% (p < 0.001) as follows:


*A Comparative Study of the Efficacy of Community Health Clubs in Rural Areas of Vietnam… DOI: http://dx.doi.org/10.5772/intechopen.97142*


#### **5. Discussion**

This paper describes for the first time, how a seemingly 'African' approach [13] is in fact transferrable to a South East Asian context, into a very different society, but one which faces the same challenges of poverty and ill health associated with WASH related disease as Zimbabwe. The Community Health Club Approach is a method of community mobilisation and is considered culturally well aligned with traditional communal life in Africa, providing a much-needed means for the empowerment of women and their advancement through increased knowledge of basic causes and prevention of disease. From its first field trial in Zimbabwe [1], the methodology spread to at least 15 countries in Africa to our knowledge, easily replicated by one of the authors in Uganda [18], and Rwanda [17] in East Africa, in Cape Town and Kwa Zulu Natal [16] in South Africa and in Sierra Leone [19] and Guinea Bissau [20] in West Africa, and by others to Haiti in the Caribbean [21]. Monitoring data from all these projects have demonstrated measurable changes in health knowledge, hygiene and sanitation behaviour change, and even in some places an impact on health but more peer reviewed research is needed to ascertain the extent of this impact is the efficacy of CHCs to improve health is to be believed.

#### **5.1 Comparison of values and norms**

The South African concept of 'Ubuntu' on which the CHC model is based, is perhaps a universal value for 'common unity' shared with Confucian and Buddhist teaching, common in Vietnam, which recognises that the strength of the individual is contingent on an effectively integrated community with shared norms and values. In Northern Provinces of Vietnam where this pilot project took place, the values of group conformity and consensus have been developed through many years of national communism, which have discouraged individualism, and very 'western' need for self-expression which has been the hallmark of liberal democracy [22]. Instead CHC members in Vietnam readily comply with the recommended practices advocated in the Community Health Club, and there is little resistance to change. It was apparent from the numbers who joined the CHC and completed the training, that the norms cultivated by the Community Health Club resonated strongly with the existing village culture of mass organisations, who readily endorsed the activities and were part of the existing village structures under the wing of the Women's Union, which is found in all villages throughout Vietnam.

#### **5.2 Comparison of facilities**

Villages in Vietnam had the advantage of a village hall, the 'Culture House', where CHC meetings could be routinely held despite the weather, meaning that CHC activities were not dependent on the seasons unlike in Africa, where training had to be timed to avoid the wet season when attendance was affected by daily downpours of rain [18]. As meetings could be held at night, they did not take away from more pressing demands of earning a living, and provided a welcome social occasion, an outlet for the creativity and musical talent of many members, who loved to sing, deliver poems and drama for the entertainment of the whole village. With electricity and a public announcement system, the Culture Houses provided a ready means to disseminate health messages over the entire village. This sophistication would be a welcome enhancement for CHCs in Zimbabwe, where CHC meet under a tree.

#### **5.3 Comparison of human resources**

Unlike many countries in Africa, where finding facilitators within the community to run the CHC is often a challenge, every village in Vietnam already has a well-trained Village Health Worker (VHW) who usually has a basic training in primary health. In addition instead of local volunteers, VHWs in Vietnam often have a motorbike and are supported by government with a small stipend to ensure that they can sustain such community commitment. As such Vietnam is in the same league as Rwanda, the only country in Africa to adopt the CHC model into a national Community Based Environmental Health Promotion Programme, where CHCs have been started in every village in the country, under the existing staff of the Ministry of Health, who supervise Village Health Workers to facilitate health club sessions. The CHC training in Zimbabwe was done by Environmental Health Technicians stationed at each of the Health Centers, in the Makoni Pilot project, with community-based facilitators in the village. Although the National Water Policy [23] and the National Sanitation Policy [24] both call for CHCs in every village, implementation of such programmes is being done by NGOs, most of which have been trained by Africa AHEAD (Zimbabwe AHEAD, as it was from 1999 to 2015) and is not done by District Health Department.

#### **5.4 Comparison of community mobilisation**

The mobilisation of the community was as easy in Vietnam as it was in Zimbabwe. The Vietnamese manual [25] was adapted from the Zimbabwean manual [8] both written by the main author. It was translated into the vernacular and a toolkit of culturally appropriate visual aids on which this training depends enabled local Ministry of Health officials to conduct the training through existing government structures. The CHC approach holds special promise in the Vietnamese context as the socialist political system ensures a strong public sector with a vibrant network of mass organisations at community level. In addition, the National Target Programme gives overall coordination in the WASH Sector. Zimbabwe (despite having been the original birthplace of the CHC approach in 1995), still has no data base of the thousands of CHCs which have been started in most districts by over 30 NGOs in the past twenty years. Nor do District Health Departments know which CHC are still active. This is a great pity as much could be done to control cholera and Covid 19 epidemics if this was properly coordinated centrally. The obvious next step would be for CHCs to be mapped and registered

#### *A Comparative Study of the Efficacy of Community Health Clubs in Rural Areas of Vietnam… DOI: http://dx.doi.org/10.5772/intechopen.97142*

in a national programme such as the Community Based Environmental Health Promotion Programme which has been so outstanding in Rwanda, so that the National Coordinating Unit which should control WASH development, can in fact coordinate NGOs and prevent the wasteful duplication which is the feature of the chaotic CHC implementation in Zimbabwe.

#### **5.5 Adaptation of the African style CHC to SE Asian context**

The hallmark of CHC programmes in Africa has been the use of a 'membership card' held by each CHC member which records their attendance of sessions and which is required to be fully completed in order that the member be awarded a certificate. It has been theorised that this is an essential part of the 'magic' of the CHC which attracts and holds a larger number of members [23] than with most other mobilisation strategies such as CLTS or PHAST. However, the authorities in Vietnam did not print or distribute membership cards; nor were certificates awarded for completion of the training to CHC members. The facilitation style in Vietnam was autocratic and didactic with top-down directives for hygiene behaviour and compliance enforced by mandatory directives from village leadership. Whilst African CHC tend to be above 80% women, in Vietnam there was more gender balance with as many men as women attending sessions. However, this perceived advantage meant that it was usually men directing proceedings, with little opportunity for gender equity. With a higher level of literacy in Vietnam, the sessions were more like conventional top-down adult education. The sessions were often done without the use of visual aids, which in many places were not printed in time for most of the training. Therefore, the participatory activities which enable women to find their voice were not done, resulting in women remaining largely passive in the meetings. This is unlike the vibrant meeting in Africa which are notable for the full participation of all women as well as men. It is surmised that in Vietnam, with stricter discipline instilled by years of communism, people are perhaps more accustomed to focus for longer periods of time as instructed, without the attraction of participatory activities and visual aids as is the case in African CHC.

#### **5.6 Time needed to effect such change**

High levels of hygiene behaviour were achieved in Vietnam which easily matches some of the best projects in Africa [2]. An interesting addition to the literature is the analysis of how long it took the majority of the CHC members to adopt total sanitation. The data collected in Vietnam shows that with weekly training in a CHC it took *at least four weeks* before the behaviour starts to shift towards zero open defecation, but that within 20 sessions all of the members had either build some sort of latrine (49%) whilst the rest were practicing cat sanitation. This is a relatively fast uptake of sanitation and supports the CHC Theory of Change [17] which advocates for at least six months of regular training in a CHC to ensure high levels of uptake of recommended practices.

In Zimbabwe the data from health centers shows that for *health gains* it needs years, not just months of CHC group pressure, to ensure non risk-hygiene behaviour is maintained and is spread to a critical mass of the population, to ensure gains in prevention of diarrhoea is maintained. Only in Ruombwe ward, the only area with over 80% spread, and nine years of CHC activity, did the number of reported cases diminish and remain low after the end of external project support. There has long been debate as to how much time is needed to achieve hygiene behaviour change. The CHC model has been one of the most thorough of training approaches

arguing for 20–24 weekly sessions [2], whilst PHAST used up to six sessions [9] and CLTS expects to achieve ODF status within two face-to-face sessions with the community [10]. This research therefore supports the call by leading WASH NGOs [26], who are now joined by some esteemed academics [27, 28], calling for more long-term investment in hygiene behaviour change which is shown to be necessary if any effect on diarrhoea is to be seen through WASH interventions.

#### **5.7 Reduction of disease**

In Vietnam the reduction of diarrhoea, dysentery and food poisoning as a direct result of this pilot project was evident in Health Center records, which provides preliminary indication of some effect of the CHC on health. The fact that in the control non-CHC communes DD & DP actually *increased*, while it decreases significantly in all CHC communes gives a preliminary indication of some impact. Project monitoring reports further convey a strong pattern of sanitation and hygiene behaviour change is still believed to be efficacious in the prevention of diarrhoea [29].

#### **5.8 Cost-effectiveness of the CHC model in Vietnam**

The CHC methodology can calculate cost-effectiveness because the exact number of beneficiaries and their attendance of health sessions is known. Costs in the first year of a programme are usually higher as training materials need to be printed, but once facilitators are equipped with toolkit and transport, cost per beneficiary should decrease.

It could have been more efficient if Village Health Workers had more than one CHC to run each, as the Zimbabwean facilitators were full time, coordinating five or more health clubs per week. Also, much expenditure went on the printing billboards and posters in Vietnam which is not needed for CHC. The amount of US\$ 1.30 for health promotion per person per year is still low and comparable with most CHC projects in Zimbabwe and well under the target in 'Classic CHC' Programmes of less than US\$5 per beneficiary per annum for hygiene behaviour change (not including water or sanitation subsidy). With number of cases saved through safe hygiene, there is little doubt that Community Health Clubs are almost always 'low cost - high impact'.

#### **5.9 The methodological debate**

We are receiving mixed messages in recent literature on the effectiveness of WASH to reduce diarrhoea and the jury is still out as to exactly which methodology is able to change people's habits in the long term to ensure non risk hygiene and sanitation behaviour. Whilst the Burden of Disease attributable to WASH has apparently been reduced from 4.2% to 1.5% in the last 30 years [3], some recent trials has led to experienced practitioners in the public health sector to question whether WASH interventions are in fact impacting on diarrhoea [30]. Our limited research indicates that comprehensive WASH programmes such as was done in Zimbabwe and Vietnam does lead to reduction in diarrhoal disease.

