In September 2016, Hurricane Matthew, a Category 4 storm, struck southern Haiti, an
impoverished region home to 1.5 million people. Disturbingly, 24 hours later, the
western half of the peninsula remained eerily silent. Communication lines were cut:
bridges had washed away, roads were flooded or destroyed, and cellular service was
virtually non-existent. As relief organizations attempted to assess damage, phone
call after phone call went unanswered. St. Boniface Haiti Foundation (SBHF) ultimately
made contact using a different tool: WhatsApp. While weak and inconsistent signals
prevented voice calls, WhatsApp messages and replies were automatically delivered
whenever signal allowed, allowing effective needs assessments. Information received
helped SBHF assess the damage, share information with other organizations, and engender
a timely, cooperative, organized, and appropriate relief effort.
Disaster response is only one way social messaging technology is impacting health
care delivery in resource-limited settings. Over the past three years, our teams at
Hôpital Universitaire de Mirebalais (HUM), a Partners In Health-supported academic
hospital in central Haiti that collaborates with SBHF – have increasingly integrated
social messaging into our operations. We present here our use of WhatsApp to improve
health care delivery and education in Haiti and discuss considerations for successful
use of social messaging in global health.
SOCIAL MESSAGING
Social messaging applications (
Table 1
) allow users to communicate directly with one or more individuals [2]. Messages are
targeted to specific groups of people, unlike social media which broadly transmits
communications. Most applications use minimal data to transmit messages, allowing
affordable use on cellular networks. Most also function over WiFi where available.
Globally, social messaging’s popularity has increased and, by some measures, surpassed
traditional social networking sites such as Facebook [3]. In resource-limited settings,
social messaging has grown as smart phone technology has become more prevalent and
affordable [4,5].
Table 1
Comparison of select features among select social messaging platforms. Platforms may
have other features such as gaming, payments, or location services not detailed here
Information
Features & Details
Monthly active users* (millions)
Platforms
End-to-end encryption
Group messaging
Calling
Voice messages
Photo / video sharing
Document / file sharing
Whatsapp
1,500
Android, iOS, Windows Phone, Web
Yes, by default
Yes
Voice and Video
Yes
Yes
Yes
Facebook Messenger
1,300
Android, iOS, Windows Phone, Web
Yes, must specifically enable
Yes
Voice and Video
Yes
Yes
Yes
WeChat
1,000
Android, iOS, BlackBerry, Windows Phone, Symbian, Web
No
Yes
Voice and Video
Yes
Yes
Yes
QQ Mobile
783
Android, iOS, Windows, OSX, Web
No
Yes
Voice and Video
Yes
Yes
Yes
Skype
300
Windows, Xbox, OSX, Linux, Android, iOS, Amazon Kindle/Fire
Yes, using “Private Conversations”
Yes
Voice and Video
Yes
Yes
Yes
Viber
260
Android, iOS, Windows, Linux, OSX
Yes
Yes
Voice and Video
Yes
Yes
Yes
Snapchat
255
Android, iOS
No
Yes, deleted by default after set timeframe
Voice and Video
Yes
Yes, deleted by default after set timeframe
No
LINE
203
Android, BlackBerry, iOS, Web, Windows, OSX
Yes, default for messaging, location share, voice & video calls
Yes
Voice and Video
Yes
Yes
No
*Average monthly users as of April 2018, as reported by Statistica [1].
Mobile technology and text messaging are recognized as promising ways to improve patient
education, follow-up, and outcomes [6,7]. However, less attention has been paid to
how social messaging applications can improve health care delivery, medical education,
and emergency response. Social messaging allows real-time group responses and transmission
of images and videos without the per message charges associated with text or multimedia
messaging. For hospitals in resource-limited settings, pager technology is often prohibitively
expensive, leaving a communication gap social messaging can fill. Our experience primarily
has been with WhatsApp, because it is free, uses default end-to-end encryption, supports
photo and video, and is already popular in Haiti, but the benefits likely apply across
platforms with similar features.
Recently, several small studies have suggested that WhatsApp can facilitate local
and remote patient consultation [8-10] and improve provider education [11]. Preliminary
data indicate that mobile technologies including WhatsApp facilitate health, security
and information access in refugee settings [12]. Additionally, our team has utilized
social messaging to improve hospital operations, develop leadership skills, and create
new educational opportunities.
