Feasibility and acceptability of implementing electronic patient reported outcomes (ePRO) collection in Zambia: Findings from a patient needs assessment.
Authors: Peterson Susan K. , Njala Bernadette , Shinn Eileen H. , Sakala Dyness , Montealegre Jane , Chiao Elizabeth Y. , Lin Lilie L. , Msadabwe Susan Citonje 
Published: June 2023

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Background: Studies in high-income countries have shown that systematic, remote and electronic collection of patient-reported outcomes (ePROs) during chemotherapy, with provider intervention if symptoms worsen, is associated with fewer symptoms, better quality of life (QOL), and improved survival. It is unknown whether similar ePRO interventions, often using electronic medical record patient portals or mobile devices, can improve outcomes for cancer patients in low- and middle-income countries (LMICs). In sub-Saharan Africa (SSA), cervical cancer (CC) is the second most common cancer and most common cause of cancer deaths in women. As most patients are diagnosed with locally advanced disease, chemoradiotherapy is standard care; many have severe comorbidities such as HIV. Due to patients’ increased risk for high symptom burden, remote monitoring of ePROs during CC treatment may improve outcomes. We evaluated the feasibility and acceptability of ePRO collection in CC patients from SSA. Methods: Patients were recruited from a prospective cohort study of women with newly diagnosed CC at the Cancer Diseases Hospital in Lusaka, Zambia from June 2022 through January 2023. Patients completed an in-person interview regarding mobile technology usage comprising questions adapted from the 2019 Pew Report on Mobile Connectivity in Emerging Economies and the 2019 Global System for Mobile Communication Association Mobile Gender Gap Report. Questions were translated into 4 primary Zambian languages (Tonga, Nyanga, Lozi and Bemba). Results: Respondents’ (n = 100) mean age was 49.6 years (range, 29-75, SD 9.2), 55% were diagnosed with stage III-IV disease and 59% were HIV+. Most (70%) completed only primary school or no school, 29% reported not being able to read at all and 29% could read only parts of a sentence. Most personally owned a mobile phone (90%) and 8% reported using a phone that belonged to another person. Most used phones to make or receive calls (98%), for banking/mobile money (92%), and text messaging (67%). Of the 26% who owned a smartphone, only half connected to the internet by phone more than once weekly. Nearly all indicated willingness to use a phone to self-report CC-related symptoms if compensated for costs (98%), with 97% preferring to do so via a phone call and fewer via text message (43%) or mobile app (17%). Most (71%) were able to charge phones at home using electricity or solar power and 18% traveled more than 30 minutes to charge phones. Conclusions: Nearly all patients owned or had access to mobile phones and expressed willingness to self-report CC symptoms via phone. Findings support the feasibility and acceptability of ePRO collection and provide contextual data to guide implementation in LMICs, including consideration of telecommunications infrastructure and literacy, low internet use, and ePRO reporting preferences (i.e., calls vs text).