#### **6. Conclusion**

Whilst epidemiologists and trialists struggle with high end statistical data, to inform the Environmental Health Departments of Ministries of Health on the efficacy of community interventions designed to prevent diarrhoea, the *curative*

*A Comparative Study of the Efficacy of Community Health Clubs in Rural Areas of Vietnam… DOI: http://dx.doi.org/10.5772/intechopen.97142*

wing of Ministry of Health continues to rely simply and systematically on the number of reported cases at Health Centres to indicate trends in the burden of disease. These trends over time may be more reliable than snapshot interventions of clustered-randomised control trials which seldom have enough time to understand the dynamics of community response. Whilst the routine data we present here has obvious limitations in that it may fail to represent the *full* disease burden, with the crisis of reliability in the WASH literature in the past few years, we may find that watching the pattern of reported cases in the catchment area of an intervention over time may be the nearest we can get to assessing impact on health by such interventions as a Community Health Club programme.

#### **Acknowledgements**

In Vietnam, the main author was funded as a consultant by DANIDA 2009-2010 in collaboration with the Ministry of Health and acknowledges the input of local consultants and officials.

In Zimbabwe, the pilot project in Makoni District from 1999 to 2001 was funded by DANIDA in collaboration with the Ministry of Health, and we acknowledge the efforts of Environmental Health Department which was the main implementor of this programme.

Thanks also to Zimbabwe AHEAD (now Africa AHEAD) for quality of training and support to Makoni District.

#### **Conflict of interest**

The corresponding authors is the original architect of the CHC Methodology and therefore has obvious bias.

#### **Author details**

Juliet Waterkeyn1 \*, Victor K. Nyamandi2 and Nguyen Huy Nga<sup>3</sup>

1 Africa AHEAD Association, Cape Town, South Africa

2 Food Safety and Port Health Services, Ministry of Health and Child Care, Harare, Zimbabwe

3 Faculty of Public Health and Nursing, Quang Trung University, Quy Nhon City, Vietnam

\*Address all correspondence to: juliet@aficaahead.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Waterkeyn J. and Cairncross S. Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts of Zimbabwe. Social Science & Medicine. Vol 61, p.1958- 1970. 2005.

[2] Waterkeyn J. Hygiene behaviour change through the Community Health Club Approach: a cost-effective strategy to achieve the Millennium Development Goals for improved sanitation in Africa. Germany. Lambert Publishing. p. 144-167.

[3] Waterkeyn J, Nguyen HN. Low costhigh Impact: Hygiene Behaviour Change in Vietnam in Community Health Clubs, University of North Carolina Water Institute Conference. Available from: https://www.africaahead. org/documentation/publications/ conference-papers/.2011. Accessed: 2021.03.05

[4] Africa AHEAD. Countries. [Internet] 2021. https://www.africaahead.org/ countries/ [Accessed: 2021.03.08]

[5] Waterkeyn J, Matimati R, Muringaniza A, Chingono A, Ntakarutimana A, Katabarwa J, Bigirimana Z, Pantoglou J, Waterkeyn A, Cairncross S. Comparative Assessment of Hygiene Behaviour Change and Cost-effectiveness of Community Health Clubs in Rwanda and Zimbabwe. in Umar B, Rozman U, Turk SS. Healthcare Access: Regional Overviews. 2019. IntechOpen. http://doi:10.5772/ intechopen.89995

[6] Government of Rwanda. Road Map for Community Based Environmental Health Promotion Programme. 2010. Revised 2020.Available from https://africaahead.org/wp-content/ uploads/2015/03/2015.4.-CBEHPP-Workshop-report\_AA.pdf [Accessed 2021.0308]

[7] Rosenfeld J, Berggen R, Frerichs L. A Review of the Community Health Club Literature Describing Water, Sanitation, and Hygiene Outcomes. 2021. Int.J.Environ. Res. Public Health. 18, 1880. https://doi.org/10.3390/ ijerph18041880

[8] Waterkeyn J. The Community Health Club Approach: A Manual for Workshop Participants. 2009. Africa AHEAD. ISBN 978-0-620-40422-8. Zimbabwe.

[9] Srinavasan L. Tools for Community Participation. A Manual for Training Trainers in Participatory Techniques*.* 1990. PROWESS/United Nations Development Programme Technical Series Involving Women in Water and Sanitation. New York.

[10] Kar K. Subsidy or self-respect? Participatory Total Community Sanitation in Bangladesh. 2003. IDS Working Paper 184. Brighton UK: Institute of Development Studies.

[11] Curtis V, Kanki B. et al. Evidence of behaviour change following a hygiene promotion programme in Burkino Faso. 2001. Bulletin of the World Health Organisation. (79): 518-527

[12] Ministry of Agriculture and Rural Development. Completion Report for the RWSS National Target Program 2006-2010 and Major Contents of RWSS NTP 2011-2015

[13] Waterkeyn J, Waterkeyn A. *Creating a culture of health: hygiene behaviour change in Community Health Clubs through knowledge and positive peer pressure.* 2013. *Journal of Water, Sanitation and Hygiene for Development. Vol 3 No 2. 144-155.* Available from: https://doi.org/10.2166/ washdev.2013.109

[14] Water Supply and Sanitation in Zimbabwe. Amcow Country Status *A Comparative Study of the Efficacy of Community Health Clubs in Rural Areas of Vietnam… DOI: http://dx.doi.org/10.5772/intechopen.97142*

Overview. 2011. Available from https://www.wsp.org/sites/wsp/files/ publications/CSO-Zimbabwe.pdf. [Accessed 2021.03.08]

[15] Waterkeyn J. Decreasing communicable diseases through improved hygiene in Community Health Clubs, In Maximizing the Benefits from Water and Environmental Sanitation, Proceedings of the 31st WEDC Conference, Kampala, Uganda, 31October – 4 November 2005. Loughborough University, UK. P.138-145. Available from https:// wedc-knowledge.lboro.ac.uk/resources/ conference/31/WaterkeynJ2.pdf [Accessed 2021.08 03]

[16] Rosenfeld J, Waterkeyn J. Using Cell Phones to Monitor and Evaluate Behaviour Change Through Community Health Clubs in South Africa Proceedings of WEDC International Conference, Addis Ababa, Ethiopia, 2009 water, sanitation and hygiene: sustainable development and multisectoral approaches. Available from https://repository.lboro.ac.uk/ articles/conference\_contribution/ Using\_cell\_phones\_to\_monitor\_ and\_evaluate\_behaviour\_change\_ through\_community\_health\_clubs\_in\_ South\_Africa/9585668/1. [Accessed 2021.03.08]

[17] Waterkeyn J, Waterkeyn A, Uwingabire F, Pantoglou J, Ntakarutimana A, Mbirire M, Katabarwa J, Bigirimana Z, Cairncross S, Carter R. 2020. The value of monitoring data in a process evaluation of hygiene behaviour change in Community Health Clubs to explain findings from a clusterrandomised controlled trial in Rwanda. BMC Public Health 20, 98. https://doi. org/10.1186/s12889-019-7991-7

[18] Waterkeyn J, Okot P, Kwame V. Rapid Sanitation Uptake in the Internally Displaced People Camps of Northern Uganda through Community Health Clubs. 2005. Kampala. 31st

WEDC Conference. Available from https://wedc-knowledge.lboro.ac.uk/ resources/conference/31/WaterkeynJ. pdf. [Accessed 2021.08.03]

[19] Azurduy L, Stakem M, Wright L. Assessment of the Community Health club Approach. Koinadugu District, Sierra Leone. 2007. CARE International, Atlanta, USA. Available at https:// africaahead.org/wp-content/ uploads/2015/08/Capstone-report-on-CHCs.pdf. [Accessed 2021.03.08]

[20] Boone P, Elbourne D, Fazzio I, Fernandes S, Frost C, Jayanty C, King R, Mann V, Piaggio G, dos Santos A, Walker P. Effects of community heath interventions on under 5 mortality in rural Guinea Bissau (EPICS): a cluster-randomised controlled trial. 2016. Lancet Glob Health. 4: e328-35. DOI: 10.1016/ s2214-109X(16)30048-1

[21] Brooks J, Adams A, Bendjemil S , Rosenfeld J. Putting heads and hands together to change knowledge and behaviours: Community Health Clubs in Port au Prince, Haiti. 2015. Waterlines 2015, 34, 379-396, doi:10.2166/ washdev.2013.109.

[22] Harris D, Kooy M, Quang NP. Scaling up Rural Sanitation in Vietnam: Political Economy Constraints and Opportunities. 2011. Working paper 341. Overseas Development Institute. London. Available at https://www. researchgate.net/publication/268051069 [Accessed 2021.0308]

[23] National Water Policy. 2012. (Internet) p.26. Available from: http:// ncuwash.org/newfour/wp-content/ uploads/2017/08/National-Water-Policy. pdf [Accessed.2021.03.08]

[24] Government of Zimbabwe. National Sanitation and Hygiene Strategy. 2017. p.2. (Internet) Available from: http://newfour.ncuwash. org/wp-content/uploads/2017/08/

National-Sanitation-and-Hygiene-Policy-Draft-2017.pdf. [Accessed 2021. 03.08.]

