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An Anthropological Approach to mHealth: Health & Care in the Smartphone Age

alex.clegg3 March 2022

Open access image by Mohamed Hassan

Author: Charlotte Hawkins

As part of the ASSA project, we are currently working to publish a volume called: ‘An Anthropological Approach to mHealth: Health & Care in the Smartphone Age’. This volume consolidates insights from the team’s various anthropological initiatives in mobile health or ‘m-health’ – health-related uses of the phone – in diverse settings around the world. Drawing from an ethnographic perspective, we seek to contribute an anthropological understanding of mHealth, a growing industry often otherwise dictated by top-down priorities such as bespoke app creation. Instead, building from our own ethnographic insights about older people’s everyday uses of phones, and other studies stressing the evident importance of ‘informal mHealth’ (Hampshire et al., 2021), we illustrate a ‘smart-from-below’ approach which prioritises the everyday appropriation of phones and existing communicative apps for health purposes. We analyse the failures of conventional mHealth initiatives and the emergence of our alternative perspective, and how that led to several initiatives in which team members were themselves involved.

In this book, we offer a grounded ethnographic picture of mHealth in our various research contexts, with a view to broader global trends in population ageing, health and economic crises, the Covid-19 pandemic, declining public investment, increasing phone access, and global migration. This shows the potential of prioritising the everyday appropriation of mobile technologies in line with both social change and longer-standing care norms.. This is intended topromote an anthropological approach to support the relevance and effectiveness of mHealth going forward. We have already created a free online course (available here) for those interested in the topic but hope that the book will benefit other medical anthropologists and ethnographers interested in digital health, as well as digital health practitioners interested in social research around the design, implementation and evaluation of their work.

We have organised the book into three parts, reflecting what anthropology can offer for contextualizing, analysing and informing mHealth. Part one consists of three chapters concerned with contextualizing mHealth;

  • Xinyuan Wang on mHealth practice in mainland China;
  • Shireen Walton on visual digital communications about health during covid in Italy, and
  • Laura Haapio-Kirk on social self-tracking in Japan.

This is followed by contributions analysing mHealth:

  • Daniel Miller on googling for health in Ireland, and the ways it exacerbates existing disparities;
  • Patrick Awondo on the failures of various mHealth initiatives in Yaoundé, Cameroon; and
  • Pauline Garvey outlining the uses of phones to seek information and support around the menopause in Dublin, Ireland.

The volume concludes with three chapters informing specific mHealth initiatives:

  • Alfonso Otaegui’s recommendations for scaling the ‘nurse navigator’ model in public oncological clinics in Chile;
  • Marília Duque’s protocol for meal-logging and WhatsApp communications in Brazil; and
  • Charlotte Hawkin’s and John Mark Bwanika’s work on a digital mental health programme in Uganda.

Taken together, the volume seeks to provide a grounded ethnographic discussion on the challenges and opportunities of anthropology for mHealth, and of seeking health and care in the smartphone age. We aim for publication in 2022 with UCL Press, follow ASSA on Twitter, Instagram and Facebook to keep updated.

References

Hampshire et al. (2021). Informal mhealth at scale in Africa: Opportunities and challenges. World Development, 139:105257, 1-23

A few thoughts on Covid surveillance technology solutions in Africa

p.awondo19 March 2021

Fig 1: Screen showing Covid-19 prevention messages in a UN office in Ouagadougou. Photo credit: Charles Somé.

A few days ago, I came across a rather unusual document. It is a compilation of different technologies put together by the European Investment Bank, entitled Covid-19: Africa’s digital solutions[1]. It was published last year, with the support of the United Nations Development Programme (UNDP), and it sets out to identify the digital solutions currently on offer in the response to Covid in Africa. Several things strike me as I read this document: firstly, the breadth of these initiatives seems to reflect a faith in the ability of technology to respond to the health crisis. The inventory reports that about 100 digital solutions have already been ‘implemented’ or tested as of 20 June 2020. It also gives an estimate of the investment needed to implement such ‘high-impact’ solutions.

