There's an app for that

When Nishant Kishore came to Rollins in 2014 to pursue an MPH, word got around that he knew how to develop mHealth platforms and applications, a skill that—judging from the response it received—is akin to being able to accurately predict the stock market. Classmates approached him to ask for tutorials, and he began meeting with small groups of interested students to share some tips and tricks on using mobile devices to support public health.

Kishore quickly realized the appetite for this knowledge was ravenous, so he and then-second year MPH student Roxanne Moore founded a new student organization, the Rollins mHealth Collaboration (RmC). The goal was twofold—to train students how to build mHealth systems in their first year and to line the students up with internships or job opportunities in their second year.

“This is a big up-and-coming field. There are a lot of organizations around the world looking for these sorts of skills, but I don’t know of a good training protocol anywhere,” says Kishore, who is now a data manager for the Malaria Zero project at the Centers for Disease Control and Prevention as well as the owner of his own mHealth consulting firm, EpiTech. “The training that is available focuses on when it’s appropriate to use mHealth and how to implement an existing program in the field. The mHealth Collaboration is the only group I know of that is specifically training people how to build these platforms.”

Every other week for two-hour sessions, Kishore met with fellow students in a first-floor classroom. Following a curriculum of his own design, he taught them how to build and use a wide variety of mHealth platforms. He also showed them how to connect to the local SMS (short message service) gateway provider, what costs are incurred, and how to devise the user interface. Most sessions required some prep work, and each featured a lecture, a demonstration, and then hands-on practice. It was a demanding curriculum, but the students were eager to take it on.

“It’s basically like taking another class but for no credit,” says Kyndall White 17MPH, who replaced Kishore as president of RmC following his graduation. “It’s a lot to take on in addition to your regular classes, but it gives you very marketable skills.”

That marketability attracted students from all Rollins departments. “It was cool to see how these mHealth skills can be useful in different contexts,” says White. “A BSHE student might want a text message reminder to reinforce a behavior. A health policy student might use it to track people’s opinions of a particular policy.”

Another facet of the mHealth Collaboration—and the reason it was dubbed “collaboration” instead of “club”—is that its members will take consulting jobs from alumni, professors, and organizations. It’s a win-win, giving students hands-on experience and researchers much-needed assistance.

Oswaldo Henriquez, a physician at Grady Memorial Hospital, reached out to the student organization when he wanted a mobile app to help low-resource cancer patients access the care they need. The mHealth team is creating a text message system that Henriquez will be able to use to remind patients of the various appointments they have. Patients will have to respond to each reminder with a “yes” or “no,” which could help reduce the number of no-shows. And Henriquez will be able to stay in touch with his patients, even if they move without telling his office, as they often do.

“A lot of our patients at Grady are marginalized, and it’s easy for them to miss appointments and fall off our radar,” says Henriquez. “They may show up again months later and the cancer has progressed. This message system will help keep them in the system so they get the care they need.”

Mark Fajans 16MPH landed a summer practicum with Family Health International 360 in Myanmar thanks to the mHealth experience he gained through RmC. The organization was using a mobile application to track people with drug-resistant TB, but the app could be used only to collect the data and store it to be analyzed at the end of the trial. The lag time meant that some participants might die before researchers could get the results. So Fajans built a dashboard that enabled the data to be analyzed in real time, allowing researchers in the field to make immediate changes to treatment, if necessary.

“I know the experience I got in the mHealth Collaboration is what got me this practicum,” says Fajans, who now works in the CDC’s global HIV and TB division. “It was totally new to me when I started, but it was surprisingly easy to pick up and learn to use.”

That’s exactly the secret Kishore has been trying to share with students. “The science of mHealth has been seen as prohibitively technical for so long that people were afraid of it,” he says. “One purpose of RmC is to show that it’s not that way anymore. Give me an hour, and I can teach you how to build a platform.”

In fact, Kishore taught himself to build and use mHealth platforms while a Peace Corps volunteer in Nicaragua from 2011 to 2014. By trial and error, he designed and implemented Chat Salud, a mobile health application to provide education on topics such as safer sex practices, HIV intervention, and domestic violence. After the Peace Corps, he worked for a nonprofit in Mexico developing mobile health systems for maternal health, again figuring it out as he went. So by the time he came to Rollins, Kishore had about three years’ experience in building mHealth platforms.

