Could telemedicine enhance traditional medicine practices?

To link to this article: DOI:10.1016/j.eurtel.2014.08.001

http://dx.doi.org/10.1016/j.eurtel.2014.08.001

This is an author-deposited version published in:

http://oatao.univ-toulouse.fr/

Eprints ID: 12006

To cite this version:

Kamsu-Foguem, Bernard and Foguem, Clovis Could telemedicine

enhance traditional medicine practices? (2014) European Research in

Telemedicine / La Recherche Européenne en Télémédecine, vol. 3 (n°3).

pp. 117-123. ISSN 2212-764X

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ORIGINAL

ARTICLE/REMOTE

CONSULTATION

Could

telemedicine

enhance

traditional

medicine

practices?

La

télémédecine

pourrait

améliorer

les

pratiques

de

la

médecine

traditionnelle

?

B.

Kamsu-Foguem

,

C.

Foguem

a_{EA1905,laboratoryofproductionengineering(LGP),ENIT-INPTuniversityofToulouse,47,}

avenued’Azereix,BP1629,65016Tarbescedex,France

b_{Centerforfoodandtastesciences(CSGA),UMR6265CNRS,UMR1324INRA,universityof}

Burgundy,9E,boulevardJeanne-d’Arc,21000Dijon,France

KEYWORDS Telemedicine; Mobilehealth; Complementary medicine; Therapeutic education; Integratedhealth center; Developingcountries

Summary Indevelopingcountries,telemedicineandmobilehealthtoolspromisetoenhance access tohigh-quality healthcare,tosupportcommunication ofmedicalinformationandto assistpharmacovigilanceprocesses.Inthisarticle,weprovidesomeargumentsonthepotential oftelemedicineandmobilehealth(mHealth)applicationstoimprovethedeliveryofhealth careinruralAfricanregions.Specifically,thedevelopmentofmobiletelemedicinecouldhelp tolaythefoundationsofahealthcareapproachintegratingmodernmedicalknowledgewith ancientmedicalpracticesontheAfricancontinent.Accesstoinformationandcommunication technology(ICT),technicaldevicesorportablemediaindevelopingcountriesisincreasingly widespread.Thiscanfosteracomplementaryapproachtohealthcare,namelyinAfrican home-basedcare(AHC),inwhichthepracticeofconventionalmedicinetakesplaceinanenvironment wherebeliefintraditionalmedicineisstrong.IntheAHC,therearecommunityvolunteerswho provideprimarycareandlinkpatientswithqualifiedmedicalpersonnelworkinginthenearest clinicsandhospitals.These volunteershavecontextualknowledgethatisatthefrontierof modernandtraditionalmedicine,stronglyinfluencingtheirpracticalapproachtohealthcare. The articleproposesaninterestingholistic lookatpotentialapplicationsoftelemedicinein thiscontextandexaminesinparticulartherapeuticandpreventiveeducationoftoxicological aspectsofmedicinalplantsandcommunicationaboutthepotentialsideeffectsoftheseplants.

∗_{Correspondingauthor.}

MOTSCLÉS Télémédecine; Santémobile; Médecine complémentaire; Éducation thérapeutique; Centredesanté intégré; Paysen développement

Résumé Lesoutilsdelatélémédecineetdelasantémobileoffrentdegrandespromessespour cequiestd’élargirl’accèsàunesantédequalité,desoutenirlacommunicationdel’information médicaleetd’assisterlesprocessusdepharmacovigilance,danslespaysenvoiede développe-ment.Danscetarticle,nousfournissonsdesargumentssurlepotentiel d’applicationsdela télémédecineetdelasantémobile(mHealth)pourl’améliorationdelaprestationdessoins desantéenmilieururalenAfrique.Particulièrement,lesdéveloppementsdesmoyensmobiles delatélémédecinepourraientpermettredejeterlesfondementsd’uneapprochedelasanté intégrantlesconnaissancesmédicalesmodernesaveclespratiquesmédicalesancestralessur lecontinentafricain.L’accèsauxtechnologiesdel’informationetdelacommunication(TIC) danslespaysendéveloppementestdeplusenplusrépandu;notammentvial’utilisationde dispositifstechniquesoumultimédiasportables.Cecipeutfavoriseruneapproche complémen-tairedesoins,enl’occurrencedanslesmaisonsdesantécommunautaires(MSC),danslesquels lapratiquedelamédecineconventionnellesedérouledansunenvironnementoùlacroyance àla médecinetraditionnelle estforte. DanslesMSC, ontrouvenotamment des volontaires communautairesquioffrentdespremierssoinsetfontlelienentrelespatientsetlepersonnel médicalqualifiéexerc¸antdanslescliniquesetleshôpitauxrapprochés.Cesvolontairesontdes connaissancesquisontàlafrontièredelamédecinemoderneetdelamédecinetraditionnelle quiauneforte influence dansleurapprochepratique dessoinsdesanté. L’article propose unregardholistiqueintéressantsurdesapplicationspotentiellesdelatélémédecinedansce contexteetexamineparticulièrementl’éducationthérapeutiqueetpréventiveavecl’aspect toxicologiquedesplantesmédicinalesetlacommunicationsurlespotentielseffetssecondaires decesplantes.