Photo: An ambulance arriving to the Hôpital Universitaire de Mirebalais emergency
department with a transferred patient. In Haiti, social messaging facilitates interfacility
transfers and patient care. Photo by Cecille Joan Avila/Partners In Health (used with
permission)
WHATSAPP TO IMPROVE HOSPITAL OPERATIONS AT HÔPITAL UNIVERSITAIRE DE MIREBALAIS
WhatsApp groups are essential to HUM’s hospital operations. HUM’s nursing leadership
uses a WhatsApp group daily for hospital-wide bed management, adjusting staffing assignments,
managing emergency situations, and disseminating general updates and communications.
During mass casualty situations and when patient surges are anticipated – including
the lead-up to Hurricane Matthew and during the fiercely-contested 2016 Haitian elections
– WhatsApp groups with hospital leadership and departmental chairs facilitated communication
and resource allocation through regular updates on patient numbers, available bed
spaces, staffing and supply needs. Similarly, during a recent outbreak, a “diphtheria
updates” WhatsApp group facilitated moving patients into isolation spaces and accelerated
contact-tracing by simultaneously notifying community health and infection control
teams of new cases.
Social messaging also improves operations for HUM’s emergency department (ED). Since
Emergency Medicine (EM) is a new clinical specialty in Haiti, until recently the ED
leadership paired senior Haitian staff and international emergency physicians (EPs)
to build capacity. Since the international support was sometimes remote, constant
and reliable communication was essential. An ED leadership WhatsApp group linked the
four physician leaders and facilitated instantaneous communication, decision-making,
and collaboration, while building local leadership capacity. The department has now
successfully transitioned to all local leadership, who continue to use WhatsApp to
facilitate ED operations. Additionally, an all-ED staff WhatsApp group transmits department
news, policies, mass casualty events, security updates, and even birthday wishes,
improving both operations and morale. Lastly, although e-consultation is not formalized,
ED staff frequently send x-ray photos to orthopedic consultants, facilitating patient
treatment and disposition.
WHATSAPP TO IMPROVE EDUCATION DELIVERY AT HUM
For Haiti’s first EM residency, WhatsApp expands teaching opportunities. As a new
specialty, few trained EPs are available to supervise EM residents. This initially
posed a dilemma: should residents train only in the HUM ED, with EM attending supervision
but without exposure to hospitals and pathology elsewhere in Haiti, or should residents
rotate at affiliated hospitals without EM specialist supervision, putting trainees
and patients at possible risk? Remote social messaging back-up offered a middle ground,
allowing residents to gain experience at other sites while ensuring they could reach
EP attendings with questions. We initially attempted video conferencing typical of
telemedicine, but found Whatsapp more successful given its baseline popularity with
residents and low band-width requirements.
Similarly, at night, WhatsApp telemedicine allows senior residents to gain experience
working independently. Senior residents supervise juniors and run the department,
but have an assigned attending remotely available. Via WhatsApp, residents send photos
of EKGs and laboratory results, videos of exam findings and ultrasounds, and make
free local and international phone calls over WiFi, allowing effective remote consultation.
If needed, in-person back-up is available, but rarely required. Remote supervision
allows limited faculty resources to stretch further and prepares residents to be independent
clinicians and teachers after graduation.
To facilitate learning, all EM residents participate in a resident-led, faculty-guided
WhatsApp group where interesting cases, teaching pearls, and questions are posted.
Residents doing off-site rotations several hours away employ the feed for clinical
questions and patient management advice (de-identified to protect privacy), and to
stay in touch with their missed co-residents for support.
After a training program is completed, WhatsApp groups offer continuing education
and support for participants. Graduates from HUM’s neonatal nurse intensive care training
certificate work throughout Haiti, but can always turn back to a moderated WhatsApp
group for advice. Similarly, international partners for HUM’s surgical team training
use WhatsApp to provide ongoing distance coaching for participants after in-person
trainings.
Finally, social messaging is not just beneficial for trainees. With few Haitian EPs,
the EM residency at HUM relies on teaching and clinical supervision from visiting
US and Canadian EPs. However, these attending physicians may be unfamiliar with the
local context. Social messaging facilitates communication between these visiting physicians
and our international leadership team, and strengthens the skills of junior US- and
Canadian-trained faculty pursuing global health careers.
WHATSAPP FOR INTER-HOSPITAL COMMUNICATION
At a national level, there is an ED communication group that includes prehospital
groups and ED leadership at most major hospitals. This group helps with pre-hospital
notification for large accidents and facilitates patient transfers between hospitals,
allowing participants to reach multiple hospitals at once when searching for a hospital
to accept a transfer, saving time and money.