He was so instrumental in building, running, and teaching in the collaboration, it would be easy to assume the organization would wither and die after his graduation. Easy but wrong. Kishore spent last year grooming five students to take over the collaboration. They plan not only to carry on what he started, but to improve on it.

“We plan to have a hack-a-thon using TeleRivit, a text messaging system, in the fall and a case competition in the spring,” says White. “We’re also adding two supplemental sessions for second-year students—one on how data is stored using the Cloud or a server and one on how to talk to product managers about incorporating mHealth in their projects. And for students who attend all of the sessions, we are going to award a certificate saying they are mobile health specialists.”

Nishant Kishore taught fellow students Kyndall White 17MPH, right, and Katherine Stanfill 16MPH, middle, how to build mHealth platforms through Rollins mHealth Collaboration.

Two tools for WASH

When the Center for Global Safe Water, Sanitation, and Hygiene (CGSW) landed a grant from the Bill & Melinda Gates Foundation to develop a tool to rapidly assess health risks from fecal contamination in poor urban neighborhoods, it needed to find a new way to collect and analyze the data. They turned to Kishore.

The tool Kishore helped design, called SaniPath, allows researchers to collect fecal contamination data on drain water, flood water, and ocean water. It also collects data about how often people come into contact with each potential source of contamination. The tool then combines the two sets of data to generate a report that city planners and government officials can use to deploy interventions where they’ll have the most impact.

“The SaniPath tool is actually constructed out of two separate open-source modules,” says James Michiel, a senior mHealth analyst at CGSW. “It’s hard to explain in understandable terms, but Nishant was basically able to take an analytical package and move it inside a data repository. The result is an incredibly sophisticated tool that is easy to use.”

Michiel also relies on two people Kishore trained in mHealth to help with another CGSW project. Katherine Stanfill 16MPH, who currently works part-time at the center, and White, the current RmC president, work on the WASH Conditions tool, an mHealth assessment tool to analyze WASH data at health care facilities in low- and middle-income countries.

“Katherine and Kyndall are basically doing the work of professional mHealth consultants,” says Michiel. “It’s almost like having an mHealth innovation lab right here at CGSW.”

Sizing up the competition

Patrick Sullivan developed an app that can help men who have sex with men (MSM) remain healthy.

Through HealthMindr, men can order condoms and HIV test kits to be delivered to their door. They can answer questions about their sexual habits and the app will suggest how often they should be tested and send reminders to help ensure that they follow through. Men can also use HealthMindr to determine if they are a candidate for pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (mPap), and if so, where they can get it.

Kishore consulted with Sullivan and his team on many of the technical aspects of the app development. In addition, Kishore created an exhaustive index of HIV-related apps already on the market to help determine the need for an app like HealthMindr. He found 147 HIV-related apps in the Google Play store and 138 in the Apple store. Kishore then classified each app by developer 
and content. His finding—71% of HIV-related apps were developed by non-academic, non-public health institutions, only 7% focus on MSM, and none of the apps dealt with PrEP or mPap.

“Nishant helped us think about how to make a case for HealthMindr in the market context,” says Sullivan.

A transmission scavenger hunt

Lance Waller turned to Kishore and other RmC members for help in preparing a grant application to study the transmission of Buruli ulcers in West Africa. The ulcer is a rare skin and soft tissue infection that tends to strike in poor rural communities.

RmC members fashioned and tested an app that could potentially allow Waller to track the route of transmission in the field. Erin Stearns 16MPH, who was RmC’s vice president, helped organize a scavenger hunt around campus. Volunteer students were randomly assigned as ”infected” or “healthy.” They were given a list of five buildings that they needed to visit and an app called Map My Run to track their movements. One building—which appeared on the lists of all the infected students and none of the healthy ones—stood in as an infected water source.

Stearns and her team were then able to create a color-coded map (healthy runners in blue, infected in red) overlaying their routes and the buildings they visited. Even an untrained eye can pick out that every infected student visited the same building.

“I wouldn’t have been able to do this without their help,” says Waller, chair of the biostatistics and bioinformatics department.

“Erin and her colleagues were able to pull multiple sources of information—routes from the running app on the phone, an open source mapping system that had the streets and buildings on campus, and the designation of infected or healthy. When you put together those three bits of information that previously had nothing to do with each other, it tells a story.”

Waller will use the results as proof of concept in his grant application and hopes to roll out a similar approach in field studies in Ghana or Benin.