Introduction

Arecent study explains the prominence of environmental

resourcesforhealthservicedeliveryingeneral[1].Thescale

of medicinal plant use can be related to the advantages

inherent in the practice of outcome-contingent contracts

by African herbal healers [2]. Medicinal plant research

has sometimes revealed certain fundamental properties

(antimicrobial,anti-inflammatory, antioxidant,anticancer,

andanti-diabeticactivities)thathaveledtosomeprogress

in medical research and development [3]. We can cite

the following examples:the use of phytosterols and

phy-tostanols(fordiminishinglowdensitylipoproteinandtotal

cholesterol),blackcohosh(forrelievingmenopausal

symp-toms)andphytoestrogenextracts(e.g.isoflavones,lignans

and coumestans in reducing plasma lipid levelsand bone

loss)[4];themedicaluseofAfricanpotato(Hypoxis

heme-rocallideaorHypoxisrooperi)forawidevarietyofdiseases

(e.g.intestinalparasites,cough,heartweaknessand

child-hood convulsions) and biomedical evidence has revealed

thathypoxisextracts(e.g.glucosides,sterolsandsterolins

testedin several invitro andin vivo modelsaswell asin

a couple of clinical trials) possess certain

pharmacologi-calproperties(antimicrobial, antiviral, anti-inflammatory,

anti-diabetic, antioxidant, anticancer, cardiovascular and

anticonvulsant)[5].However,thereisalackofsound

stud-iesonthecomprehensivetoxicityofthemostusedherbal

products in African traditional medicine. It is therefore

imperativetoimprovethemeansforinformingpeopleabout

toxicologyaspectsandadversedrugreactions ofdifferent

medicinalplantsusedintraditionalhealthcaresystems[6].

The challenges presented by the low number of

health professionals and unequal distribution of medical

infrastructures, within the context of rapid population

growth,aswellasexistingbudgetaryconstraintsdrivethe

needfornewpatient-managementmodelsandhealthcare

organizationsacrossdevelopingcountries.

Theseneworganizationscanencouragecooperationand

removebarriersbetween programsconductedwithin

con-ventional medical frameworks and traditional medicine

settingsand nurture local competencies, asource of

sus-tainabledevelopment.Thiswouldprovideopportunitiesto

extend knowledge, taking into account the expectations

of patients more involved in their healthcare. We livein

apervasive(orubiquitous)environmentwherewidespread

computing allows smart devices to recognize and

auto-maticallylocate each other.This majorbreakthrough has

beenachievedthankstorecentprogressincommunication,

informationprocessing and human—computer interaction

technologies. In fact, in both developed and developing

countries, healthcare improvements must focus besides

care,onprevention, promotionof goodhealth habitsand

develop community medicine. This is why telemedicine

mustaddresstheseissues,amongothers,withthefollowing

objectives:

• improve access to quality health care services to all

individuals regardlessof theirphysical location(remote

areas, territories with few medical professionals and

dependentpersonswithmultiplechronicconditions);

• optimize the management of scarce medical resources

(expertsorspecialistsandinfrastructuresordevicesfor

theprevention,monitoringandmanagementofcomplex

diseases);

• improve collaboration between health professionals for

theimplementationoftelemedicineprocedures,whether

institutions(e.g.collaborativeactivitiesforthe

manage-mentofcriticalsituations);

• makethemostappropriatecoordinatedhealthcare

path-ways(e.g. greater regulation ofhealthcare channelsor

more standardized care pathways in healthcare

provi-sions)byoptimizinghealthprogramswithinasecureand

optimizedmedicalframework.

