Psycho-Oncology

Psycho-Oncology 21: 332–335 (2012)

Published online 11 F ebruary
F 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.1894

Brief Report

The mobile phone as a tool in improving cancer care

in Nigeria
V. I. Odigie1, L. M. D. Yusufu1, D. A. Dawotola2, F. Ejagwulu3, P. Abur1, A. Mai1, Y. Ukwenya1, E. S. Garba1,
B. B. Rotibi4 and E. C. Odigie5
1
Division of General Surgery/Breast Unit, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2
Centre for Oncology and Radiotherapy, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3
Department of Trauma and Orthopaedic Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
4
Department of Physiotherapy/Rehabilitation, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
5
Department of Nursing Services, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

* Correspondence to: Division Abstract

of General Surgery/Breast
Unit, Ahmadu Bello
University Teaching Hospital,
Zaria, Nigeria. E-mail:
odigievincent@yahoo.co.uk
Received: 31 October 2010
Accepted: 10 November 2010
Objective: The use of mobile phone as a tool for improving cancer care in a low resource setting.
Methods: A total of 1176 oncology patients participated in the study. Majority had breast
cancer. 58.4% of the patients had no formal education; 10.7 and 9.5% of patients had college
or graduate education respectively. Two out of every three patients lived greater than 200 km
from hospital or clinic. One half of patients rented a phone to call.
Results: At 24 months, 97.6% (1132 patients) had sustained their follow-up appointments
as against 19.2% (42 patients) who did not receive the phone intervention. 72.8% (14 102 calls)
were to discuss illness/treatment. 14% of the calls were rated as emergency by the oncologist.
86.2% of patients found the use of mobile phone convenient/excellent/cheap. 97.6% found the
use of the phone worthwhile and preferred the phone to traveling long distance to hospital/
clinic. Also the patients felt that they had not been forgotten by their doctors and were been
taken care of outside the hospital/clinic.
Conclusions: Low resource countries faced with the burden of cancer care, poor patient
follow-up and poor psychosocial support can cash in on this to overcome the persistent problem
of poor communication in their healthcare delivery. The potential is enormous to enhance the
use of mobile phones in novel ways: developing helpline numbers that can be called for cancer
information from prevention to treatment to palliative care. The ability to reach out by mobile
phone to a reliable source for medical information about cancer is something that the
international community, having experience with helplines, should undertake with colleagues in
Africa, who are experimenting with the mobile phone potential.
Copyright r 2011 John Wiley & Sons, Ltd.
Keywords: cancer; oncology; care; mobile phone; Nigeria

Introduction important for patients [1–14], there has been little

Poor follow-up of patients after being seen by a
doctor is a problem in health-care delivery to
patients in developing and low resource countries.
This is due to patients’ poor education, limited
resources, poor road network, underdeveloped
communication infrastructure, and poverty. A key
problem is the inability to access a physician or
clinic easily and promptly. As a result, patients
have unmet needs for information, poor follow-up
visits, and poor to absent psychosocial support.
The widespread availability of mobile phones has
suddenly provided a new, inexpensive means of
communication, even for those in remote areas.
Despite the fact that communication, both face-to-
face and by telephone, is well proven to be
study of telephone support for patients with cancer
in Nigeria, a low resource country.
Several studies have shown improved adherence
to treatment in Africa for patients who require
lengthy medications for tuberculosis and HIV/
AIDS [15–17]. The mobile phone was available in
2001 to less than 3% of the population; however,
sharing, renting, and borrowing phones has meant
that even remote village homes without electricity
and water can have access to a mobile phone.
The impact on health care has been positive in
several areas: reminders of appointments; self-
assessment tests; social support; research; and
information [16].
In developed countries, the telephone provides
a feasible, convenient, and acceptable approach to

Copyright r 2011 John Wiley & Sons, Ltd.

