Applying ethnography to digital health aims; challenges and opportunities
By Charlotte E Hawkins, on 10 August 2019
Author: Charlotte Hawkins
How can a holistic ethnographic understanding of ageing experiences, particularly related to health mobile phone engagement, contribute to an mHealth initiative and improve the accessibility of health services and information through mobile phones? This applied challenge in the ASSA project has initiated partnerships with digital health practitioners in most of our fieldsites – in particular, with collaborators working within existing phone practices. This aligned with our early finding across the fieldsites, that mobile phones are commonly used for health purposes, but through communication on apps evidently most popularly used, such as calls, Facebook and WhatsApp. In Kampala, I worked with The Medical Concierge Group (TMCG), a medical call centre founded by Ugandan medics to improve the accessibility, affordability and quality of healthcare. They offer a 24-hour toll-free phone line, SMS, WhatsApp and Facebook access to a team of doctors and pharmacists and have 50,000 interactions each month. At the time of fieldwork, they were in the process of researching the development a psychiatric call line, or ‘telepsychiatry’. This early stage of service development meant that TMCG were interested in and able to accommodate holistic ethnographic insight in their considerations.
Ethnographic insights included systematic information on 50 low income research participants’ existing mobile phone and mobile health practices as relevant to accessing TMCG services. For example, access to airtime and data is intermittent, with a tendency towards regular low-cost subscriptions. This suggests that calling or using the internet could be inaccessible to users at least once a day. Furthermore, 54% of participants had made health-related calls in the last month, and 27% of their previous three remittances were for health purposes, which confirmed an existing propensity to use mobile phones to support family health – but only across their own network of friends and relatives. Interviews with 50 respondents encountered during the wider ethnography also offered TMCG feedback on mental health perceptions, experiences and help-seeking preferences. These interviews were predominantly with older people, mostly older women, who would not typically opt to engage with research on mental health, and yet who represent an advisory position within their family or community. This also included interviews with health workers, including psychiatric clinicians at the local government hospital, and private health clinicians within the fieldsite. Research showed that treatment for mental illness was perceived to be unavailable, costly, or stigmatised. Often respondents said they prefer to handle mental health problems through prayer or counselling within their community, with hospital treatment sought only once problems become severe. This suggested that optional, confidential, accessible or community-based mental health services could be useful for low-income people in Kampala, if advertised accordingly.
Initially, the wide-reaching interview responses were considered thematically, from causality to treatment seeking, and condensed into representative quotes for presentation back to the team. More recently, alongside the team, these themes have been expanded to inform a draft publication in psychiatric journals, which TMCG hope to use seek further funding. We also hope to further disseminate findings in accessible formats amongst other digital and mental health service providers in Kampala. As familiar to many applied medical anthropologists, translating interpretive, subjective and relativist ethnographic information within positivist, objective and universalist medical paradigms brings challenges, such as risking that complex human experiences and perceptions are reduced into ‘practical’ or digestible concepts (Kleinman, 1982; Scheper-Hughes, 1990). However, this assumes that the health practitioners and their discipline are not open to understanding their patient’s everyday realities, which has not been the case in this instance, perhaps reflecting a particular affinity between anthropology of digital health – appropriation of phone based health services is entirely dependent on their relevance and usefulness for their target populations.
The on-going collaborative process has also highlighted what anthropology might learn from the research and writing processes of health disciplines, for example: ensuring findings are widely disseminated and thus accessibly written; avoiding anecdotal, emotive or biased claims; and ensuring that quantitative statements, “many people said xxx”, are qualified and backed-up. The collaboration has also confirmed that the flexibility of anthropological research and richness of qualitative insight potentially has much to offer health programmes, to ensure their contextual relevance. In ethnographic research, we have the privilege of time, which comes with in-depth insight, and familiarity with the community – time and understanding which we can offer usefully to other audiences. The data provided can perhaps confirm a hunch of a practitioner from the area but can also surprise them. When documented and publicised, the data encourages practitioners to both tailor their approach, but also allows them to share the specific requirements of their target population, encouraging others to do the same – or hopefully even to offer funding to support them.
Scheper-Hughes, N. Three Propositions for a Critically Applied Medical Anthropology. (1990) Social Science & Medicine 30 (2): 189-97.
Kleinman A. The teaching of clinically applied medical anthropology on a psychiatric consultation-laison service. In Clinically Applied Anthropo1ogy: Anthropologists in Health Science Settings (Edited by Crisman N. and Maretzki T.) Reidel. Dordrecht, 1982.