Telemedicine is a fundamental lever for the

devel-opment of these new organizations from cost-sharing

arrangements to collaborative networks for data and

information and knowledge exchanges. It enables

orga-nizations’ socio-economic constraints to be related with

national/international technological-medical

advance-ments.Socio-medicalimpactincludesnotonlyconventional

servicedeliveryorganizations,butalsoalternativemedical

organizations that identify complementary approaches

to address contextual native problems. Collaborative

management contributes to expressing a coordinated

vision and harmonized direction, bonding and

stimulat-ing every level of the healthcare organization: mapping

primary care (between community-based practice and

conventional healthcare activity) with specialized care

and rehabilitation services to which complex situations

are referred. Telemedicine activities engage in emerging

technologiestoprovidecontinuityofcareinremoteregions

with an enhancementof professionalcapabilities through

knowledge sharing. Particularly, it provides innovative

methodologiestoreinforceinterdisciplinarypracticesthat

continuously improvethe skills of medicalworkers in the

fieldsofconventionalandtraditionalmedicines.Asaresult,

there are new opportunities to improve quality of care

by expeditingdiseaseprevention, managementof chronic

conditions and continuing medical education of people

living and working in geographically remote locations

(isolatedregions,ruralareasorislands).

Telemedicine and mobilehealth provide valuable tools

forbridgingbetweendifferentcultures,traditionalmedical

knowledge and medicalinformation systems,and enables

rich and complexAfrican knowledge of diseases and

tra-ditional treatment approaches to be shared. We provide

compelling reasons that telemedicine and mobile health

(mHealth)willenhanceruralhealthcaredeliveryinAfrica.

Accesstoinformationandcommunicationtechnologies(ICT)

indevelopingcountriesisgrowing.Wemakethevalidpoint

that African home-based care (AHC) increases the

num-ber of people or patients to treat. We also link AHC to

African TraditionalMedicine (ATM).In Sub-SaharanAfrica,

AHCreferstocommunityvolunteerswhoprovidehome

sup-portandreportbacktomedicalandnursingstaffatclinics

and hospitals. Theyare involved in modernmedicine and

haveatraditionalmedicalbackground.Thepaperprovides

aninterestingholisticperspectiveontelemedicine

applica-tions andalsoexamineseffortsin developingcountriesto

helpbridgethedigitaldividewiththemodernageofmedical

technology.

The paper is divided into four sections. Thefirst

sec-tion outlines various types of telemedicine and mobile

healthinitiativeswithinformativecharacteristics.The

sec-ondsection describes somechallenges ofherbal medicine

practices in an African context. The third section

out-linesatahighlevelvariouspolicyandpracticeissueswith

implementation. The fourth section describes the use of

telemedicineinruralcommunitycentres.Thefifthsection

integrates aspects concerning the relationships between

informationtechnologiesandusabilityconsiderations.The

conclusion delivers remarkable information onhealthcare

informationtechnology(IT)/policyandprovidesdirections

for future research and development of healthcare IT

applications.

Telemedicine

and

mobile

health

in

Africa

Sharing knowledge between Western health practitioners

and traditional practitioners is sometimes difficult, but

telemedicineactuallyopensdoorsandcreatesavenuesfor

the traditional medical community to work with modern

medical service providers. Viable projects for rural

com-munitiescreate opportunitiestointegrate traditionaland

allopathic healthcare issues, for example by

collaborat-ingwithformalor informalcaregiverorganisationsandby

increasingtheadoptionofICTframeworks.

Intelligentdecisionsupportsystemsareparticularly

help-ful,sincetheyareabletointegratedifferentcomponents

fromemergentsensorsfordatacapturethroughhardware,

software,case-based reasoning technologies,

communica-tionandsuggestedrecommendations.

