Rajesh's mobile phone rings at 9am sharp. The automated voice on the other end of the line reminds him to take his anti-retroviral medicines. This morning, he's not sure he should take his dose because he has an unusual rash on his arms. He presses a key on his phone to report his symptoms and, after answering a few automated questions, the voice on the other end of the phone reassures him it's safe to take his medicine. With the encouragement of this mobile phone based system, Rajesh has not missed a dose of his HIV treatment in 18 days. At his next visit to the community health clinic, his nurse congratulates him on his diligence. His mobile phone is bringing him better health.
This is the great promise of mobile services, especially for the poor who are not easily reached through other methods. Identify the problem, take advantage of the ubiquity of mobile networks and mobile phones, and install some software. Lives are transformed.
Except when they aren't.
Take a look at the Health Tips program in rural Uganda, for example. This was Grameen Foundation's first entry into mobile services in 2008. This pilot program was launched to better understand the potential to reduce risky sexual behaviors and lower the prevalence of sexually transmitted diseases. Participants could text questions to the service and receive SMS replies with automated answers about sexual health. Identify the problem, write some software, and harness the reach of mobile phones. The result will be a big positive change in the sexual behavior of participants, right?
The reality, as detailed in a new study, was disappointing in some important ways. While women in the program reported greater knowledge of sexually transmitted diseases, men in the study engaged in more risky sexual behaviors, especially more infidelity. However, it also offered evidence that access to information can and does change behavior (though not always in ways we expect). This is where the potential for transformation exists.
What separates a successful mobile technology program from one with disappointing results? Why does Rajesh's mobile phone increase his ability to manage his HIV while the mobile phones of many of the rural Ugandans led them to make choices which negatively impacted their health?
At Grameen Foundation, we believe in the promise of mobile services to have a positive effect on poverty, livelihoods, and health. We have learned, however, that a successful service requires much more than smart software and a strong mobile network. Successful services need to be delivered in the context of a trusted human network, the technology and content must be tailored to the experiences and needs of the participants, and the goals of the program implementers and the participants must be aligned.
Rely on Human Networks
Rajesh's pill reminders are delivered in the context of his relationship with his nurse. She receives alerts notifying her of how well he is following his treatment plan and discusses adherence strategies with him at his follow up appointments. His mobile phone is an extension of the trusted relationship he has with his caregiver.
Mobile services are most effective when there is a trusted human network to complement the mobile network. This human network is necessary to make participants aware of the service, help them learn to use it, and make it relevant and actionable.
In 2010, building on key findings from the Health Tips program and other relevant projects, Grameen Foundation launched the Community Knowledge Worker (CKW) Initiative in Uganda. The CKW Initiative relies on a network of over 1,130 trusted community agents to provide agricultural information to subsistence farmers in their communities. The CKW agents are chosen by their community and are given the tools to access and provide information to the other farmers. The agents know the people they are serving and are able to provide a link between the needs of the farmers and the capabilities and content of the mobile service. Our studies have shown that CKWs are able to strongly influence the behavior of the people whom they are serving: as farmers themselves, CKWs are oftentimes the first to utilize the information that they have been deployed to disseminate, while more skeptical farmers may choose to use the newly available knowledge only after observing a CKW's own personal farming successes. Specifically, efforts of CKWs have resulted in measurable increases in knowledge of farming practices and value received for crops at a cost far lower than alternate approaches.
Mobile solutions which function independently of any human network aren't used as frequently or with as much success. When they are used, the information is more easily misinterpreted because there is no one available to help put it into context for the participant.
Understand Your Audience
When Health Tips were launched in Uganda in 2008, there were still many people in the developed world who weren't comfortable sending an SMS message. For many rural Africans, SMS messaging is still not comfortable today. Illiteracy, discomfort, and technology limitations make it a challenging medium, especially for longer or more complicated content.
Our Mobile Midwife project in Ghana delivers maternal and child health information to pregnant women. After piloting it as an SMS-only service, Grameen Foundation added an interactive voice response (IVR) option so recipients could hear the messages instead of reading them. Today, 99% of recipients choose to receive the messages via IVR. A mobile service needs to reach its audience in the format and context that makes sense for them.
There's No Magic Here
Technology won't miraculously change anyone's goals or motivations. Putting it more succinctly, Kentaro Toyama says: "Technology is a magnifier of human intent". If the participants in a system want to do a better job taking their medicines regularly, a well-designed technology can help them do that. If a farmer wants to fight blight on his bananas, a mobile application can provide him with actionable information about how to treat his field. And if a pregnant woman has a priority to improve the health of her baby, a mobile phone service can successfully encourage her to go to her prenatal appointments.
In the case of the Uganda Health Tips, it appears many of the women in the study shared the project's primary goal to reduce their risk of sexually transmitted diseases. In pursuit of this goal, they applied the information they received from the service and refused to participate in risky sexual behavior or denied sex to their partners if they hadn't been tested. The men in the program, however, seemed to prioritize sexual activity over reducing their risk of disease. So, rather than go along with their partner's requests, they sought sex from others. Mobile technology isn't sufficient to change anyone's values.
Build, Measure, Learn, Improve
We are just beginning to realize the potential of mobile services to address the needs of the poor and suffering. We are encouraged by what we have seen - that under the right circumstances access to information can change behavior and result in better outcomes. We also increasingly have the ability to measure our efforts and make adjustments in real-time, modifying approaches and information being delivered to ensure behavior changes do result in positive outcomes. At Grameen Foundation we are committed to continue to openly share our lessons learned (such as with our mobile health efforts) and push the thinking (and doing) to deliver on the promise of the mobile phone.