The mobile phone for cancer care in Nigeria
providing patient-centered support and informa-
tion [5–7,10].
We proposed to study the use of the mobile
phone in cancer care in Nigeria:
1 To determine its effectiveness as a means of
communication and to improve follow-up of
African cancer patients in Zaria, Northwestern
Nigeria.
2 To determine the value and effectiveness of the
mobile phone as a way to increase communica-
tion in the follow-up of cancer patients in this
clinical low resource setting.
Patients and methods
The study period extended from January 1, 2004 to
June 30, 2009. Consecutive adult patients who
volunteered to participate in the study were recruited
after obtaining informed consent. The patients were
recruited from the clinics of the Ahmadu Bello
University Teaching Hospital in Zaria, Nigeria. The
study period for each patient was 24 months. The
authors were fluent in the commonly spoken local
languages of the region: Hausa, Yoruba, Ibo, and
Pigin English. Patients were given their oncologists’
mobile phone numbers. Most patients either had a
mobile phone or had access to one through their
family or a neighbor or they could rent a phone.
They were advised to feel free to call about their
medical care and to seek advice at any time in the
language that was most comfortable for them.
Entry point was the day the patient received the
doctor’s phone number. Exit point was 24 months
later. Every call from patients was entered in the
database. Patients were identified by name, hospi-
tal number, serial number, and occasionally by
voice or phone numbers. The reason for the call
and its duration were noted as was distance from
the hospital and the cost of transportation to and
from the hospital.
At 24 months, each patient’s perception and use
of the mobile phone were assessed by structured
interviews. The interview schedule queried: was
the phone useful for medical follow-up and psycho-
social support; what worked well and what was not
helpful; what could be improved; costs of phone use;
and preferences for future follow-up and support.
Results
A total of 1176 patients participated in the study
which included 173 patients (14.9%) whom we
identified as ‘incidental’/‘new patients’ recruited by
patients and friends in their homes. Sixteen patients
died within 2 years. Thus, the study was composed
of 1160 patients: 502 males, 658 females whose ages
ranged from 18 to 82 years. They were compared to
219 patients who did not receive the oncologist’s
Copyright r 2011 John Wiley & Sons, Ltd.
333
phone number and who were interviewed at 24
months as to their follow-up medical care over the
two years.
Patients: 469 patients were breast cancer or
endocrine; 367 patients were from radiotherapy;
174 patients were orthopaedic oncology; 122
patients were general surgical oncology patients.
The majority of patients were women with breast
cancer, but others came from radiotherapy clinic,
orthopedics, and surgical clinics.
A total of 661 patients (58.4%) had no formal
education. Two hundred and forty-three patients
(21.5%) had a primary education. One hundred
and twenty-one patients (10.7%) had college
education. One hundred and seven patients
(9.5%) had graduate education. Eight hundred
and twenty-one patients (72.5%) preferred to speak
in the local language; 237 (20.9%) patients used
pigin English, and only 74 patients (6.5%) spoke in
English. Mean length of calls was 5.4 min costing
$1.35 (range l.5–8.5 min). 14% were rated as
emergency by the oncologists.
Data were collected on 1132 patients at two
years (97.6%). Only 28 patients did not contact the
oncologist during the study period. Almost 500
patients called over 25 times in the two years. Two
out of every three patients lived more than 200 km
from the hospital. Half (52%) had rented a phone
to call, and about one quarter (22%) owned a
phone while another quarter borrowed a phone.
86.2% (976 patients) found the use of mobile
phone as convenient/excellent/cheap. 72.8% of the
calls (14 102) were made to discuss their illness and
treatment. 25.9% (5016) were to arrange their next
clinic visit. 1.3% (257) were to extend social
greetings. Over 80% found the phone very useful.
They perceived it most valuable (1) to obtain
information, (2) to arrange an appointment, and
(3) as a ‘morale booster.’
Anecdotally, most patients felt the mobile phone
helped them to keep their clinic appointments.
Three of the four married women found that
having their husband speak to the doctor made it
easier to arrange for follow-up visits to the clinic
because the husband makes all decisions for the
spouse about health care. They preferred the
phone, when possible, because it eliminated
the cost of transportation and time spent to travel
the long distance to the hospital.
97.6% of patients found the use of the phone
worthwhile, and preferred the phone to traveling a
long distance to the hospital/clinic. Most agreed
the phone afforded them an opportunity to talk to
their doctors whenever they needed to. It gave
them the feeling that they had not been forgotten
by their doctors and were being taken care of
outside the hospital/clinic.
Four of the five (80.1%) men were satisfied with
the mobile phone, which eliminated waiting long
hours at clinics to see the doctor.
Psycho-Oncology 21: 332 – 335 (2012)
DOI: 10.1002/pon
334 V. I. Odigie et al.