Forinstance, in the Republic ofSouth Africa,a recent

projecthasimplementedaremoteandsustainablesupport

systemforruralhealthcaredelivery[7].Moretraditionally,

primary healthcarein SouthAfrica is home-based,

estab-lishednaturallywithinruralcommunitiesinordertoprovide

basicnursingcarebyformalorinformalcaregiversto

per-sons in their own homes. The proposed decision support

system includestwoadvancedcomponents:ahome-based

healthcaredeliverymodelandatelemonitoringpatient

sys-tem.Theformercomponentsimplifiespatientinformation

flow from home-based care workers to a local clinic or

hospital while the latter component assists medical staff

(nursesanddoctors)indecidingthecourseofintervention

orfurthertreatment.Commentsfromparticipantsandearly

evaluationresults suggest thatthe proposedsystem hasa

positiveimpactonthequalityofhealthcare,error

elimina-tion,decisionassistanceandaccuracyofalertingofcritical

cases.

Insituationswherethereareprogramsthatsupport

inter-active activities for information sharing between health

professionalsandtraditionalpractitioners,theadvancesof

communication technology in health care are beneficial.

Realization of the telemedicine paradigm should

facili-tateinformationsharingamongst health professionalsand

primarycaregiverssothattheymayadapttheirdecision

sup-portsystemstoaddressthespecificissuesoftheirpatients.

Thedecisionsupportsystemscanprovideadvicebasedona

combinationofexperiencedknowledgeandpatient

numer-ical data. As such, the local health actors (e.g. disease

generalists or specialists,social workers, nutritionistsand

psychologists)mayprovidereferralstospecializedhospitals

andagenciesprovidinghome-basedcare.

Basedonthecomprehensivecharacteristicsofemployed

terminologyandtheirmeanings, theWorldHealth

Organi-zation(WHO)hasproposedaclassificationofkeyresearch

• healthcarecallcenters/healthcaretelephonehelpline:

provision of triage services and health care advice by

trainedprofessionals,bytelephone;

• toll-freeemergency:oftenusedforrapidaccesstohealth

professionals orstafftrainedtodeliverguidanceduring

medicalemergencies;

• publichealthemergencies:canbedefinedastheuseof

mobiledevicestoreacttourgentsituations;

• mobiletelemedicine:canbedefinedastheuseof

func-tionsofamobiledevice(e.g.,voice,text,data,imaging,

orvideo)fordifferentsituations,suchasteleconsultation

ortele-expertise;

• appointment reminders: comprise services that rely on

voice or SMS (short messageservice) messages sent to

patients;

• Communitymobilizationandhealthpromotion:definedas

theuseoftextmessagingforhealthpromotionoralerting

targetgroupsofhealthcampaigns;

• patientrecords:theuseofmobiledevicestosupportthe

treatmentofpatients,includingcollectinganddisplaying

patientrecords;

• information initiatives: comprise services that offer

accesstohealthsciencepublicationsordatabasesatthe

point-of-care,bymeansofportabledevices;

• patientmonitoring:definedasusingtechnologyto

man-age,monitor,andtreatapatient’sillnessfromadistance

(e.g.,patientssufferingfromdiabetesorcardiac

condi-tions);

• health surveys:the useof mobiledevicesfor collecting

andreportinghealth-relateddata;

• surveillance: defined as the use of mobile devices for

inputting and transmitting data that will be used by

surveillanceprogramstotrackdiseases;

• awareness-raising:comprisestheuseofhealth

informa-tionproducts,games,orquizprogramstoinstructpeople

onrelevanthealthtopic;

• decisionsupportsystems:definedassoftwarealgorithms

thathelphealthproviderstomaketheirclinicaldiagnoses

at thepoint-of-careor healthmanagers totakeactions

basedondatacollectedfromhealthsurveys.

The telemedicine system with ATM is described as an

integrative medicine system, technically correct because

clinicalstaffusetheinformationsentbyvolunteersinthe

fieldtomakeclinicaldecisions.Thisintegrativeframework

canbeappliedtohealthinterventionsacrosshealthdomains

toexplorehowandwhetheravailableeHealthtechnologies

cansupportdeliveryoftheassociatedtypesofassistanceor

interventionswiththetargetAfricanpopulations,e.g.the

surveillancestrategy(usuallyconsideredaneHealth

activ-ity). But it can also be used in telemedicine and mobile

healthtools.Theuseofsurveillanceproceduresishelpfulin

emphasizingthefactthatitisimportantforprimary

care-giverstobeinvolvedinanalyzingtheconsequencesofpublic

healthpolicyonAHCpracticesandintelligencereportswith

regardtodrugsafetystrategy.

