MICA: BIOS - Assessing the potential of wearable digital biosensors for health system strengthening in LMICs.

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Public Health and Policy

Abstract

Non-communicable diseases, including heart diseases, cancers, chronic respiratory diseases, and diabetes, are increasingly important health concerns in many developing countries. In 2012, for example, a global survey found that non-communicable diseases accounted for 34.5 million deaths of the 52.8 million deaths worldwide, and nearly 75% of those occurred in developing countries. Most premature deaths from these diseases are preventable through changes in lifestyle, such as increasing physical activity, quitting smoking, reducing the consumption of alcohol, and eating healthier food. However, capacities of public health authorities to promote healthier habits and thus improve lives are still inadequate worldwide. In poor-resourced countries, moreover, the burden of non-communicable diseases and the prevalence of associated risk factors is often not known with precision due to the lack of resources and weak information systems. For example, recent reviews of global trends in health surveys found that population data on cholesterol were not available in 100 countries, and no data on blood pressure were obtained for 64 countries. As a result, health authorities lack essential information to develop policy and programmes to address these challenges.

The development of new wearable technologies for health monitoring, such as smartwatches and smartbands, is a promising technological innovation with great potential to support programmes for the prevention and control of non-communicable diseases. Boosted by commercial success of wireless medical devices and the rapid uptake of fitness trackers in high-income countries, advances in this sector have led to increasingly sophisticated hardware and software which can capture a wide range of biometric data, including respiration, oxygen saturation, heart rate, blood pressure, skin temperature, and more. In parallel, there has been a great expansion of wireless networks in developing countries, which can provide the necessary infrastructure to enable data transfer from users to health information systems. Thus, wearable health systems could be introduced to conduct regular surveys on risk factors for preventable diseases and their distribution across population groups, providing important information to health authorities who develop policy to minimise these risks. Wearable health systems can also be used to deliver messages to the users based on individual progress, helping them to achieve health targets and reduce risks. Despite these promises, however, the public health potential of wearable health monitors remains untapped, as no studies to date have explored ways in which such devices could support health policy and programmes.

This project aims to conduct a preliminary evaluation of this potential, laying the foundation of a more comprehensive multi-country study. Research activities will be conducted in Cambodia, where a prototype device will be deployed for field evaluation. This is an exemplary case country in which most research and prevention to date have focused on infectious diseases, while non-communicable diseases have received much less attention and support despite their increasing importance. In this context, the introduction of wearable devices could be useful for strengthening preventive programmes and monitoring of population health. Aware that the introduction of a novel technology is a complex process, we will explore the full range of institutional, socio-economic and technical factors that may be more or less conducive to the uptake of the proposed innovation, with particular attention to the response of individual users.

Technical Summary

Evidence shows that many low- and middle-income countries (LMICs) are experiencing a rising burden from non-communicable diseases (NCDs), mainly cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. However, capacities of national health systems to address the challenges of NCDs are still inadequate. Structural gaps also remain in the ability of health information systems to collect and analyse pre-disease and clinical evidence on associated risk factors. The development of new wearable technologies for health monitoring is a promising technological innovation with potential to support health system strengthening in LMICs for the prevention and control of NCDs. Wearable digital health systems could be deployed, for example, to conduct regular surveys on risk factors for major NCDs and their distribution across socio-economic and demographic strata, informing policy development and resource allocation. In addition, wearable devices can deliver user experiences based on individual progress and health targets, contributing to behavioural change and improved data about the management of chronic conditions. Despite these promises, the public health potential of wearable digital health analytics has yet to be recognised and evaluated in systematic ways. This project aims to conduct a preliminary investigation of this potential, laying the conceptual and empirical foundation for a larger multi-country study. Key elements that will inform data collection and analysis include: (1) cultural relevance and appropriateness of the proposed technology; (2) ethical implications; (3) policy and regulatory barriers and opportunities; (4) health system support, capacities, and responsiveness; (5) usability and affordability. Empirical research will be conducted in Cambodia, where a prototype wearable device will be deployed for field assessment.