[25] Government of Vietnam. Ministry of Health. Introduction to the Community Health Club Approach: Participatory Community Training Sessions for Village Health Workers. Vietnam. 2011. Ed. J.Waterkeyn. Available from: https:// www.africaahead.org/wp-content/ uploads/2021/03/2009-11-11- Trainers-Manual\_Final.pdf. [Accessed 2021.03.08]

[26] WaterAid. Revitalising Community Led Total Sanitation: A process guide. 2009. Available from file:///C:/Users/ Juliet/Downloads/community%20 led%20total%20sanitation%20 process%20guide.pdf [Accessed 2021.03.08]

[27] Carter RC. Can and should sanitation and hygiene programmes be expected to achieve health impacts? 2017. Waterlines, Vol. 36, No. 1: 92-103. http://doi: 10.3362/1756-3488.2017.005

[28] Schmidt WP. The elusive effect of water and sanitation on the global burden of disease. 2014. Trop Med. & Int. Health; 19.5. 522-527. https:// doi:10.1111/tmi.12286

[29] Pruss-Ustun A, Bartram J, Clasen T, Colford LM, Cumming O, Curtis V, Bonjour S, Dangour A, De France J, Fewtrell l, Freeman MC, Gordan B, Hunter P, Johnston RB, Mathers C, Mausezah D, Medlicott.K, Neira M, Stocks M, Wolf J, Cairncross S. Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries. 2014. Trop Med & Int. Health. 19.8. 894-905. http://doi:10.1111/tmi.12329

[30] Cumming O, Arnold BF, Ban R, Clasen T, Esteves Mill J, Freeman MC, Gordon B, Guiteras R, Howard G, Hunter PR, Johnston RB, Pickering AJ, Prendergast AJ, Prüss-Ustün A, Rosenboom JW, Spears D, Sundberg S, Wolf J, Null C, Luby SP, Humphrey JH and Colford JM. 2019. The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement. BMC Medicine 17:173: http:// doi.org/10.1186/s12916-019-1410-x

#### **Chapter 10**

### New Approaches for Improved Service Delivery in Rural Settings

*Isaac Oluwafemi Dipeolu*

#### **Abstract**

The health status of the people in rural areas is faced with challenges primarily due to availability, acceptability, financial accessibility to healthcare services. These include traditional and cultural beliefs, behavioural norms that explain community viewpoints of social roles and various community members' functions. Rural and remote areas are medically underserved, access to healthcare services is difficult sometimes. Distance covered to access the nearest available health facility by some rural dwellers is discouraging. Thus, moving critically ill or injured persons is hampered because of long-distance or poor transportation means. In the end, many prefer to use traditional medicine than travel that long distance for medical treatment. Recently, healthcare delivery systems have focused on innovative approaches to improve health outcomes, control costs, and foster achieving the Sustainable Development Goals (SDGs). One of these innovations is mHealth (Short Messaging Service) [SMS] texts, which have peculiar attributes, making it particularly suitable for health care in rural and hard-to-reach areas in Low and Middle-Income Countries (LMICs). Moreover, text-messaging interventions are uniquely suited for underserved populations. This chapter highlights some interventions on the uses and benefits of SMS text applications in healthcare service delivery.

**Keywords:** mHealth, reminders, text message, rural areas, health care

#### **1. Introduction**

The term "rural area" or "rurality" is difficult to define as there is no standard definition of a rural area. There is no standard universal definition of rural area or rurality. Countries or individuals define rural areas, characterised by the main activities such as farming, type, and size [1, 2]. A rural area is considered "a place with agricultural orientation; the houses are farmhouses, barns, sheds and other structures of similar purposes" [3]. He noted that population is the main characteristic differentiating rural from urban areas, especially in developing countries. This definition and description of the rural area may seem adequate; however, this measure might not adequately capture what rural areas means to different people in different countries [3]. There are various categories of rural areas, depending on their ease of access from urban centres. These range from rural-urban fringe to remote rural areas [4]. Rural areas change over time, and these changes are triggered by three factors, namely:


It has been found that most rural areas are heterogeneous. Thus, defining rural areas based only on people and or one economic activity (commonly agriculture) is not enough to classify areas or regions as rural [2, 5]. Due to the difficulties in getting a unified standard definition of rural areas, census commissions or agencies at the national levels, development partners/organisations and academics in various disciplines turn to and adopt selected approaches in their definitions. However, these definitions also have their limitations [2]. Researchers and international organisations developed typologies and indicators to understand better rural areas [2, 5]. In 2018, about half (49.7%) of the population in Nigeria lived in rural areas [6]. Udo and colleagues noted that each compound houses a man, his immediate family, and some relatives in the rural areas. Some compounds make up the village, usually inhabited by people claiming a common ancestor, often the village's founder. Villages are rural areas, and they share similar characteristics along the line of various ethnic groups in Nigeria [6].

Studies on rural areas and rural residents' health is not new [7]. Freeman & Lumsden [8] reported an outbreak of typhoid in rural Virginia, USA, and some early researchers called out the need to approach health in rural areas differently. This is because rural and remote areas have scarce resources, inadequate supply of physicians and health workers, limited access to service, and an inadequate healthcare delivery system [9–16]. Knowing that rurality reflects a range of demographic, culture, social, economic, and health systems, it may be appropriate to measure these characteristics rather than using a geographic definition of rurality only [7].

#### **2. Rural people's health status**

In most developing countries, there are cultural differences between rural communities and urban centres. Even in the rural areas, there are significant cultural differences from community to community, and these reflect in the social roles and functions they are engaged in [17, 18]. So, health is a low priority, which often means that medical services and hospitals are the last resort [18, 19]. This is due to different norms, long traditions and religious practices, culture and beliefs the rural dwellers hold on to and previous experiences with healthcare workers [20–22]. One other important factor is accessibility to rural and remote communities. This is due to the physical structure and topography, with mountains, deserts and jungles of these areas, consequently creating difficulties for transportation and often complicated by varying natural disasters. Hence, no means of transportation and evacuation of critically ill or injured patients is impossible in some rural areas [18, 23].

Globally, rural people's health status is worse than urban areas [18]. Although much progress was made in the Health for All target by 2000 and the Millennium Development Goals (MDGs), some of these goals have not been attained. This is evident in the rural and remote areas where most of the world's population live [18]. In some African countries, infant mortality rates in rural and remote areas are usually higher than those obtained in urban centres [24, 25]. Children in rural and remote areas are more likely to suffer from one health challenge or the other compared with their counterparts in the urban centres [18, 26, 27].

The health status of the people in rural areas worldwide is faced with many challenges primarily due to availability, acceptability, financial accessibility to healthcare services. These include poverty resulting in low health status and high disease burden; one of the main factors responsible for rural-urban drift, traditional and cultural beliefs, behavioural norms that explain community viewpoints of social roles and various community members' functions [18]. Topography most time affects accessibility to rural and remote communities, making it difficult for transportation and sometimes complicated by varying harsh climatic conditions. As a result, moving critically ill or injured persons is hampered because of poor or no transportation means in rural and remote areas.

#### **2.1 Limited funding and other resource constraints**

Another factor affecting health services in rural and remote areas is limited funding and other resource constraints. It is a known fact that rural and remote areas are medically underserved, access to healthcare services is difficult sometimes. Some health facilities are understaffed, and in some instances, the health facilities do not have essential equipment or consumables. Distance covered to access the nearest available facility by some rural dwellers is discouraging. Many people living in rural areas have to travel or walk some kilometres from their homes to get to the nearest healthcare facilities. In the end, many prefer to use traditional medicine than travel that long distance for medical treatment.

#### **2.2 Healthcare workers' attitude to patients**

The attitude of healthcare providers is another factor influencing the health status of rural community members. There have been concerns about the attitudes of healthcare workers towards their patients in health facilities. Healthcare workers, especially nurses, sometimes do not treat patients or clients well, use abusive words on patients, and be rude and harsh. In some other instances, healthcare workers were accused of giving preferential treatment to patients they knew [28]. Studies show trends in the unprofessional behaviours and attitudes of healthcare workers towards their patients. A study in Nigeria found healthcare workers showing discriminatory attitudes and engaging in unethical behaviour towards patients with HIV/AIDS [29, 30]. In a related study, some pregnant women in South Africa expressed their hesitations in delivering in the hospital due to previous experiences of being shouted at, beaten or neglected by nurses [31, 32].

Another study revealed that healthcare workers in some hospitals also exhibited these unprofessional behaviours and attitudes by using education level as a yardstick for high-quality services [33–35]. Patients with little or no education considered "villagers or rural dwellers" were treated with impatience and disrespect, given less information, and accorded less attention [33–35].

#### **2.3 Healthcare access in rural communities**

Rural areas in developing countries, especially in Africa, are plagued with persistent social inequality, poverty, unemployment, a heavy burden of disease, and healthcare service provision's inequitable quality [36]. Inequitable quality of healthcare service bothers on accessibility, affordability, and acceptability. Accessibility and affordability of healthcare services are crucial to good health, yet rural residents face various access barriers. Access is defined as "the timely use of personal health services to achieve the best possible health outcomes" [37]. That means the rural residents should access primary care, dental care, behavioural health,

emergency care, and public health services conveniently and confidently. Rural residents face serious difficulties in accessing healthcare services which are usually found in urban centres. This is a true and common feature across rural communities in most African countries. For some people who live in rural areas, the nearest health facilities are some kilometres away from their villages or townships, as the case may be. For instance, 56% of South Africa rural communities live 5 km from a health facility; and 75% of South Africa's poor people live in rural areas [36, 38].

If access to primary healthcare is a fundamental human right, primary healthcare must be brought to rural communities. Asabere reported that the main goal of primary healthcare in most developing countries, including Nigeria, was to make healthcare available, accessible and affordable to all citizens by the year 2000 [39]. This goal has not been achieved yet in most countries, and it seems it will not be soon unless there is a change. For example, despite citing some healthcare centres in rural and urban centres, about two-thirds of the Nigerian population are still medically underserved for many reasons, some of which have been highlighted. Suttle reported that accessing, delivering, or providing healthcare services in rural areas presents unique challenges [40]. Some rural dwellers may travel between two to 3 h to get to the closest health facilities.

Despite the huge gap between developed and developing countries, the main point is that rural health is the same worldwide [41]. The major rural health challenges are availability, accessibility, affordability, and inadequate health workers [15, 42]. Even in countries where most of the population lives in rural areas, the resources are concentrated in the cities [15, 43, 44]. With the concentration of poverty, low health status, and high disease burden in rural areas, there is a need to re-strategize the healthcare delivery systems. Attention must be paid to improving people's health in rural and remote areas if the rural-urban drift (a common trend now) is reversed remarkably [18].

#### **3. New approaches to improving health services delivery in the rural areas**

With the concentration of poverty, low health status and high burden of diseases in rural areas, there is a need to focus specifically on improving people's health in rural and remote areas, particularly if the urban drift is to be reversed. A paradigm shift in the healthcare delivery system focuses on finding new and innovative approaches and organisational frameworks to improve health outcomes, control costs, and improve population health. Lunze, Higgins-Steele, Simen-Kapeu, Vesel, Kim and Dickson [45] pointed out that "innovative approaches have the potential to accelerate progress and to lead to better health outcomes", especially in medically underserved areas. In addition, to achieve the Sustainable Development Goals (SDGs), designing and implementing innovative approaches in the health systems is germane. For instance, immunisation is one of the best global health investments, and it is of great import in achieving 14 of the 17 SDGs. As one of the most far-reaching health interventions, it closely reflects the ethos of the SDGs, "leaving no one behind". Other proven interventions that reduce the burden of diseases and mortality are well established; these interventions are not implemented on a large scale in most Low-and-middle-income countries (LMICs) [45–47].