Challenges

of

herbal

medicine

in

Africa

Nowadays, quality control of herbal medicine and good

practices are indispensable for the advancement of the

herbal medicine system [9]. Quality problems of herbal

medicines can becategorizedinto: external factors

(con-tamination,adulterationandmisidentification)andinternal

factors(complexity andnon-uniformityoftheingredients)

[10].Moregenerally,ensuringandimprovingpatients’safety

inintegrativehealthcareinvolvesthefollowingfiveresearch

priorities(listedinorderofimportance)[11]:

• activesurveillanceprojectsincludingvulnerablepatients

andconcomitantuseofconventionalcare;

• attitude to safety among ATM practitioners (i.e. the

extenttowhichsafetyisintegraltoclinicalpractice)and

attitudetosafetyinATMprofessionalorganizations(i.e.

the extent to which safetyis considered integral in all

thinkinganddecisions);

• influenceson,andchangesin,publicandpatientbeliefs

andattitudestoATMsafety;

• procedures (and their effectiveness) that ATM

profes-sionalorganizationsusetoensurecontinuedsafepractice

bytheirmembers;

Thereisparticularlyarequirementforthesafety

moni-toringofherbalremedies,andthereisagrowingnecessity

tocorrectly inform consumers about the medicinal

prod-ucts they use. The WHO Drug Dictionary (WHO-DD), the

herbalanatomic-therapeutic-chemical(HATC)classification

andthesystemchecklistforcross-referencingbotanicaland

vernacularnamesareparticularlyvaluabletoolsfor

improv-ingthe operational performance of the safetymonitoring

programs of herbal medicines for national

pharmacovigi-lancecentres[12].

Regulationisfundamental toprofessionalizingand

pro-tectingtheimage oftraditional medicinepractice.It will

helptoeliminateharmfulpracticesandpromotethe

posi-tiveaspectsoftraditionalmedicine[5].Thiswillinvolvethe

adoptionofcommondiagnosticnomenclature,therapeutic

methods,orcurriculum[13].Moreover,insituationswhere

traditionalmedicineisdeemedtobeessential,researchand

developmentincludinganevaluationoftherapeutic

poten-tialandtoxicologicalprofilearecrucialinfosteringpatient

confidence[14].

Potential herb-drug interactions can cause

haemor-rhaging, mild serotonin syndrome, induction of mania,

exacerbation of extrapyramidal effects, increased risk

of hypertension, and decreased or increased blood

con-centrations or bioavailability of certain blood substances

(enzymes,hormones,...)orothersdrugs[15],glycemic

dis-orders or more severe side effects such as convulsions,

medullar aplasia with leucopoenia, and therefore risk of

severeinfections.Governmentshavearesponsibilityto

sen-sitizetheirtraditionalmedicinepractitionersaboutadverse

drugreactionsandprovidethemwiththenecessary

knowl-edge and training that will promote rational traditional

medicinepractices[16].Aneffectivesystemofsurveillance

foradversedrugeffects,frombothareflexivereportingand

adynamicsurveillanceviewpoint,mustalsobeestablished

[17]. Computational methods (e.g. surveillance methods)

foradversedrugreactionsorsemanticformalization

tech-niquestoremoveinteroperabilitybarriers,cancontribute

toensuringthatsafe,effectiveandgood-qualitytraditional

Telemedicine

in

rural

community

centres

Generally, ruralcommunity developmentincorporates the

improvementofhealthcareservicethroughtheprovisionof

basichealth care for thelargest possible number of

peo-ple.Particularly,theuseoftelemedicineinruralcommunity

centres implies the incorporation of modern information

andcommunicationtechnologiesforimprovingmedical

ser-vicesofpersonslivingin ruralregions.Ruraltelemedicine

development consists primarily of teleconsultation and

telemonitoring activities [20]for community-basedhealth

services:

• teleconsultation: the medical community worker and

patientarebasedataruralsite,whilethemedical

pro-fessionaldeliversinteractiveconsultationservicesfroma

remoteurbanlocation;

• telemonitoring: the medical community worker and

patientarebasedataruralsite,whilethemedical

pro-fessionalmustcorrectlyinterpretmedicaldata(clinical,

radiologicalorbiological),necessaryforagivenmedical

monitoringprocedureintheremoteworkplace.