CONSIDERATIONS FOR SUCCESSFUL USE
As our experience in Haiti demonstrates, social messaging creates educational opportunities
and facilitates clinical operations. As use expands into other clinical environments,
best practices at each site will need to be developed. Any proposed role for messaging
technology mandates caution and evaluation of risks and benefits to ensure responsible
and appropriate use. We propose five considerations for deciding how and when to use
social messaging in clinical care.
First, consider connectivity, cellular data costs, and smartphone availability in
each setting. Most of our staff’s phones support WhatsApp, but this may not be true
in all settings. Though social messaging requires WiFi or cellular phone internet
access, we have found social messaging more available than email communications, particularly
for staff without personal computers. Hospital WiFi connections, even when too slow
for voice calls, typically allow social messaging. When WiFi is not available, using
cellular data for WhatsApp text and calls is affordable due to small amounts of data
required. Similarly, since clinical images can be gradually uploaded over slow connections,
we find image resolution sufficient, unlike video chats which are frequently disrupted
due to low-bandwidth.
Second, group social messaging feeds require active administration, including ‘rules
of conduct’ and periodic membership review. Members must understand the group’s intent
to facilitate clear communication. Groups for emergent or high level messages should
be clear of casual conversation to avoid interrupting members unnecessarily. We find
this requires periodic reminders by a designated senior administrator. Groups for
non-emergent functions can be more loosely regulated, as members can mute the group
and check it daily for updates. Further, someone should be assigned to manage group
membership, ensuring its continued relevance as staff come and go. In larger groups,
new members may require introduction beyond WhatsApp’s automatic notification that
a member was added. Finally, when deciding group size, consider the group’s objective.
We advise limiting membership to people who would be invited to an ‘in person’ meeting
with the same purpose. Groups intended to broadly communicate information can be larger,
whereas groups to facilitate decision-making should have the fewest possible members.
Third, assure patient privacy. Privacy is an essential ethical and legal consideration
in all areas of health care, and social messaging should be no exception. For many
services, information passes through and is stored unencrypted on a central server
[13]. Though WhatsApp’s end-to-end encryption increases security by keeping messages
on the central server private [14], messages are received on individual smart phones
which may not be encrypted or password protected. Similarly, cloud backups of phone
data are unencrypted. Given this, all patient information and photographs must be
de-identified and photographs taken only with permission. This also protects privacy
against lost or stolen devices.
Fourth, we recommend safeguards to prevent disseminating incorrect information. Social
media can spread false information [15]; similar risks exist with social messaging.
Though false information is more likely to come from simple error than deliberate
deceit, educational feeds require a reliable faculty moderator. Since messages arrive
at all hours, we have found having several faculty on a group ensures at least one
person can correct information as needed.
Finally, we recommend backing cross-cultural remote consultation with in-person relationships.
Our international faculty providing remote social messaging support also supervise
residents in-person in the HUM ED. The pre-existing personal connections facilitate
trust and communication necessary for effective teaching. Residents have a working
relationship with each remote back-up attending, empowering them to text or call at
all hours. Attendings know each resident’s abilities, and understand the system and
context. These personal connections and contextual understanding are essential to
our program’s success.
In addition to these five principles, we recommend users consider potential limitations
to social messaging. First, consider patient perception of provider phone use and,
if needed, develop usage guidelines. Second, the quality of remote supervision and
consultation depends on what, how, and when information is provided; both sides may
need training on this. Similarly, WhatsApp cannot replace in-person supervision for
complex cases and procedures, but can create a false sense of security in these circumstances.
Third, while we have found bandwidth adequate to gradually upload photos, we rarely
require high resolution images; this may be different in some medical fields. Fourth,
our experience has focused on nurses, physicians and hospital administrators; different
strategies may be required for use with patients or other employees less likely to
have smartphones. Finally, the evidence base for social messaging remains limited.
Future studies should evaluate and quantify the impact of social messaging on hospital
operations metrics, provider knowledge, clinical outcomes, and disaster response.
CONCLUSION
Social messaging offers a powerful new medium for global medical education and health
care operations, including daily hospital management, mass casualty response and disaster
situations. For many programs in resource-limited settings, supervision, education,
and support are constrained by gaps in human and monetary resources. Despite its limitations,
social messaging offers a compelling opportunity to improve global health delivery
and education. Our positive experiences in Haiti add to the growing evidence of the
efficacy of this new modality, and we recommend its appropriate use to improve health
equity.