Improvements in technology and new approaches to organising healthcare delivery are occurring quickly. Information and Communication Technologies (ICTs) are now integrated into existing facilities to stimulate development and enhance service delivery [48]. For example, ICT is integrated into service delivery to manage conditions, monitor progress, improve patients' health, and use reminders for clinic *New Approaches for Improved Service Delivery in Rural Settings DOI: http://dx.doi.org/10.5772/intechopen.101705*

appointments and service uptake, disaster management, and emergency. It is also used in seeking feedback from patients in developed and developing nations [49]. Information and Communication Technologies improve service delivery in various ways, such as increasing accessibility to basic needs and increasing efficiency by increasing connectivity and knowledge sharing [50]. The inclusion of different forms of ICTs into health workers daily routines and their patients is common worldwide [51]. The health status of the masses in developing countries is very poor and providing healthcare services to people living in rural and remote areas is a challenge [52]. This is due to inadequate planning for the populace, predominantly rural areas, rising poverty levels, cultural beliefs, inadequate human resources for health in most rural areas, and increased population size [52].

About half of most countries live in rural areas with a high disease burden and are always left behind during planning and budgetary allocation. Nyasulu and Chawinga pointed out that 11% of the world's population is projected to be in Africa, with a global disease burden estimated to be 22% [48]. To take care of this population, additional 1.5 million health workers must fill the existing human resource for health gap. Information and communication technologies have a growing influence on all areas of human life, and the health care sector can leverage this [53]. They can transform health services delivery [54].

#### **4. Delivery of healthcare services via technologies**

Technology drives the world today, and new technologies are making a significant impact on healthcare delivery. Transformation in healthcare will be driven by future technological innovation. While development in new drugs and treatments, new machines and devices, smartphones, new social media platforms for healthcare, etc., will drive innovation, human factors will remain one of the stable limitations of these innovations [55]. Personal electronics used for communication and social networking are ubiquitous, spreading into mobile healthcare (mHealth) [56]. In Mobile Health News, Jeffrey Shuren, director of the US Food and Drug Administration's Center for Devices and Radiologic Health, was quoted thus, "the use of mobile medical apps on smartphones and tablets is revolutionising health care delivery" [57]. Thus, we can leverage this to improve healthcare access and delivery in rural areas. Mobile Medical Applications (MMAs) tools can be useful in managing or preventing some health conditions. With smartphones everywhere and their revolution in our day-to-day activities, the thousands of MMAs currently available can take some of the strain off the healthcare system [57].

Kabachinski also noted that, as the number of all cadre of health workers continues to shrink, the sick and elderly Americans continue to increase. mHealth and other innovations can readily be deployed to mitigate these frightening developments [56]. Today, it is remarkable to see how mobile devices and applications are incorporated into healthcare systems to deliver effective and improved services. Almost all health workers have smartphones, and their ownership is expected to increase yearly. Many health workers with multiple mobile devices use them at the point of care [58]. Mobile technology is making a significant impact on human life today, and its application in healthcare systems is on the increase. Some of the apps in the mobile devices have been applied in various areas of health services delivery ranging from enquiry/consultation, clinic appointment reminders, adherence, diagnosis to treatment. Specifically, apps malaria diagnosis, check blood pressure and blood sugar levels are common today, thus providing quick feedback to patients. Unlike before, the waiting time for clinic consultation or appointment is always long, and the results of some tests or investigations take longer to be ready. Learning through the mobile app is on the increase in the healthcare community. Apart from its primary use, today's mobile devices have apps that allow patients to complain to doctors, refill prescriptions, or find the nearest healthcare facility. Efforts are being made to leverage mobile technology for improved communication in healthcare systems [56].

In developing countries, healthcare services and product uptake face barriers, particularly in rural areas. Therefore, emphasis should be on the adoption of cost-effective and cost-efficient and user-friendly technology for sustainability. Mobile devices such as mobile phones fall into this category and have been used effectively in various health programmes or interventions. These include improvement in service delivery and uptake, disease surveillance, prevention, diagnosis, management and behaviour modification [59, 60]. Some patients used their mobile phones to remind themselves to take medication or attend their clinic appointments; some patients and health workers accessed websites and used social media to gather health information [61, 62]. Schwebel and Larimer presented a summary of a systematic review on the impact of reminders messages on the targeted health outcomes [63].

#### **5. Prospect of mHealth and mobile phone text messages in public health interventions in rural areas**

There is an increased mobile phone usage with Short Messaging Service (SMS) applications in interventions to deliver health care services. With high success rates in previous intervention in developed countries, Short Messaging Service (SMS) texts have peculiar attributes, making it particularly suitable for health care in rural and hard-to-reach areas in Low and Middle-Income Countries (LMICs). Moreover, text-messaging interventions are uniquely suited for underserved populations. This section highlights some interventions on the uses and benefits of SMS text applications in healthcare service delivery. These interventions are categorised into three major areas, namely


#### **5.1 SMS used to enhance the efficiency of healthcare service delivery**

Mobile text messaging communication has proven to be an effective way to foster desired behaviour change in patients and improve the way care is delivered. A review shows many ways SMS enhances healthcare service delivery efficiency; some of these are highlighted below.

#### *5.1.1 Appointment reminders*

Atun, Sittampalam and Mohan reported that missed appointments in England led to substantial costs for many health systems and the National Health System (NHS) [64]. These costs are due to direct costs involved in arranging the appointment and the opportunity cost of missed appointments. For instance, in 2019, about 307 million were sessions scheduled with doctors, nurses, therapists and other practise staff every year, and 5%—one in twenty, 15.4 million—are missed

#### *New Approaches for Improved Service Delivery in Rural Settings DOI: http://dx.doi.org/10.5772/intechopen.101705*

without enough notice to invite other patients [65]. Most of the doctors pointed out that patients missed clinic appointments due to forgetfulness [64]. Almost all the respondents stressed that patients who missed clinic appointments wasted NHS resources. Most doctors also stated that these behaviours from patients have negative impacts on running the NHS efficiently. Most doctors, therefore, noted that they would consider de-list patients who missed clinic appointments repeatedly. However, most doctors opined that charging patients for missed appointments might reduce the challenge [64, 66].

According to the report, the estimated cost of a GP appointment is £18, while that for a nurse is £7 [64]. Thus, in England, the annual direct cost of missed appointments to the NHS is £180 million for GP appointments and £34 million for practice nurse appointments [64, 66]. Hence, in England, missed appointments cost the NHS £789 million a year. To reduce the extent of the problem, the Department of Health (DOH) in England issued a Missed Appointment Guidance, which identifies ways GP surgeries can improve attendance rates for hospital and GP appointments [67]. To address this problem, some pilot trials, which use mobile phone SMS to remind patients to attend NHS appointments, were launched in England in 2003. Some of these pilots reported success or benefits [64, 67], while others identified organisational factors influencing the uptake and adoption of the reminder messages. Poor healthcare service uptake influenced by ineffective administrative staff stuck to the business-as-usual idea could be enhanced when clinicians sign up patients to the innovations on health-related mobile apps [68].

Reminder SMS is now used in imaging diagnostics [69], paediatrics, sexually transmitted infections, maternal health, antenatal clinics, child, adolescent and mental health, and dental services [64]. Reminder SMS was used for mothers of infants in rural areas on appointment keeping of routine immunisation in Nigeria [54]. The intervention using reminder SMS enhanced infant immunisation timely uptake, completion and service delivery.

#### *5.1.2 Improving communication between healthcare workers*

Short Messaging Service has been identified as a useful communication tool between surgeons with enhanced coordination of patient care, improved efficiency of administrative activities, greater accuracy of messages, and even increased responsiveness to urgent cases. Communication problems between health care professionals were observed to be one of the factors that lead to errors within healthcare systems, which adversely affect patients' well-being [64, 70]. According to Atun and colleagues, it was noted then that much of the clinical information used by doctors come from peers, personal notes on patients or diagnostic tests [64]. Doctors prefer to seek the opinion of experts rather than consult guidelines, manuals or computer-aided decision systems. SMS is now used to enhance communication among healthcare workers [64, 67, 71].

#### *5.1.3 Managing queues*

It has been observed that long waiting times and queuing when accessing health care services led to customer dissatisfaction. Hence, efficient waiting times and queue management are critical to improving service quality and user satisfaction [64, 72–75]. One of the hospitals in England, for instance, has reduced patients waiting time for drug refill and collection of dispensed drugs. Patients receive a text message to inform them when their prescription is ready for collection [76]. This has reduced long waiting times in the hospital and provided much the flexibility to return any time during the day to collect their medication [64].

#### *5.1.4 Contacting blood donors*

Customised SMS is used to invite older adolescents and young adults for blood donation. The providers also use the opportunity to develop a database on blood groups of individuals so that donors can be contacted in emergencies, particularly blood of rare groups is needed [77, 78]. In addition, in India, evidence shows that when a blood centre issued a text message-based request to potential donors for blood to help a young patient with leukaemia was made, 150 calls were received offering donations within an hour [79].

#### *5.1.5 Enhancing access of disabled people to services*

Narasimhan and colleagues reported that people with disabilities, such as the deaf and hard of hearing (DHH) or mute, could benefit from SMS-based applications to contact emergency services [80]. Yousaf, Mehmood, Saba, Rehman, Rashid, Altaf, and Shuguang modelled and evaluated a mobile phone application that utilises speech-to-text and text-to-sign language to visualise the sign language using an avatar and convert the sign language to text [81]. This enables DHH individuals and hearing people communicate. Text messaging services to contact emergency and health services for the deaf and hard of hearing have been launched in some countries, such as Poland. Finding from this intervention show that without this solution, a deaf person would, in many cases, not be able to call for help [82].