Inbothcases,theconditionsfordeploymentare[21]:

• patientidentification;

• the requirement to directly or indirectly collect a

patient’sfreeandinformedconsent;

• theauthentication ofeach healthpersonnelinvolved in

theremoteconsultation;

• the training or preparation of the medical community

workerintheuseofthetelemedicinedevice;

• notinginthepatientrecordandintheobservationrecord

(asummaryofthemedicalactwithcontext,diagnosisand

prescriptionorrecommendations).

Atelemedicineproject isbasedondedicated

organiza-tionofcareandprofessionalpracticesforthetargetmedical

environment[22—24].Clarificationsanddetailsonthe

con-ditionsunderwhichthetelemedicineactivityisperformed

must takeinto account the specificities for the provision

ofcareintheconsideredregionoftheworld[25,26].

Par-ticularly, theimplementationof telemedicineprogramsin

developingcountriesneedstoensurethegood

understand-ingofspecificsocial,culturalandeconomiccharacteristics.

Forinstance,theAfricanrealityclearlyshowsthatnatural

products are perceived as safe and secure,

differentiat-ingthemfromotherpharmaceuticalproducts.This means

that patients would tend to want to increase the doses,

but when they do so, they might increase risks to their

health. Telemedicine activities (e.g. teleconsultation and

telemonitoring) may harmonize safety monitoring

organi-zation andtheeffective disseminationofsafetyrules and

procedures. The roles and responsibilities of each actor

involved in the telemedicine activity must have formal

written terms of description and should entail functional

locations, workplace sheets and behavior guidelines with

update options. Therefore, each medical or paramedical

actorhastoactinaccordancewiththerequiredprofessional

conditions(inforceinthecountry)inordertoparticipatein

a telemedicine activity. Furthermore, telemedicine

activ-ities mustmeet some technicalrequirements for assuring

compliance withpersonal health data protection and the

guaranteeoffundamentalrightsandfreedomsinpractice.

Community health centres play a pivotal role in rural

areasinpreventiveandtherapeuticsupportforlocal

popu-lations.They ensurethesocialandmedicallinks between

conventionalhospitalsandpatients.Themedicalworkerof

a community health centre assisting with a telemedicine

activityplaysanessentialroleinhighlightingrealliving

con-ditions,actualexperiencesandexpectationsofthepatient

inconsultation.Aspreviouslymentioned,ataninitialstage,

thetwomaintelemedicineactivitiesareboththe

telecon-sultationandtelemonitoring.

Aframeworkforsupportinteleconsultation:the

commu-nityhealthcentre’sactorassistingthepatientbecomesthe

mediatoroftheconsultation,therelationshipbetweenthe

hospitaldoctorandthepatient,andguaranteesthe

trans-missionofdifferentexchanges[27].

A framework for supportin telemonitoring: the

princi-pleofthetelemonitoringofpatientswithchronicdiseases

(e.g.heartdisease,chronickidneydiseaseanddiabetes)is

increasingly recognizedasessentialin meetingthe

impor-tantneedsofthesepatients[28,29].

Theseprofessionalactorsinvolvedincommunityhealth

centresdescribeanimprovedrelationshipwiththepatient

because of this support of telemedicine activities. As a

result,knowledge sharingoccursbetween thehealth

pro-fessionalsandthepatientandhisfamily.Infact,thefamily

membersofpatientscanprovideusefulinformationforthe

planningandmanagementofhealthcare;inturnthey

ben-efitfromtheinterestingcarecounsellingprovidedbyhealth

professionals.

The situation of developing countries requires the

deployment of telemedicine projects with low operating

costs. mHealth provides the means to increase the use

of digital technologies and Internet access around the

world.Thedefinitionofpurchaserequirementsforagiven

telemedicine project should also develop guidelines to

ensure goodlevelsof accessfor large numbers of African

people.Besides,coherentchoiceswithsustainable

consider-ationscanbemadeforspecificoperationandmaintenance

ofthemedicaldevicesandinformationsystemsusedinrural

conditions.Somedirect orindirect fundingby theAfrican

governments can reduce costs for communityhealth

cen-tresandmakemHealthdevicespricesmoreaffordable.In

addition,non-governmental organizations andother

char-itable foundations may provide supplementary budgetary

resourcesfortheacquisitionofcriticalmaterials,devices,

and information technology equipment. Hence, the rural

Africanpopulationcanhaveaccesstoacertainnumberof

healthcareservicesatmorereasonableprices.