Planned Impact

This project aims to assess and generate interest in the potential public health value of wearable health monitors for the prevention and control of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs); concepts and research findings will be useful to academic beneficiaries in health system research, development studies, anthropology of health, and health policy analysis. Concurrently, this project is expected to have practical public health and social benefits, involving key categories of users:

(1) The first category of users includes policy makers, health managers and international partners who can enact policy development and support capacity building in Cambodia. Available data indicate that morbidity and mortality for preventable NCDs, particularly heart diseases, have increased over the past ten years in this country. However, NCDs have not received adequate attention in national programmes, especially as global investments have tended to prioritise other health issues. Our project will contribute knowledge and data that can be used to inform policy development and programme implementation in this area, including the potential introduction of the proposed technology and other similar applications. In order to maximise the opportunities for the uptake of research findings and datasets, key stakeholders in relevant institutional bodies and international organisations will be involved in the research project from the early stages to the final dissemination workshop.

(2) The second category of users include actors that are key to the development of global policy for NCDs. In recent years, the World Health Organization (WHO) and others have developed new strategic plans to support health system development for NCDs such as the Global Action Plan for the Prevention and Control of NCDs. The World Health Assembly also called for an integrated, people-centred approach to the development of health systems that can better respond to the global tendency towards unhealthy lifestyles. Our project will speak to these policy debates by stimulating interest in the evaluation of innovative approaches to collect data on risk factors and minimise these risks. Investigators in this proposal have strong links with major global networks for the prevention and control of NCDs, and will use these connections to disseminate findings to wider audiences and global health actors.

(3) The third category of users is the private sector (Biosensors Beyond Borders), which will provide the prototype for field evaluation in this project. Through partnership with Biosensors Beyond Borders, our proposal will assess and qualify a novel system for population-based NCD analysis and surveillance with potential relevance across LMICs. This will be achieved by combining deep industry experience of devices, sensors, algorithms, online/Cloud-based metrics and tools with multidisciplinary evaluation expertise to determine the benefit of such systems to public health planners and national health systems. Research outcomes will be of broad use to the public health communities in LMICs and will also enable Biosensors Beyond Border to develop of an improved system that can be introduced and potentially scaled up into other geographical and country contexts.

Publications

10 25 50
 
Description Training in research methods
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
Impact In early 2019, the National Institute of Public Health and Dr Marco Liverani organised a one-day workshop to train local researchers in Cambodia in methods for the collection and analysis of survey data, with a focus on the BIOS project. Participants engaged with enthusiasm and reported positive impact on skills development
 
Description An implementation trial of continuous quality improvement for antenatal syphilis and HIV detection and treatment in Indonesia: The MENJAGA stud
Amount £1,000,000 (GBP)
Funding ID MR/T010142/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 02/2021 
End 02/2024
 
Description The DOMINO Study: Measuring and mitigating the indirect effects of COVID-19 on TB and HIV care in Indonesia
Amount £788,210 (GBP)
Funding ID MR/V030825/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 09/2020 
End 03/2022
 
Title Questionnaire to assess user experiences with health wearables. 
Description In collaboration with the National institute of Public Health in Cambodia, an original questionnaire was developed to assess user experiences with health wearables, including utilisation patterns, perceived usefulness and usability, and willingness to pay. The questionnaire was used to conduct the field survey in this project and will be made publicly available after the publication of the scientific report (which is currently under review). 
Type Of Material Improvements to research infrastructure 
Year Produced 2019 
Provided To Others? No  
Impact The surveyquestionnaire has not been published yet. 
 
Title Key informant interviews with stakeholders in Cambodia 
Description Qualitative interviews with local and international stakeholders were conducted to inform the health system evaluation as part of this project. 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? No  
Impact Findings from the analysis of these interviews will be published in anonymised form. 
 
Title User experiences and perceptions of health wearables in Cambodia 
Description Quantitative dataset from the survey in rural and urban Cambodia to explore views and experiences with health wearables. 
Type Of Material Database/Collection of data 
Year Produced 2020 
Provided To Others? No  
Impact The dataset will be made available as soon as the main analysis is accepted for publication. 
 