#### **5.2 SMS used to improve diagnosis, treatment and rehabilitation of illness**

#### *5.2.1 Improving adherence to health advice and medication*

Adherence is the extent to which a patient's actions are consistent with the advice given by his or her doctor or nurse. According to Kalogianni [83] and Demoz, Berha, Alebachew Woldu, Yifter, Shibeshi and Engidawork, 50% of patients with chronic diseases do *not* use their *medications as* recommended, particularly problematic for long-term conditions which require daily medication [84]. Adverse health outcomes are always the consequences for patients and lead to significant expenses to the health systems. Non-adherence to treatment/medication often result to relapse in patients' health condition leads to hospital admission. This interruption of treatment for infections may result in the emergence of resistant strains. Reminder SMS would be useful to remind patients of the need to use their medication at the right time. The same reminder SMS would be useful in encouraging and reminding patients of the benefits of treatment regimens completion for a wide range of conditions, including acne, asthma [85], diabetes [86, 87], tuberculosis, and AIDS [88, 89] and teenagers on contraceptive [90]. A study was conducted among a cohort of 32 young adult asthma patients. They used SMS text messages written in 'txtspk' from a fictitious friend 'Max' (e.g., "yo dude, it is Max reminding U2 take ur inhaler"). A stream of celebrity gossip and horoscope messages accompanied the SMS and was reported to be successful. Findings showed that participants described the service as acceptable and said they had developed a rapport with Max's fictitious character [91].

A double-blind, randomised clinical trial in Spain, which involved 26 primary healthcare centres, analysed the effect of printed information followed by two SMS text messages (on lifestyle or a reminder to take the medication) on adherence and lifestyle changes in patients with hypertension. Although there was no difference in the rate of non-adherence in both groups, the experimental group could control blood pressure and bodyweight reduction better [92]. Another study from Spain

involved the administration of hepatitis A and B vaccines to patients, patients in the intervention group received reminder SMS for follow-up vaccination. Those in the control group did not receive any reminders. Results showed that the vaccination completion rate was higher in the intervention group than the control group, and this difference was statistically significant [93].

#### *5.2.2 Monitoring of illness and medical interventions*

In 2005, the World Health Organisation noted that effective monitoring of medical conditions, especially chronic illness, improves health outcomes and reduces health care costs [94]. SMS applications are being used in various settings to monitor acute and chronic conditions and monitor the effectiveness of health interventions. For instance, a rheumatologist experimented with a patient reporting system that uses SMS. Patients who received corticosteroid injections for joints of soft tissue inflammation are to report whether injections were beneficial in alleviating pain or improving movement. This allowed remote monitoring and reduced the need for follow-up clinic appointments, thus reducing treatment costs [95]. Reminder SMS was also used in South Africa in monitoring people living with HIV and who receive anti-retroviral drugs. Affected persons can use the app in reporting side effects directly to health workers [96]. In Italy, cancer patients used SMS applications, which enabled them to report their symptoms systematically from home to doctors. Thus, reducing the need for hospital admission for monitoring [64]. Moreover, SMS has enabled improved self-monitoring by diabetic patients and more regular reporting to clinicians in England, France and Thailand [64].

The monitoring of patients in the intensive care unit has been improved through an innovative application. The nurses will send alerts to clinicians through SMS when specific changes are noticed in the patient's physiological status. Through this application, the clinician received a quick update about critical patients' conditions compared with pagers [97]. Furthermore, the feasibility and impact of using SMS to improve asthma self-care by reminding patients of their medication, recording symptoms, measuring peak flow rate and completing an SMS-based asthma diary to send to clinicians were tested in Denmark. Findings from the study showed that patients could effectively use the SMS-based asthma diary and gave them excitement. This gave them more control over their condition [98].

A randomised control trial evaluated the impact of the use of SMS on asthma symptom profile monitoring. The intervention was requested to send the peak flow results to their clinicians daily through SMS and a matched control group who were only counselled to monitor theirs. Findings show that the symptom profiling in the intervention group was better than that in the control group. It was also noted that the patients found the intervention suitable [64].

#### *5.2.3 Provision of psychological support*

The literature indicates that some health conditions, such as bulimia, can be better managed and improved if healthcare providers maintain continuous support through mobile apps. For patients on hospital admissions who have restricted interaction with the outside world, for instance, immuno-suppressed patients or those who had an infection and required isolation, psychological supports and interaction with other patients and relatives could have a therapeutic effect. Text messages may be a useful option in such instances.

Several interventions have been used to encourage young people to access counsellors to seek support on a range of issues, such as bulimia [99, 100], chronic illness, managing stress during end-of-year exams, and receiving advice on health or relationship problems [64]. A randomised controlled trial was conducted using SMS in supporting and prompting young diabetes patients to keep clinic appointments. A customised reminders SMS in a system called 'Sweet Talk' uses progressive goal setting to stimulate health behaviour, help patients set self-management goals, and improve glycemic control. Findings show significant improvement in diabetes control (as measured by metabolic control and self-efficacy) in the intervention group who used "Sweet Talk", as compared with those who received standard care [101–103]. Finding from another study, which explored the acceptability and feasibility of SMS based psychological support among patients with bulimia nervosa, show that SMS intervention is appropriate for aftercare after hospital discharge [104].

#### *5.2.4 Communicating results of diagnostic tests*

In recent times, it has been found that traditional approaches used to communicate diagnostic results are time-consuming and inefficient as these often require the patients to return to the provider unit in person to receive the results. Text messaging interventions have been used in developed countries to communicate results of in-vitro diagnostic tests (such as blood or microbiology tests) [105–108] and radiological imaging for breast cancer screening [109], sexually transmitted infection screening [110, 111]. In developing countries, where healthcare services access barriers exist, reminder SMS was used more effectively in sending results to clinics in rural areas [112]. Text messaging has also been used to accelerate communication to employers of occupational health examination results on foreign workers [105, 106].

#### **5.3 SMS used in public health programmes**

#### *5.3.1 Contact tracing and partner notification for communicable diseases*

An increase in the incidence and prevalence of sexually transmitted infections (STIs) is a significant public health challenge worldwide. Partner notification (partner management or contact tracing) is an essential public health strategy in controlling STIs because sexual partners of those with STIs are likely to be infected. If asymptomatic, they might not seek care [113, 114]. Text messages applications are being used to notify partners of individuals with STIs [115] and strengthen control efforts for major global public health problems such as tuberculosis, HIV, and SARS [116–118]. StarHub and the Singapore Tourism Board launched a text alert service named "SARS Contact Tracing SMS" to trace persons in case of future SARS outbreaks in Singapore [119].

Tomnay, Pitts and Fairley reported that clients attending a STIs clinic found calls or SMS to mobile telephones as acceptable and efficient means to contact tracing. Recent sexual partners could be traced, details of a website that had information on the STIs to which he or she can potentially be exposed are provided [120]. On the other hand, an SMS can be sent from the clinic to the client and forwarded to their partner(s) thereby maintaining the anonymity of the partner [120]. Newell further described how text messaging was used to reach the client's partner, who was diagnosed with an infection after the initial visit to the STIs clinic. Even though the partner was unaware of why his girlfriend participated in a STIs clinic, the text message he received from her contained the diagnosis code used to initiate appropriate treatment. Therefore, SMS may be adjunct to contact slips for contact tracing in genito-urinary clinics [121].

#### *5.3.2 Communicating health information to the public*

Short Messaging Service is beneficial for rapid communication of health information to the general public for public health emergencies during an outbreak

of infectious diseases like COVID-19, Ebola, Lassa fever, and avian influenza. It can also be used for rapid communication when a group of people or patients are accidentally exposed to an infectious agent. It has been a valuable tool in rapidly reaching people to recall harmful food products or pharmaceuticals [122–124].

Short Messaging Service has also been used in public awareness campaigns in India to inform and educate the public on WHO tuberculosis control strategy; in Kenya, Nigeria and Mali, to educate the public on HIV and malaria control programmes [116]. It has been used in Iraq to support polio immunisation campaigns targeting about 5 million children [125]. During the SARS epidemic in Hong Kong, one of the mobile telecommunication operators sent SMS to the citizens, educating every one of safety measures that helped reduce the risk of exposure to the virus [126].

Programmed bulk SMS can also be used for a specific population effectively. After the floods in India, most people in Mumbai were exposed to floodwaters. Through sent text messages, everyone in the area was advised to take 200 mg of doxycycline to prevent leptospirosis infection [127]. In the UK, health promotion advice and information was provided through NHS Direct Interactive text messages to people with long-term conditions like diabetes and asthma [128]. Shortly after, other UK health organisations adopted text messages to address the health challenges of people living in rural areas [116]; health educate students [118, 129, 130]. This interactive text message was used to provide confidential health information to pupils [131], provide teenagers and young people with information on sexual health, anti-smoking education, mental health, pollen count to asthmatics or hay fever sufferers and alerts on high levels of smog and air pollution to high-risk groups [116].

#### *5.3.3 Use of SMS in smoking cessation programmes*

Short Message Service has been used in Australia, New Zealand, Spain, and the UK to provide health education, anti-smoking campaigns, and assist behavioural change in people trying to quit smoking [132, 133].

Findings from a randomised control trial on SMS effectiveness in smoking cessation programmes in New Zealand found that the proportion of participants who stopped smoking in the intervention group who received reminder SMS support was significantly higher than the control group [134]. Findings from the follow-up study show similar results [135]. Findings from a cohort study assessing smoking cessation among college students in the US showed higher cessation rates among the group that used Web and text-messaging programmes than those in minimalcontact or self-help smoking-cessation interventions [136]. In conclusion, studies reviewed from the literature demonstrate wide use of SMS-based applications with benefits in health outcomes. These studies also show that SMS-based healthcare applications are acceptable to patients: thus, it can be concluded that SMS can develop new service delivery models.

#### **6. Potential challenges of reminder SMS**

No innovation comes without one challenge or the other. The same applies to using reminder SMS or messages in health programmes or interventions. A frequently cited challenge in its use in healthcare treatment pertains to patient confidentiality, especially regarding diseases that run in some families (such as mental illness, genetic diseases), predisposing the bearers to discrimination if made publicly known [63, 137]. Although the confidentiality of patients poses some

risks, some steps can be taken to mitigate the concern. These steps include sending generic and coded reminders informing patients to open messages in a private place and delete messages after reading them [63].

One major obstacle with sending reminder SMS is for individuals not reading the messages they have received. Recipients of reminders SMS may sometimes become annoyed at receiving multiple messages over time.

