By Kristy M. Hackett (Department of Global Health and Population, Harvard T.H. Chan School of Public Health)
With the release of the World Health Organization’s Global Strategy on Digital Health, the inaugural State of Digital Health 2019, and novel tools like the Digital Health Atlas, the digital health community is all abuzz. WHO Director General, Dr. Tedros Adhanom Ghebreyesus recently emphasized the critical role of digital health in achieving universal healthcare coverage, and promoted such technologies as “vital tools to promote health, keep the world safe, & serve the vulnerable”.
There is good reason for all this enthusiasm around digital health. Both research and practice in this arena has grown in recent years, with a focus on improving implementation, coordination, reach, and impact of digital health interventions. Despite progress, oftentimes these initiatives are not rigorously evaluated, and critical questions remain around health equity (who benefits and who does not?), and how communities perceive and respond to new technologies. To harness the potential of digital health, both impact and implementation studies are needed to investigate the intended and unintended risks and benefits of such applications, from the perspective of local communities.
One widely implemented strategy in digital health is the use of smartphone-based job aids by frontline community health workers (CHW). These tools aim to simplify CHW tasks, enhance health service delivery, and improve data collection, client tracking, and counseling. In this qualitative study, we wanted to gain a nuanced understanding of rural Tanzanian women’s perceptions of, and reactions to, a smartphone-based application used by CHW during antenatal home visits. Several important findings emerged:
- Unintended benefits:
In general, use of smartphones by CHW was well accepted, and considered a welcomed health systems addition by participants, even among those who misunderstood the intended benefits of the smartphone application. The application was specifically designed to improve the quality of health counselling during pregnancy through enhanced diagnostics, decision-making and referral by CHW. Yet some of the most important perceived benefits were actually ‘non-prescribed’ functions of the device (e.g. using the phones to call for transportation during emergencies, schedule household visits in advance, and follow-up with clients via text message).
Findings suggest that smartphones may strengthen existing relationships between CHW and their clients, by opening up new lines of private communication, independent of facility-based clinicians. As a result, smartphone support for CHW may facilitate more meaningful and longer-term engagement with clients and their families, providing an opportunity to strengthen the links between rural communities and the formal health system.
- False expectations:
Smartphones can be a persuasive tool, as they shape client and supervisor views of frontline health workers, the health information they deliver, and even perceptions of the broader
health system. Most clients associated the smartphones with modern, up-to-date biomedical information, and consequently, high quality counselling. Our findings also suggest that the mere presence of smartphones during CHW-client interactions signaled overall health system improvements to clients and their families. While these perceptions could partially explain increases in women’s health service use, they may also manifest as false expectations of the health system; in reality, no policy or health systems level improvements were implemented at the time of the study.
These findings led to several important considerations: can well-intended, digital health interventions cause more harm than good? If the intervention sparks unrealistic expectations of the broader health system, what happens when a woman arrives at a facility for antenatal care or delivery services, only to find that nothing has changed? In order to maintain patient confidence and trust in the health system, policy makers, program implementers, and healthcare providers must ensure these new expectations are met.
As we move towards a more “digitally enhanced” world, global health practitioners must design, implement, and evaluate strategies to promote behavior change with the client perspective in mind, and researchers must ultimately re-prioritize the perspectives of communities to ensure that the needs of intended beneficiaries are placed paramount to all others. Ultimately, digital health interventions must be deeply embedded into health systems to have long-term impacts on maternal and newborn health, and to strengthen, not detract from, efforts to achieve universal healthcare.
Read the paper: “It makes you someone who changes with the times”: Health worker and client perspectives on a smartphone-based counselling application deployed in rural Tanzania
Image credit: Kristy M. Hackett