Description Collaboration with MoPoTsyo 
Organisation MoPoTsyo Patient Information Centre
Country Cambodia 
Sector Charity/Non Profit 
PI Contribution MoPoTsyo is a NGO which aims to improve access to health information for diabetic patients in Cambodia, especially the poor. BIOS provided free-of-charge wearable biosensors to a sample of patients linked with MoPoTsyo.
Collaborator Contribution MoPoTsyo facilitated access to hypertensive patients to conduct the baseline and follow-up survey as part of this project.
Impact Thanks to the support from MoPoTsyo, we could complete data collection for this projected. Upon completion of the survey, all participants were given free-of-charge a sample of the wearable health monitor.
Start Year 2019
 
Description Partnership with the National Institute of Public Health, Cambodia 
Organisation Government of Cambodia
Department National Institute of Public Health, Cambodia
Country Cambodia 
Sector Charity/Non Profit 
PI Contribution Initiated partnership, developed the research protocol and tools, co-organised a major stakeholder engagement event, which will be held in Phnom Penh on 18th March 2019.
Collaborator Contribution Supported the development of research design, protocol, and tools. Facilitated meetings with key informants and stakeholders. Facilitated administrative practices related to the ethics approval of the research protocol in Cambodia. Co-organised a major stakeholder engagement event, which will be held in Phnom Penh on 18th March 2019.
Impact All administrative and ethics requirements have been completed. Data collection in Cambodia is ongoing. A major stakeholder engagement event will be held on 18th March 2019.
Start Year 2017
 
Description Final dissemination meeting 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The final BIOS dissemination meeting was held on 30th August 2021. It aimed to discuss the health sector response to NCDs in Cambodia, past and current experiences with digital health, and key findings from the BIOS project. The meeting included presentations by stakeholders from the Ministry of Health in Cambodia and BIOS investigators. It was held on Zoom due to COVID-19 travel restrictions and was attended by about 100 participants. These included MoH directors and policymakers, international experts, and researchers/postgraduate students from the National Institute of Public Health in Phnom Penh.
Year(s) Of Engagement Activity 2021
URL http://www.biosproject.org/workshop
 
Description Presentation, GIZ 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The research project and preliminary findings were presented and discussed with technical officers and consultants at the GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit), a German development agency with a country office in Cambodia.
Year(s) Of Engagement Activity 2019
 
Description Presentation, Hospital managers, Cambodia 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact The research Project was presented to the management of a hospital in Cambodia, specialised in care for NCDs. Plans to enrol patients in data collection for the project survey were made.
Year(s) Of Engagement Activity 2019
 
Description Presentation, NGO Cambodia 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Third sector organisations
Results and Impact The research project was presented to a NGO supporting prevention and management of diabetes in Cambodia
Year(s) Of Engagement Activity 2019
 
Description Presentation, R&D company, Cambodia 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Industry/Business
Results and Impact The project was presented to the director of a local Cambodian company, focused on technology and innovation for health sector development. Plans for potential future collaboration on the design of user interfaces for wearable health monitors were discussed.
Year(s) Of Engagement Activity 2019
 
Description Presentation, Research organisation, Phnom Penh 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact The research project and preliminary findings were presented and discussed with the directors of a public health training and research organisation in Phnom Penh, Cambodia.
Year(s) Of Engagement Activity 2019
 
Description Presentation, WHO 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The BIOS research project was presented and discussed with technical officers at the WHO Cambodia Country Office.
Year(s) Of Engagement Activity 2019
 
Description Presentation, World Bank, Cambodia 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Preliminary findings were presented and discussed with technical officers at the World Bank country office in Cambodia.
Year(s) Of Engagement Activity 2019
 
Description Presentation, academic institution in Cambodia 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact The research project was presented to and discussed with the vice-rector of an academic institution in Cambodia
Year(s) Of Engagement Activity 2019
 
Description Project website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact In early 2020, the project website was launched to support stakeholder engagement and dissemination activities.
Year(s) Of Engagement Activity 2020
URL http://www.biosproject.org
 
Description Stakeholders meeting, Phnom Penh 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact On 18 March 2019, the National Institute of Public Health (NIPH) organised in Cambodia (Himawari Hotel, Phnom Penh) a BIOS stakeholder engagement workshop. The event involved high-level politicians and policymakers in the Ministry of Health and about seventy stakeholders from local and international organisations, NGOs, and donor agencies.
Year(s) Of Engagement Activity 2019
URL https://www.biosproject.org/events