Urgent Need for Context-Specific Interventions

Certain precautionary measures have been recommended to limit the spread of COVID-19: hand hygiene, facemasks, social distancing, self-isolation, and adequate nutrition. However, these measures are often not possible for the 5.6 million Syrian refugees in neighboring countries, or displaced persons living under difficult conditions globally. It is important to understand and consider these unique needs in both the planning and execution of a comprehensive COVID-19 response, with particular attention to preparedness, surveillance, and communication plans. Preventing infection is the best way to protect both refugee and host communities; however, there is little evidence on how to best do this for those affected by a humanitarian crisis, during a global pandemic from an emerging disease. Directed research on agile interventions is crucial to better understand target areas for scale during rapidly evolving crises.

Unlike in prior epidemics, the overwhelming majority of reported deaths from COVID-19 have been in higher income countries (HICs) [17]. While these countries appear to have been affected by COVID-19 earlier due to social mobility, the virus quickly spread worldwide to include outbreaks in low- and middle-income countries (LMICs). While HICs have struggled to manage the pandemic, LMICs face potentially devastating morbidity and mortality, given their relative lack of resources and context-specific interventions [18]. Demographic differences across these contexts can be significant enough to affect population-level behavior and epidemiology. For example, the population of Syrian refugees in and around Istanbul alone is estimated to be one million, with 43% under 18, and 47% female; this is younger than the local population in the same regions [2]. Thus, a mobile health application targeted towards a younger and female demographic could provide an important modality for public health interventions.

Uptake and Sustainability of Mobile Technology: Solutions in the Field

Information and communication technology infrastructure has grown substantially over the past two decades worldwide, and particularly in LMICs over recent years [18]. Communicating and collecting data with innovative and user-friendly mobile technologies could serve as an important tool for accessing displaced and other highly mobile populations. Such a tool could also serve to empower this population by increasing control over their own health.

Evidence on the sustainability of mhealth implementation in traditionally resource-constrained environments is limited but continues to grow [19, 20, 21, 22, 23]. Positive long-term impact of mHealth in LMICs has been demonstrated with chronic disease management [24], including behavior change [25], and medication adherence [26]. In particular, mobile technology has been an effective tool to reduce the burden of disease through more efficient prevention, treatment, education, data collection, and management support in HIV/AIDS and tuberculosis care [24]. In complex humanitarian emergencies, improved surveillance and monitoring with mHealth applications has been shown, with examples including the West African Ebola outbreak, the Haitian earthquake, and the cholera outbreak [27, 28, 29]. While successful mhealth innovations exist in humanitarian contexts globally, quality evidence is overall limited and requires ongoing contextualization of local needs.

The HERA App is an open-source mobile application specifically designed for the Syrian refugee population in Turkey [30]. It was created in 2018 to harness the high levels of smartphone usage among the Syrian refugee community in Turkey to improve access to healthcare. The mobile application enables users to safely and privately receive healthcare appointment reminders, access health-related communication, store medical records, contact emergency services, and navigate the Turkish healthcare system in the three most commonly spoken local languages: Arabic, Turkish, and English [30]. A feasibility pilot study of 200 Syrian refugee women in Istanbul who were either pregnant or had at least one child under the age of two was conducted in 2018 with the HERA App. It found that automated reminders for antenatal visits and childhood immunizations were effective in improving compliance, were positively received, and can be a low-cost, high-value alternative to other reminder methods [31, 32]. Importantly, the study confirmed that these women had access to smartphones and that they use them as a method of accessing health information.

In response to the evolving COVID-19 pandemic, the HERA App was modified to include a COVID-19 response component in March of 2020. HERA App was chosen as it was already in use and shown to be a feasible method of mobile communication by the target population. The education content was adapted to include general information about COVID-19, including basic protective measures, a virus tracking map, government restrictions, and testing site referrals. Users were notified about these updates on their mobile devices. This intervention was performed in a primarily urban setting with Syrian refugees who live in and around Istanbul, Turkey, focusing on women, under a previously obtained ethics review board approval from Acibadem University. Following the initial incorporation of these educational features to the HERA App, 75% (n = 150) of the user-base was successfully contacted for symptomatic assessment at two-week intervals.

The Future of mHealth in the Refugee Context

Novel mHealth applications can enable broad use of innovative end-user centered interventions for highly mobile populations during a pandemic response. Within this context, they can be used to: 1) widely disseminate health information for refugees, 2) identify and educate high-risk mobile populations to ensure proactive screening and early case identification, 3) support data collection of mobile populations during infectious outbreaks, and 4) decompress hospital-based triage by improving access to health information and safety planning.

MHealth tools can be a low-cost and agile method to rapidly adapt and scale both individual and population-level health interventions. In our example, uptake of the HERA App in Turkey was rapid, and users received education on preventing the spread of COVID-19 while completing regular COVID-19 symptomatic self-assessments. This approach can be broadened to include additional health interventions, including increased education, contact-tracing, and triage support for overstretched public services. As infectious disease outbreaks exacerbate pre-existing health disparities, particularly among maternal, child, and refugee health, mHealth can be used to increase access to education and outreach for these doubly vulnerable populations [33]. In lower-resourced regions with poor access to health care, where access to a cell phone is often easier than soap, mHealth can play an important role in beginning to close the disparity gap [34]. Mobile health platforms can serve as a key policy innovation for future outbreaks and other urgent global needs for diverse and moving populations in humanitarian crises.

This mHealth intervention is uniquely designed to provide focused behavioral influence to increase the uptake of available public health services. The platform utilized an agile methodology framework with an iterative improvement process, allowing for meaningful incorporation of user-identified feedback on application features. Importantly, it was initially designed not only as a medical tool but also to facilitate female empowerment and to encourage independent learning. This targeted education promotes the involvement of Syrian women in the decision-making process about the family’s health. Building capacity for health literacy within a population historically susceptible to poverty and gender inequality is a stepping-stone in achieving health as a human right [35].

MHealth interventions propose a unique, value-based opportunity to communicate with moving populations, as users do not need to carry anything other than a phone, and may provide affordable alternatives for information dissemination and health behavior change. When scaled, interventions such as this may allow for accurate symptomatic tracking, health education outreach, and triage offloading with minimal personnel and financial resource input, in order to reduce exposure risks within the health system. The data collection capacity allows for timely policy responses and subsequent cost-effective interventions for mobile populations.

Limitations

This was an exploratory evaluation of a modification to an mHealth platform, and the findings are limited by small sample size and lack of a control group. Baseline data for population size, clinic appointment compliance, and vaccination status is difficult to assess, given the high mobility of the population. Only self-assessment of the presence or absence of COVID-19 symptoms was performed, and COVID-19 infection incidence by laboratory testing among participants was not assessed.