#### **7. Future directions**

Reminder messages show great potential for use across the broad spectrum of healthcare services. They are effective as appointment and drug/medical compliance reminders. Additionally, SMS reminders effectively prompted other health behaviours, including self-medical examinations, socialisation, and goal-directed behaviours. It is currently unclear the most effective dose of reminder messages (i.e., timing, frequency, and the total number of messages) and under what conditions the dosage should be changed over time [63]. Dosage varies between individuals and is impacted by the perceived importance of the reminder (e.g., if something is crucial to one's health or for changing behaviour) [63]. Further research on these areas can help inform future implementations of reminder messages in healthcare service delivery.

#### **8. Conclusion**

Accessibility and affordability are the major issues about rural health around the world. In the countries where most of the population lives in rural areas, the resources are concentrated in the cities. Rural areas worldwide are faced with transport and communication difficulties, and they all face the challenge of shortages of doctors and other health professionals in rural and remote areas. Many rural people are caught in a downward spiral of poverty—ill-health—low productivity, particularly in developing countries.

Reminder messages have tremendous and untapped potential in transforming health systems in low- and middle-income countries (LMICs) predicated on the growing availability and use of mobile phones among communities members, families and health care service providers. They are relatively inexpensive, easily customised, sent directly to individuals, and a part of many daily lives. These attributes further explain why many studies utilise SMS as a reminder to help improve healthcare services. Several studies reviewed on reminder messages to improve health outcomes in developed countries show promising results. Adopting and integrating this innovation into existing health delivery systems will have robust health outcomes in rural communities. It presents a convenient and cost-effective method to support healthcare interventions. Reminder SMS can function as a reminder for periodic (e.g., daily medication adherence) and distal, one-time (e.g., to complete a follow-up vaccination 2 months after initial vaccination) behaviours.

*New Approaches for Improved Service Delivery in Rural Settings DOI: http://dx.doi.org/10.5772/intechopen.101705*

#### **Author details**

Isaac Oluwafemi Dipeolu Faculty of Public Health, Department of Health Promotion and Education, University of Ibadan, Ibadan, Nigeria

\*Address all correspondence to: oludipeolu@yahoo.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Food and Agriculture Organization of the United Nations [FAO]. Guidelines on defining rural areas and compiling indicators for development policy. Publication prepared in the framework of the Global Strategy to improve Agricultural and Rural Statistics. 2018. Available from: http://www.fao.org/3/ ca6392en/ca6392en.pdf

[2] Madu IA. The structure and pattern of rurality in Nigeria. GeoJournal. 2010;**75**(2):175-184

[3] Egbe EJ. Rural and community development in Nigeria: An assessment. Nigerian Chapter of Arabian Journal of Business and Management Review. 2014;**62**(1101):1-14

[4] British Broadcasting Corporation (BBC). What is a rural area?— Characteristics of rural areas—GCSE [Online]. 2021. Available from: https:// www.bbc.co.uk/bitesize/guides/ zpmq4j6/revision/1 [Accessed: 2 February 2021]

[5] Wineman A, Alia DY, Anderson CL. Definitions of "rural" and "urban" and understandings of economic transformation: Evidence from Tanzania. Journal of Rural Studies. 2020;**79**:254-268

[6] Udo RK, Kirk-Greene AHM, Falola TO, Ade-Ajayi JF. Nigeria. Encyclopedia Britannica. 2021. Available from: https://www.britannica.com/ place/Nigeria [Accessed: 5 April 2021]

[7] Bennett KJ, Borders TF, Holmes GM, Kozhimannil KB, Ziller E. What is rural? Challenges and implications of definitions that inadequately encompass rural people and places. Health Affairs. 2019;**38**(12):1985-1992

[8] Freeman AW, Lumsden LL. Typhoid fever in rural Virginia a preliminary report. American Journal of Public Health. 1912;**2**(4):240-252. DOI: 10.2105/ ajph.2.4.240

[9] Knopf SA. The modern aspect of the tuberculosis problem in rural communities and the duty of the health officers. American Journal of Public Health. 1914;**4**(12):1127-1135. DOI: 10.2105/ajph.4.12.1127-a

[10] Ruediger GF. A program of public health for towns, villages and rural communities. American Journal of Public Health. 1917;**7**(3):235-239

[11] Mustard HS, Mountin JW. Measurements of efficiency and adequacy of rural health service. American Journal of Public Health and the Nations Health. 1929;**19**(8):887-892

[12] Mountin JW, Pennell EH, Brockett GS. Location and movement of physicians, 1923 and 1938: Changes in urban and rural totals for established physicians. In: Public Health Reports (1896-1970). London, EC1Y 1SP: Sage Publications, Inc., 1945. pp. 173-185

[13] Ebuehi OM, Campbell PC. Attraction and retention of qualified health workers to rural areas in Nigeria: A case study of four LGAs in Ogun State, Nigeria. Rural and Remote Health. 2011;**11**(1):41

[14] Eley DS, Laurence C, Cloninger CR, Walters L. Who attracts whom to rural general practice?: Variation in temperament and character profiles of GP registrars across different vocational training pathways. Rural and Remote Health. 2015;**15**(4):82

[15] Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annual Review of Public Health. 2016;**37**:395-412

[16] Webster CS, McKillop A, Bennett W, Bagg W. A qualitative and semiquantitative exploration of the experience of a rural and regional clinical placement programme. Medical Science Educator. 2020;**30**(2):783-789

*New Approaches for Improved Service Delivery in Rural Settings DOI: http://dx.doi.org/10.5772/intechopen.101705*

[17] Pew Research Center. What Unites and Divides Urban, Suburban and Rural Communities [Online]. 2018. Available from: https://webcache. googleusercontent.com/search?q=cache:R T9hFZC6xWoJ:https://www.pewresearch. org/social-trends/2018/05/22/whatunites-and-divides-urban-suburban-andrural-communities/+&cd=15&hl=en&ct= clnk&gl=ng [Accessed: February 2021]

[18] Strasser R. Rural health around the world: Challenges and solutions. Family Practice. 2003;**20**(4):457-463

[19] National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Health Care Utilization and Adults with Disabilities. Factors that affect healthcare utilization. In: Health-Care Utilization as a Proxy in Disability Determination. Washington (DC): National Academies Press (US); 2018

[20] Ejike CN. The Influence of Culture on the Use of Healthcare Services by Refugees in Southcentral Kentucky: A Mixed Study [Dissertations]. Paper 116. 2017. Available from: http:// digitalcommons.wku.edu/diss/116

[21] Arousell J, Carlbom A. Culture and religious beliefs in relation to reproductive health. Best Practice & Research Clinical Obstetrics & Gynaecology. 2016;**32**:77-87

[22] Rumun AJ. Influence of religious beliefs on healthcare practice. International Journal of Education and Research. 2014;**2**(4):37-48

[23] Brovarone EE, Cotella G. Improving rural accessibility: A multilayer approach. Sustainability. 2020;**12**(7):2876

[24] Akinyemi JO, Chisumpa VH, Odimegwu CO. Household structure, maternal characteristics and childhood mortality in rural sub-Saharan Africa. Rural and Remote Health. 2016;**16**(2):117 [25] Van de Poel E, O'donnell O, Van Doorslaer E. What explains the ruralurban gap in infant mortality: Household or community characteristics? Demography. 2009;**46**(4):827-850

[26] Teckle P, Hannaford P, Sutton M. Is the health of people living in rural areas different from those in cities? Evidence from routine data linked with the Scottish Health Survey. BMC Health Services Research. 2012;**12**(1):1-16

[27] Clark SJ, Savitz LA, Randolph RK. Rural children's health. Western Journal of Medicine. 2001;**174**(2):142

[28] Dapaah JM. Attitudes and Behaviours of Health Workers and the Use of HIV/AIDS Health Care Services. Nursing Research and Practice. 2016; **2016**:5172497. DOI: 10.1155/ 2016/5172497

[29] Amoran OE. HIV related stigmatising attitude and practice among health care workers in Northern Nigeria. Journal of Infectious Diseases and Immunity. 2011;**3**(13):226-232

[30] Reis C, Heisler M, Amowitz LL, Moreland RS, Mafeni JO, Anyamele C, et al. Discriminatory attitudes and practices by health workers toward patients with HIV/AIDS in Nigeria. PLoS Medicine. 2005;**2**(8):e246

[31] Kruger LM, Schoombee C. The other side of caring: Abuse in a South African maternity ward. Journal of Reproductive and Infant Psychology. 2010;**28**(1):84-101

[32] Jewkes R, Abrahams N, Mvo Z. Why do nurses abuse patients? Reflections from South African obstetric services. Social Science & Medicine. 1998;**47**(11): 1781-1795

[33] Andersen HM. "Villagers": Differential treatment in a Ghanaian hospital. Social Science & Medicine. 2004;**59**(10):2003-2012

[34] Umar N, Quaife M, Exley J, Shuaibu A, Hill Z, Marchant T. Toward improving respectful maternity care: A discrete choice experiment with rural women in northeast Nigeria. BMJ Global Health. 2020;**5**(3):e002135

[35] Afulani PA, Kelly AM, Buback L, Asunka J, Kirumbi L, Lyndon A. Providers' perceptions of disrespect and abuse during childbirth: A mixedmethods study in Kenya. Health Policy and Planning. 2020;**35**(5):577-586

[36] de Villiers K. Bridging the health inequality gap: An examination of South Africa's social innovation in health landscape. Infectious Diseases of Poverty. 2021;**10**(19):1-7. DOI: 10.1186/ s40249-021-00804-9

[37] Rural Health Information Hub. Healthcare Access in Rural Communities [Online]. 2019. Available from: https://www.ruralhealthinfo.org/ topics/healthcare-access [Accessed: 2 February 2021]

[38] Axsel C. Strategic Location Modeling for Mobile Clinics in Rural Areas in South Africa [Unpublished Bachelor's Degree Project]. South Africa: University of Pretoria; 2015

[39] Asabere NY. mMES: A mobile medical expert system for health institutions in Ghana. International Journal of Science and Technology. 2012;**2**(6):333-344. ISSN 2224-3577

[40] Suttle A. Using technology to improve rural health care. Harvard Business Review. October 18, 2017:1-5

[41] Strasser R, Neusy AJ. Context counts: Training health workers in and for rural and remote areas. Bulletin of the World Health Organization. 2010;**88**:777-782

[42] Dassah E, Aldersey H, McColl MA, Davison C. Factors affecting access to primary health care services for persons with disabilities in rural areas: A "best-fit" framework synthesis. Global Health Research and Policy. 2018;**3**(1): 1-13