Table 1. Age and sex distribution of patients using mobile breast cancer is a major site of cancer among
phone for follow-up in Zaria North Western Nigeria women. The data are also informative about the
Sex cultural issues for women’s health care, in that they
can travel to the doctor only with the permission of
Age group Male Female Number of pts. % the husband which, before advent of mobile
11–20 29 27 56 4.8 phones, was extremely difficult to arrange dates
21–30 53 115 168 14.5 for visits to the doctor for treatment or follow-up.
31–40 73 158 231 19.9 The presence of the mobile phone has produced
41–50 97 201 298 25.7 a revolution in communication, which has allowed
51–60 69 121 190 16.4 people in even remote villages to be able to
61–70 81 20 101 8.7
communicate outside their geographic area. In
71–80 75 12 87 7.5
81–90 25 4 29 2.5
terms of health care, mobile phones have remark-
Total 502 658 1160 100.0 ably increased the potential for between-visit
contact with physicians and their offices. Mobile
Mean 5 45.8 years; Male:Female 5 1:1.3; Age range 5 18–82 years; p50years 5 753 phones are widely available for renting from
pts 5 64.9%.
roadside vendors and patients in the study largely
used this means of access to a phone, while others
either owned or borrowed a phone, so that in fact,
About 219 patients who did not receive the even in remote areas, most people nowadays have
phone intervention were interviewed at 24 months. access to a phone. This study reflects the first
Only 42 of these patients (19.2%) had kept their information from Africa about the positive impact
follow-up appointments as compared to the 1132 of oncologists giving patients with cancer their
patients (97.6%) who had sustained their follow-up mobile phone number and encouraging them to
appointments (Table 1). call whenever they had a question or wished to
arrange a visit to the clinic. They particularly made
Proforma for use of GSM as psycho-social support/follow-up in Zaria it clear patients could speak in their own language
Name. Age... Sex M/F Serial no. which enhanced their ability to describe their
Date of 1st call Hosp Number Address
physical problems more clearly. Patients were
Literacy Level: Primary Sch, Secondary Sch, Tertiary (specify)
Distance from Hosp: Transport Fare:
followed over 24 months and the ability to keep
Disease Condition: Breast&endocrine, G/S Orthopaed, Radiotherapy (specify) follow-up appointments was remarkably improved
GSM: Personal; Borrowed; Rented (specify) as compared to a comparison group of patients
Reason for calling: fix appt (confirm/rebook; drug reaction/medication; who did not participate in the study and thus did
psychosocial/morale booster; and family discussion; others (specify) not have access to the doctors’ telephone number.
Duration of Call: (time spoken) in minutes (specify) The feeling of being able to reach the doctor at any
Language of Communication: English, Pigin English, Local language
time gave them a strong sense of support and
Hausa, lbo, Yoruba (specify)
At 24-months Follow-up
ability to reach the doctor if needed. They called it
(i) Worth while psychosocial support Yes or No (Specify) a ‘morale booster’ and some patients called the
(ii) Usefullness of GSM: Not useful, Useless, Useful, Very Useful oncologists just to thank them for the innovation.
(iii) Specify aspect of usefulness; drug therapy, psychosocial/morale There are limitations to the design of the study,
booster, fix appointment, in particular, the fact that the comparison group
(iv) Cost effectiveness of psychosupport/followup using GSM; GSM vs was identified from refusers and the fact that some
Road Transport to hospital: convenient/inconvenient; good/excellent/bad;
patients called ‘incidental patients’, who heard
cheap/costly (specify)
(v) Number of patients in follow up: consented patients vs not consented
about the mobile phone number access, actually
patients at the end of study at 6, 12, 18 and 24 months (specify) called at the suggestion of their friends.
The mobile phone is providing a new means of
improving communication among poor patients
Discussion who live a long distance and can little afford the
cost of transportation. This confirms the value of
This study highlights the characteristics of many the mobile phone to enhance adherence to treat-
patients with cancer in Africa who come to a ment of cancer as well as infectious diseases in
tertiary cancer hospital for treatment: they are Africa [18–20]. It appears equally of value in cancer
largely young, poor, and illiterate. They often live a by meeting the needs for information; substituting
distance from the cancer hospital which can be or arranging follow-up visits; and for young
reached only by paying for transportation to travel women who depend on their husbands for permis-
the distance over poor roads. The sample reported sion and money for visits to the doctor, which often
is representative of many patients in low resource become infrequent because of logistics and cost.
countries like Nigeria. The large number of women These early data suggest that the mobile phone has
in the study reflects the fact that the cohort was added an important new dimension to health care
drawn from the Surgical Breast Unit and the to improve follow-up visits and to provide psycho-
Radiotherapy Unit at the teaching hospital, though social support to patients with cancer.

Copyright r 2011 John Wiley & Sons, Ltd. Psycho-Oncology 21: 332 – 335 (2012)
DOI: 10.1002/pon
The mobile phone for cancer care in Nigeria
Conclusion
Globalization and medical care are becoming
technology driven. Low resource countries faced
with the burden of cancer care, poor patient
follow-up and poor psychosocial support can cash
in on this to overcome the persistent problem of
poor communication in their health-care delivery.
The mobile phone is almost ubiquitous in most low
resource countries. It is potentially a simple, effective,
efficient, cheap, and a sustainable mode of com-
munication/outreach for patients. Old or new
patients can access medical care, psychosocial
support, information about their disease or ther-
apy, book their appointment, and also harness the
multidisciplinary management of cancer in a
follow-up visit. It obviates the perils and costs of
multiple travels by the patient and circumvents
some socio-cultural ills that militate against follow-
up and psychosocial support in developing coun-
tries (where women cannot travel to keep hospital
appointments without permission from their
spouses who are most often the breadwinner for
the family). For the clinician in low resource
countries, it enables patients to be discussed with
the whole team (oncology board) during follow-up
visits. Its disadvantage may be the burden of
answering phone calls and the need to be fluent in a
patient’s local language, or language of choice, in
sub-regions where the literacy rate is low. Never-
theless, the experience of the investigators was that
the burden was tolerable.
The potential is enormous to enhance the use of
mobile phones in novel ways: developing helpline
numbers that can be called for cancer information
from prevention to treatment to palliative care.
The ability to reach out by mobile phone to a
reliable source for medical information about
cancer is something that the international commu-
nity, having experience with helplines, should
undertake with colleagues in Africa, who are
experimenting with the mobile phone potential.
Acknowledgements
I thank Dr George Kwanashie of Ahmadu Bello University
for all his very useful advice during the study and writing of
the manuscript.
The study was approved by the Local Research Ethics
Committee.
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Psycho-Oncology 21: 332 – 335 (2012)
DOI: 10.1002/pon