Then, there are different types of tools being promoted in different countries. There are collaborative tools such as Zoom and Skype, which have multiplied greatly, and use messaging apps such WhatsApp in professional contexts such as education, has also gone up. Traditional media, such as television, for example, has remained important due its ability to reach a great number of people during the crisis. Innovations also include tracking applications based on geographic information technology for epidemic surveillance purposes. On page 15 of the document, contact tracing apps are described as follows: “These applications, which often use geolocation data from telecommunications companies, help to identify contacts of people who have tested positive and help to locate areas where the virus is spreading.” We learn that applications have been developed and put to use in Kenya, Morocco and Rwanda among other countries. FabLab, an innovation hub in Kenya, has developed an application called Msafari, which can track public transport users.

Other digital tools have been used for mass communication and self-assessment of risks and symptoms. In Sierra Leone, for example, an existing public platform using unstructured supplementary service data (USSD) has been expanded to allow citizens to self-assess their symptoms and get alerts on developments on the COVID-19 front in the country.

The use of drones has also been experimented with to deliver pharmaceutical products or to transport PCR tests from remote areas to laboratories in big cities like Abidjan in Côte d’Ivoire or Kigali in Rwanda.

But are all these innovations and techno-digital solutions going to make a difference in the medium or long term? Firstly, let us recall that there is a gap between the international presence and publicity around various technological innovations, some of which can even be award-winning, and what actually happens on the ground.  Throughout our 18 months of fieldwork in Yaoundé for the ASSA project, we noted this significant gap, which says something about the difficulty of digital applications and solutions when it comes to capturing the attention of users.

The profile of a young Snapchat user in Cameroon. The screen shows various COVID-19 messages superimposed onto a photo of the user. Photo sent to the author by research participant.

In most of these countries, although tracking applications were received with curiosity, they nevertheless worried public opinion because they raised problems of data use and privacy. Not only are they worrying, but they are not always seen as appropriate solutions for the local context. Interfaces such as the one in the picture above, where COVID-19 related messages fit into the user interface seamlessly, work well in the context because they fit into the social media landscape. Young people want to show concern about the virus and they might adopt features of a social media network that support COVID-19 messaging for a few hours occasionally during the outbreak. But for that, they also need to be reminded by other channels of support and communication that the crisis is still there. The resonance of this issue is strongly linked to the strategic orientations of African countries in terms of their politics, economic situation and sensitivity to innovations.

Another part of the current debate concerns the mistrust of not only technological solutions but also of vaccines against COVID-19. For example, medical anthropologist Alice Desclaux and a team of French researchers [2], who undertook an exploratory study among 215 people in four African countries this year, found that 2 out of 3 participants said they would refuse to be vaccinated against Covid-19. They say: “reasons for refusal included firstly fear of any side effects hidden by the pharmaceutical companies, and secondly the perception of the vaccine as a tool in a plot by Bill Gates to reduce the African population or by a coalition of the powerful (states, global institutions) to enslave populations and ensure a “new world order” using corrupt authorities in African countries (“coronabusiness”). The study also found there was a preference for endogenous solutions to control SARS-CoV2, such as traditional medicine or the protection provided by religion.” There is therefore an urgent need to study more seriously the sources of the constant doubt surrounding the surveillance of epidemics, which are reflected and accentuated at pivotal moments such as Ebola or recently, Covid-19.

The central hypothesis of this is that the operational responses of nation-states are aligned with a policy of systematically using surveillance (biometric) and the tracing of infected persons (mHealth) as the preferred institutional response to emerging epidemics. However, this response has underestimated the capacity for the circulation of alternative interpretations of epidemics favoured by an abundance of content conveyed via social networks and smartphones. The direct access of the public to this content reinforces a widespread suspicion of local governments that are seen as corrupt and that accept servile compromises with the leaders of large pharmaceutical groups to the detriment of ‘African solutions’. Therefore the solution for helping people accept technological and digital solutionism to the crisis is not just to blame them for pharmaceutical nationalism, or their non-openness to innovations, but rather like anthropology and the ASSA team’s approach, making an effort to understand and carefully analyse not only people’s perceptions of the vaccine and the Covid outbreak, but also the intertwining of the logics behind them.

References

[1] European Investment Bank (EIB): Africa’s digital solutions to tackle COVID-19, found at: https://www.eib.org/en/publications/african-digital-best-practice-to-tackle-covid-19

[2] Desclaux A, 2021, « Covid-19: En Afrique de l’Ouest, le vaccin n’est pas le nouveau « magic bullet », available at: https://vih.org/20210202/la-mondialisation-des-informations-et-la-fabrique-des-opinions-sur-les-traitements-du-covid-en-afrique/