Discussion

Thereis an expectationthatmobile phoneswill facilitate

a range of telemedicine activities (cardiology, radiology,

nephrology, dermatology, obstetrics, psychiatry and

oph-thalmology) in Africa [30]. Nevertheless, there may be

certaincasesorcircumstancesin whichhealthworkersdo

notnecessarily acceptmHealthintheir routineactivities.

Furthermore, due to network disruptions that affect the

quality of mobile phone and Internet services in Africa,

healthcareprofessionals’ organisationalbarriers tohealth

informationtechnologies[31]:

• structureofhealthcareorganisations;

• tasks;

• peoplepolicies;

• incentives;

• informationanddecisionprocesses.

Usabilityissuesareagreatobstacletohealthinformation

technology (IT) acceptance. The health ITusability

eval-uation model (Health-ITUEM) was designed and usedin a

numberofpolicyexercisesfocusingoninteractionsbetween

theuser and tasks ina web-basedcommunication system

[32].Health-ITUEMconceptsinclude:

• perceivedeaseofuse:errorprevention,otheroutcomes,

informationrequirementsandmemorability;

• perceived usefulness:learnability,competency,perform

speed,flexibility/customizability;

• efficiencyandeffectiveness.

TheHealth-ITUEM frameworkhas recentlybeentested

andevaluatedtoprovideappropriateanduseful

understand-ingandknowledgeofadjustedmanagementintheusability

issues related tomHealth technology [33]. As the

poten-tial inherent in this technology is broadly recognized by

globalhealthagenciesandindustrialpractitioners working

inthefield,evidence-basedstrategiesareneededtoprovide

guidance to implementing organizations, help legitimize

mHealthandpromoterelatednationalgovernmentpolicies

[34]. In this respect,improvement measures, which

opti-mize meaningful mHealth utilization and health systems,

arerequired toassist developing countriesless advanced

in the field. In practice, the strengthsand disadvantages

associated with each mHealth category can be of a

dif-ferentnature, depending on the level of health workers’

involvement,thedegreeofformalityoftheorganisational

structure,theavailabilityofresources,initialarrangements

withmobileoperatorsandrequirementsregardingthe

appli-cation’scapabilities[35].

Conclusion

Telemedicine and mHealth can play an important role in

forging strategiclinks between the different stakeholders

working in research issues of traditional,

complemen-tary andalternative medicines. Particularly, theeffective

communicationofinformationontoxicologicalevaluations

ofthemostfrequentlyusedmedicinalplantscanbe

impor-tantinthesafetyandmonitoringoftheAfricantraditional

medicine. The promising potential of telemedicine and

mHealth applications for an integrated approach in the

Africanhealthcaresystemcansignificantlycontributetothe

holisticdimensionoftraditionalsocietiesandlocal

commu-nitieswithculturalvaluesandancestralknowledge.

There is evidence to demonstrate that the ‘‘informal

mobiletelecenter’’besidestheformalone,denotesa

boom-ing informal businessin Africa’s mobile telephonesector.

This informal business, which is practiced by millions of

Africansbothinurbanandruralareas,involvesobtaininga

mobilephoneandatableinanopenareaonastreet.In

addi-tiontobuying airtime,thecustomers can alsomake calls

andcover thecostsof communications.It isalsopossible

to borrow mobile phones from relatives or friends and

reimbursethemtheassociatedcostsofcommunicatingthe

findingstomedicalmembers andotherhealthcare

organi-zations.As a consequence, it is realistic toconsider that

mobilephonescanplayanimportantrole(e.g.the

educa-tionaladvantagesoftelemedicine)inreachingpeopleliving

ontheruralareas.

However, more research is required to learn lessons

from socio-cultural and economic contexts for

continu-ousimprovement that effectively and efficiently supports

primary healthcare services (evaluated from a

sustain-ableuser-centred perspective)inremoteregions ofAfrica

or others regions of the world [36—39]. Organizational,

legal,ethical,conceptualandtechnologicalissuesare

cru-cial in allowing mHealth services to become widespread

throughoutthe emergingarea andparticularly withsome

imperativesfortheiradoptioninAfrica[40].

Disclosure

of

interest

Theauthorsdeclarethattheyhavenoconflictsofinterest

concerningthisarticle.

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