[43] Adogu PO, Egenti BN, Ubajaka C, Onwasigwe C, Nnebue CC. Utilization of maternal health services in urban and rural communities of Anambra State, Nigeria. Nigerian Journal of Medicine. 2014;**23**:61-69

[44] Scheil-Adlung X. Global evidence on inequities in rural health protection: New data on rural deficits in health coverage for 174 countries. ESS Doc. 47. Geneva: Int. Labour Organ; 2015. Available from: http://www.socialprotection.org/gimi/gess/RessourcePDF. action?ressource.ressou

[45] Lunze K, Higgins-Steele A, Simen-Kapeu A, Vesel L, Kim J, Dickson K. Innovative approaches for improving maternal and newborn health-a landscape analysis. BMC Pregnancy and Childbirth. 2015; **15**(1):1-19

[46] Besnier E, Thomson K, Stonkute D, Mohammad T, Akhter N, Todd A, et al. Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low-income and middle-income countries (LMICs): Protocol for an umbrella review. BMJ Open. 2019;**9**(12): e032981

[47] Stover J, Hardee K, Ganatra B, García-Moreno C, Horton S. Interventions to improve reproductive health. In: Black RE, Laxminarayan R, Temmerman M, et al., editors. Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities. 3rd ed. Vol. 2. Washington (DC): The International Bank for Reconstruction and Development/The World Bank; 2016. Chapter 6. pp. 95-114. DOI: 10.1596/ 978-1-4648-0348-2\_ch6

*New Approaches for Improved Service Delivery in Rural Settings DOI: http://dx.doi.org/10.5772/intechopen.101705*

[48] Nyasulu C, Chawinga WD. The role of information and communication technologies in the delivery of health services in rural communities: Experiences from Malawi. South African Journal of Information Management. 2018;**20**(1):a888. DOI: 10.4102/sajim. v20i1.888

[49] Ramachandran D, Canny J, Das PD, Cutrell E. Mobilizing health workers in rural India. In: Proceedings of the ACM Special Interest Group on Computer-Human Interaction (SIGCHI) Conference on Human Factors in Computing Systems; ACM, Atlanta, GA; April 10-15. New York, NY, United States: Association for Computing Machinery (ACM); 2010. pp. 1889-1898

[50] Ruxwana NL, Herselman ME, Conraide DP. ICT Application as e-Health Solutions in Rural Healthcare in the Eastern Cape Province of South Africa. Health Information Management Journal. 2010;**39**(1):1833-3575

[51] World Health Organization (WHO). Strategy 2004-2007. e-Health for healthcare delivery. [Online]. 2004. Available from: http://www.who.int/ eht/en/eHealth\_HCD.pdf [Accessed 2 February 2021]

[52] Shekar M, Otto K. ICTs for health in Africa [Online]. 2014. Available from: http://siteresources.worldbank.org/ extinformationandcommunicat ionandtechnologies/Resources/282822- 1346223280837/Health.pdf [Accessed: February 2021]

[53] Nair P. ICT based health governance practices: The Indian experience. Journal of Health Management. 2014;**16**(1):25-40. DOI: 10.1177/ 0972063413518678

[54] Oladepo O, Dipeolu IO, Oladunni O. Outcome of reminder text messages intervention on completion of routine immunization in rural areas, Nigeria.

Health Promotion International. 2021;**36**(3):765-773

[55] Thimbleby H. Technology and the future of healthcare. Journal of Public Health Research. 2013;**2**(3):e28

[56] Kabachinski J. Mobile medical apps changing healthcare technology. Biomedical Instrumentation & Technology. 2011;**45**(6):482-486

[57] Mobile Health News. Wireless Health: State of The Industry 2009 Year End Report. 2010

[58] Ventola CL. Mobile devices and apps for health care professionals: Uses and benefits. Pharmacy and Therapeutics. 2014;**39**(5):356-364

[59] Carrillo MA, Kroeger A, Sanchez RC, Monsalve SD, Runge-Ranzinger S. The use of mobile phones for the prevention and control of arboviral diseases: A scoping review. BMC Public Health. 2021;**21**(1):1-16

[60] Grantz KH, Meredith HR, Cummings DA, Metcalf CJE, Grenfell BT, Giles JR, et al. The use of mobile phone data to inform analysis of COVID-19 pandemic epidemiology. Nature Communications. 2020;**11**(1):1-8

[61] Balogun MR, Boateng GO, Adams YJ, Ransome-Kuti B, Sekoni A, Adams EA. Using mobile phones to promote maternal and child health: Knowledge and attitudes of primary health care providers in southwest Nigeria. Journal of Global Health Reports. 2020;**4**: e2020060. DOI: 10.29392/001c.13507

[62] Watkins JOTA, Goudge J, Gómez-Olivé FX, Griffiths F. Mobile phone use among patients and health workers to enhance primary healthcare: A qualitative study in rural South Africa. Social Science & Medicine. 2018;**198**:139-147

[63] Schwebel FJ, Larimer ME. Using text message reminders in health care services: A narrative literature review. Internet Interventions. 2018;**13**:82-104. DOI: 10.1016/j.invent.2018.06.002

[64] Atun RA, Sittampalam SR, Mohan A. Uses and Benefits of SMS in Healthcare Delivery. Discussion Paper V 21.1. London: Centre for Health Management, Tanaka Business School, Imperial College; 2005

[65] National Health System (NHS). Missed GP appointments costing NHS millions. England: National Health System; 2020

[66] Curtis L, Netten A. Unit Costs of Health and Social Care 2005. Canterbury: Personal Social Services Research Unit, University of Kent; 2005

[67] NHS Connecting for Health. A Guide to the National Programme for Information Technology. Delivering Better Care. London: Department of Health; 2005. p. 3. Available from: www. connectingforhealth.nhs.uk/resources/ brochures/npfit\_brochure\_apr\_05\_ final.pdf

[68] Vodafone Text Message Pilot Evaluation. Homerton University Hospital NHS Foundation Trust; 2004

[69] Hospitals embrace SMS technology. 2004. Available from: http://www. textually.org/textually/archives/ 2004/08/004930.htm

[70] Zinn C. 14000 preventable deaths in Australian hospitals. BMJ. 1995;**310**:1487

[71] Sherry E, Colloridi B, Warnke PH. Short message service (SMS): A useful communication tool for surgeons. ANZ Journal of Surgery. 2002;**72**(5):369

[72] Davis MM, Heineke J. Understanding the roles of the customer and the operation for better queue management. International Journal of Operations & Production Management. 1994;**14**(5):21-34

[73] Pierce RA II, Rogers EM, Sharp MH, Musulin M. Outpatient pharmacy redesign to improve work flow, waiting time, and patient satisfaction. American Journal of Hospital Pharmacy. 1990;**47**(2):351-356

[74] Jones P, Dent M. Improving service: Managing response time in hospitality operations. International Journal of Operations & Production Management. 1994;**14**(5):52-58

[75] Lin AC, Jang R, Lobas N, Heaton P, Ivey M, Nam B. Identification of factors leading to excessive waiting times in an ambulatory pharmacy. Hospital Pharmacy. 1999;**34**(6):707-713

[76] Medicine text alert to offer patients greater choice. 1998. Available from: http://www.uhb.nhs.uk/news/press\_ releases/05\_04.htm#2

[77] The Times of India. 2013. Now, blood is available just an SMS away. Available from: http://timesofindia. indiatimes.com/city/mysuru/Nowblood-is-available-just-an-SMS-away/ articleshow/17879908.cms

[78] PRNewswire. AT & T Wireless Grant Helps Blood Center Use Technology to Reach Blood Donors. 2004. Available from: http://www. prnewswire.com/news-releases/ att-wireless-grant-helps-blood-centeruse-technology-to-reach-blooddonors-72220192.html

[79] Cell Phone mobilize support in medical emergencies. 2005. Available from: https://textually.org/textually/ archives/2005/08/009518.htm/ [Accessed: December 2020]

[80] Narasimhan N, Leblois A, Bharthur D, Haridas L, Lal P, Looms, et al. Making mobile phones and services accessible for persons with disabilities. A joint report of ITU—The International Telecommunication Union *New Approaches for Improved Service Delivery in Rural Settings DOI: http://dx.doi.org/10.5772/intechopen.101705*

and G3ict—The global initiative for inclusive ICTs. 2012

[81] Yousaf K, Mehmood Z, Saba T, Rehman A, Rashid M, Altaf M, et al. A novel technique for speech recognition and visualization based mobile application to support two-way communication between deafmute and normal peoples. Wireless Communications and Mobile Computing. 2018;(7):1-12

[82] Observatory for Public Sector Innovation. Mobile application "Deaf Help"—Deaf assistance in emergency situations. 2018. Available from: https:// oecd-opsi.org/innovations/ mobile-application-deaf-help-deafassistance-in-emergency-situations/

[83] Kalogianni A. Factors affect in patient adherence to medication regimen. Health Science Journal. 2011;**5**(3):157

[84] Demoz GT, Berha AB, Alebachew Woldu M, Yifter H, Shibeshi W, Engidawork E. Drug therapy problems, medication adherence and treatment satisfaction among diabetic patients on follow-up care at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. PLoS One. 2019;**14**(10): e0222985

[85] Yun TJ, Arriaga RI. A text message a day keeps the pulmonologist away. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems; Paris, France; April 27–May 02, 2013. Also available at Association for Computing Machinery. 2013. pp. 1769-1778. DOI: 10.1145/2470654.2466233. Available from: http://www.cc.gatech.edu/~arriaga/ YunArriagaCHI13.pdf

[86] Ferrer-Roca O, Cárdenas A, Diaz-Cardama A, Pulido P. Mobile phone text messaging in the management of diabetes. Journal of Telemedicine and Telecare. 2004;**10**:282-286

[87] McMahon GT, Gomes HE, Hohne SH, Hu TM-J, Levine BA, Conlin PR. Web-based care management in patients with poorly controlled diabetes mellitus. Diabetes Care. 2005;**28**(7):1624-1629

[88] Harris JL, Furberg R, Martin N, et al. Implementing an SMS-based intervention for persons living with human immunodeficiency virus. Journal of Public Health Management & Practice. 2013;**19**(2):E9-E16

[89] Lewis MA, Uhrig JD, Bann CM, et al. Tailored text messaging intervention for HIV adherence: A proof-of-concept study. Health Psychology. 2013;**32**(3): 248-253. DOI: 10.1037/a0028109. Epub 2012 Apr 30.

[90] Johns Hopkins Medicine. Text messages can help boost teen birth control compliance. ScienceDaily, May 19. 2015. Available from: www. sciencedaily.com/releases/2015/05/ 150519083307.htm

[91] Neville R, Greene A, McLeod J, Tracy A, Surie J. Mobile phone text messaging can help young people manage asthma. BMJ. 2002;**325**:600

[92] Marquez Contreras E, de la Figuera von Wichmann M, Gil Guillen V, Ylla-Catala A, Figueras M, Balana M, et al. Effectiveness of an intervention to provide information to patients with hypertension as short text messages of reminders sent to their mobile phone (HTA-Alert). Atencion Primaria. 2004;**34**(8):399-407

[93] Vilella A, Bayas J, Diaz M, Guinovart C, Diez C, Simó D, et al. The role of mobile phones in improving vaccination rates in travelers. Preventive Medicine. 2004;**38**:503-509

[94] World Health Organisation. Preventing chronic diseases: A vital investment. World Health Organization. 2005. Available from: http://www.who. int/chp/chronic\_disease\_report/en/

[95] Pal B. The doctor will text you now: Is there a role for the mobile telephone in health care? BMJ: British Medical Journal. 2003;**326**(7389):607

[96] Pérez GM, Hwang B, Bygrave H, Venables E. Designing text-messaging (SMS) in HIV programs: Ethics-framed recommendations from the field. Pan African Medical Journal. 2015;**21**:201

[97] Chen HT, Ma WC, Liou DM. Design and implementation of a real-time clinical alerting system for intensive care unit. In: Proceedings of the American Medical Informatics Association Symposium. Bethesda MD, USA: American Medical Informatics Association; 2002. pp. 131-135

[98] Anhøj J, Møldrup C. Feasibility of collecting diary data from asthma patients through mobile phones and SMS (short message service): Response rate analysis and focus group evaluation from a pilot study. Journal of Medical Internet Research. 2004;**6**(4):e42. DOI: 10.2196/jmir.6.4.e42. Available from: http://www.jmir.org/2004/4/e42/

[99] Hazelwood A. Using text messaging in the treatment of eating disorders. Nursing Times. 2008;**104**(40):28-29

[100] Walsh R. Texting can be bulimia aid. The New Zealand Herald. 2004. Available from: http://www.nzherald. co.nz/nz/news/article.cfm?c\_id=1& objectid=3566605

[101] Franklin V, Greene S. Sweet talk: A text messaging support system. Journal of Diabetes Nursing. 2007;**11**(1):22-26

[102] Franklin VL, Waller A, Pagliari C, Greene SA. A randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetes. Diabetic Medicine. 2006; **23**(12):1332-1338

[103] Franklin V, Waller A, Pagliari C, Greene S. "Sweet Talk": Text messaging support for intensive insulin therapy for young people with diabetes. Diabetes Technology & Therapeutics. 2003;**5**(6): 991-996

[104] Bauer S, Percevic R, Okon E, Meermann R, Kordy H. Use of text messaging in the aftercare of patients with bulimia nervosa. European Eating Disorders Review. 2003;**11**:279-290

[105] Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Car J, Atun R. Mobile phone messaging for communicating results of medical investigations. Cochrane Database of Systematic Reviews. 2012;**13**(6): CD007456. DOI: 10.1002/14651858. CD007456.pub2

[106] Atun RA, Sittampalam S. A review of the characteristics and benefits of SMS in delivering healthcare. In: Atun RA et al., editors. The Role of Mobile Phones in Increasing Accessibility and Efficiency in Healthcare. London: Vodafone Group PLC; 2006

[107] Lim EJ, Haar J, Morgan J. Can text messaging results reduce time to treatment of *Chlamydia trachomatis*? Sexually Transmitted Infections. 2008;**84**(7):563-564

[108] Menon-Johansson AS, McNaught F, Mandalia S, Sullivan AK. Texting decreases the time to treatment for genital *Chlamydia trachomatis* infection. Sexually Transmitted Infections. 2006;**82**(1):49-51

[109] Lamont M. Text messaging and breaking bad news. British Medical Journal. 2005;**330**:1217

[110] Lovitt CJ. Patient choice? British Medical Journal. 2005;**330**:1217. DOI: 10.1136/bmj.330.7501.1217

[111] Bradbeer C, Mears A. STI services in the United Kingdom: How shall we

*New Approaches for Improved Service Delivery in Rural Settings DOI: http://dx.doi.org/10.5772/intechopen.101705*

cope? Sexually Transmitted Infections. 2003;**79**(6):435-438

[112] Wright B. Rural Doctors Advance Care With Wireless: A South African pilot project lets a developer test under extreme conditions. New York, NY: M Business, CMP Media LLC; 2001

[113] World Health Organisation. Sexually transmitted infections (STIs). Fact sheet No. 110. 2015

[114] Centers for Disease Control and Prevention (CDC). Trends in Reportable Sexually Transmitted Diseases in the United States, 2004: National Surveillance Data for Chlamydia, Gonorrhea, and Syphillis. Atlanta, USA: Centers for Disease Control and Prevention; 2005

[115] Swendeman D, RotheramBorus MJ. Innovation in sexually transmitted disease and HIV prevention: Internet and mobile phone delivery vehicles for global diffusion. Current Opinion in Psychiatry. (London, United Kingdom: Wolters Kluwer Health, Inc.,) 2010;**23**(2):139-144. DOI: 10.1097/ YCO.0b013e328336656a

[116] Déglise C, Suggs LS, Odermatt P. Short message service (SMS) applications for disease prevention in developing countries. Journal of Medical Internet Research. 2012;**14**(1):e3. DOI: 10.2196/jmir.1823. Available from: http://www.jmir.org/2012/1/e3/

[117] Nsubuga P, White ME, Thacker SB, et al. Public health surveillance: A tool for targeting and monitoring interventions. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd ed. Washington (DC): World Bank; 2006. Chapter 53. Available from: http://www. ncbi.nlm.nih.gov/books/NBK11770/

[118] Vital Wave Consulting. mHealth for Development: The Opportunity of Mobile Technology for Healthcare in the Developing World. Washington, D.C. and Berkshire, UK: UN Foundation-Vodafone Foundation Partnership; 2009

[119] SARS contact tracing SMS program. 2003. Available from: https:// textually.org/textually/archives/ 2003/05/000689.htm

[120] Tomnay JE, Pitts MK, Fairley CK. New technology and partner notification--why aren't we using them? International Journal of STD & AIDS. 2005;**16**(1):19-22

[121] Newell A. A mobile phone text message and *Trichomonas vaginalis*. Sexually Transmitted Infections. 2001;**77**(3):225

[122] Revere D, Calhoun R, Baseman J, Oberle M. Exploring bi-directional and SMS messaging for communications between Public Health Agencies and their stakeholders: A qualitative study. BMC Public Health. 2015;**15**:621. DOI: 10.1186/s12889-015-1980-2

[123] Baseman JG, Revere D, Painter I, Toyoji M, Thiede H, Duchin J. Public health communications and alert fatigue. BMC Health Services Research. 2013;**13**:295. DOI: 10.1186/1472-6963- 13-295

[124] Free C, Phillips G, Felix L, Galli L, Patel V, Edwards P. The effectiveness of M-health technologies for improving health and health services: A systematic review protocol. BMC Research Notes. 2010;**3**(1):1-7

[125] Cell phones alert users of natural disasters. 2005. Available from: https:// textually.org/textually/archives/ 2005/01/006683.htm.

[126] America's Network. The SARS files: How telcos kept Asia on its feet during the crisis. Article by Clark R. 2003. p. 18

[127] D'Silva J. Rx: Beat leptospirosis with Doxycycline. The Economic Times. The Times of India Group. Bennett, Coleman & Co. Ltd. All rights reserved. 2005. Available from: www. economictimes.com

[128] Colledge A, Car J, Donnelly A, Majeed A. Health information for patients: Time to look beyond patient information leaflets. Journal of the Royal Society of Medicine. 2008;**101**(9): 447-453. DOI: 10.1258/jrsm.2008. 080149

[129] Blackburn L, Blatnik A. Promoting sexual health with SMS texting technology. Nursing for Women's Health. 2013;**17**:465-469. DOI: 10.1111/ 1751-486X.12074

[130] Chen Z, Fang L, Chen L, Dai H. Comparison of an SMS text messaging and phone reminder to improve attendance at a health promotion center: A randomized controlled trial. Journal of Zhejiang University. Science. B. 2008;**9**(1):34-38. DOI: 10.1631/ jzus.B071464

[131] Health Organization. mHealth: New Horizons for Health through Mobile Technologies: Second Global Survey on eHealth. 20 Avenue Appia, 1211 Geneva 27, Switzerland: World Health Organization; 2011

[132] Chamberlain C, O'Mara-Eves A, Oliver S, Caird JR, Perlen SM, Eades SJ, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. The Cochrane Database of Systematic Reviews. 2013;**10**:CD001055. DOI: 10.1002/14651858.CD001055.pub4

[133] Abroms LC, Whittaker R, Free C, Mendel Van Alstyne J, Schindler-Ruwisch JM. Developing and pretesting a text messaging program for health behaviour change: Recommended steps. Journal of Medical Internet Research mHealth and uHealth. 2015;**3**(4):e107. DOI: 10.2196/mhealth.4917

[134] Rodgers A, Corbett T, Bramley D, Riddell T, Wills M, Lin RB, et al. Do u

smoke after txt? Results of a randomized trial of smoking cessation using mobile phone text messaging. Tobacco Control. 2005;**14**:255-261

[135] Bramley D, Riddell T, Whittaker R, Corbett T, Lin R, Wills M, et al. Smoking cessation using mobile phone text messaging is as effective in Maori as non-Maori. The New Zealand Medical Journal. 2005;**118**(1216):U1494

[136] Obermayer JL, Riley WT, Asif O, Jean-Mary J. College smoking-cessation using cell phone text messaging. Journal of American College Health. 2004;**53**(2):71-78. DOI: 10.3200/ JACH.53.2.71-78

[137] Branson CE, Clemmey P, Mukherjee P. Text message reminders to improve outpatient therapy attendance among adolescents: A pilot study. Psychological Services. 2013;**10**(3): 298-303

Section 8
