I have witnessed how a rural mother had to walk for several kilometers to a health facility to ask a community health nurse for information about her pregnancy. She could have accessed this same information from a mobile application that provides relevant health information to pregnant mothers, but she did not have access to a mobile device with internet access. That is how digital health inequality manifests.
I have been struggling with an eating disorder for the past few years. I am afraid to eat and afraid I will gain weight. The fear is unjustified as I was never overweight. I have weighed the same since I was 12 years old, and I am currently nearing my 25th birthday. Yet, when I see my reflection, I see somebody who is much larger than reality.
I told my therapist that I thought I was fat. She said it was 'body dysmorphia'.
She explained this as a mental health condition where a person is apprehensive about their appearance and suggested I visit a nutritionist. She also told me that this condition was associated with other anxiety disorders and eating disorders. I did not understand what she was saying as I was in denial; I had a problem, to begin with. I wanted a solution without having to address my issues.
Upon visiting my nutritionist, he conducted an in-body scan and told me my body weight was dangerously low.
I disagreed with him.
I felt he was speaking about a different person than the person I saw in the mirror. I felt like the elephant in the room- both literally and figuratively. He then made the simple but revolutionary suggestion to keep a food diary to track what I was eating.
This was a clever way for my nutritionist and me to be on the same page. By recording all my meals, drinks, and snacks, I was able to see what I was eating versus what I was supposed to be eating. Keeping a meal diary was a powerful and non-invasive way for my nutritionist to walk in my shoes for a specific time and understand my eating (and thinking) habits.
No other methodology would have allowed my nutritionist to capture so much contextual and behavioural information on my eating patterns other than a daily detailed food diary.
However, by using a paper and pen, I often forgot (or intentionally did not enter my food entries) as I felt guilty reading what I had eaten or that I had eaten at all.
I also did not have the visual flexibility to express myself through using photos, videos, voice recordings, and screen recordings. The usage of multiple media sources would have allowed my nutritionist to observe my behaviour in real-time and gain a holistic view of my physical and emotional needs.
I confessed to my therapist my deliberate dishonesty in completing the physical food diary and why I had been reluctant to participate in the exercise. My therapist then suggested to my nutritionist and me to transition to a mobile diary study.
Whilst I used a physical diary (paper and pen), a mobile diary study app would have helped my nutritionist and me reach a common ground (and to be on the same page) sooner rather than later.
As a millennial, I wanted to feel like journaling was as easy as Tweeting or posting a picture on Instagram. But at the same time, I wanted to know that the information I provided in a digital diary would be as safe and private as it would have been as my handwritten diary locked in my bedroom cabinet.
Further, a digital food diary study platform with push notifications would have served as a constant reminder to log in my food entries as I constantly check my phone. It would have also made the task of writing a food diary less momentous by transforming my journaling into micro-journaling by allowing me to enter one bite at a time rather than the whole day's worth of meals at once.
Mainly, the digital food diary could help collect the evidence that I was not the elephant in the room, but rather that the elephant in the room was my denied eating disorder.
The elephant in the room
Health inequalities refer to systematic disparities in health between social groups, that is, the differences in people's health across the population and between specific groups. The fact that some people can access health care and others do not is an inequality.
We know that these inequalities are avoidable, but they continue to manifest. As digital health technologies are integrated into health, inequalities will increase. This is because as health services are delivered online, those who lack the skill to access and means to afford technologies are alienated and face exclusion from these services.
For this reason, The United Nations General Assembly in 2017 passed a resolution on the Impacts of rapid technological change on achieving the Sustainable Development Goals. The resolution acknowledged that despite technology's prospects to improve health, it could deepen inequalities for vulnerable groups.
Currently, digital health inequalities are present in Sub-Saharan Africa, including Ghana, where the increased adoption and use of digital health in Ghana are challenged. Some end-users cannot access electricity, the internet and lack the skills to use these health innovations.
In consultations with 16 digital health end users, health professionals, and systematic document analysis, this article establishes how specific groups are left behind in the process of digitizing healthcare in Ghana. Those in rural communities and populations with lower education, income, and persons with disabilities do not benefit from Ghana's ongoing digital health transformation. Three main factors account for this.
The Ghana EHealth Strategy, published in 2010, is the official policy framework guiding Ghana's use of digital health. The document provides a clear vision for implementing digital health in Ghana but lacks clarity on addressing digital health inequalities.
The top three challenges presented by the strategy do not directly address digital health inequalities as experienced by end-users. It only emphasis:
The strategy only focuses on equipping health centers with computers and strengthening internet connections but ignores that end-users, especially those in rural communities and persons with disabilities, cannot access the internet and lack the skills to interact with these technologies.
Even in capacity building to use digital health tools, the focus is on health professionals' competencies, neglecting the end-users.
End-users of digital health technologies experience struggles in internet connection and are discontent. Even when the internet may be available for use, it comes with challenges such as broadband speed, reliability, and affordability.
Data cost in Ghana is exceptionally high, affecting how people access digital health services. In the end, those in rural communities who are not connected, are unemployed, and have no income cannot afford internet data are denied access to digital health tools.
To harness the benefits of digital health, one must perform simple tasks such as navigating buttons on a digital health application and performing basic internet searches. But not everyone has that skill in Ghana.
A World Bank Development Report (2019) confirms a gap in digital skills in Ghana. About 18 million people, more than half of Ghana's population, lack the digital skills to use digital health applications and online services.
What is the effectiveness of deploying digital health interventions when the countries' populations lack the basic skills to harness the benefits?
Despite this lack of adequate digital skills, the government of Ghana is aggressively pushing for digital transformation initiatives, the health sector included.
Information literacy is also a problem: the end user's ability to independently evaluate health information for relevance, currency, and accuracy. Persons with disabilities are also denied access to digital health tools as devices do not support their unique needs.
In developed countries, digital technology is helping to transform unsustainable healthcare systems into sustainable ones. Digital health is introducing cheaper, faster, and more effective solutions for health.
These positive outcomes are also possible in Ghana. However, it will require proactive policy frameworks that address the current inequalities.
Beyond physical access like providing computers and internet connections, there must be a focus on developing the skills of end-users to use digital health technologies.
Future digital health policies in Ghana should focus on digital skills competencies, including information literacy skills for end-users of digital health.
The cost of data in Ghana remains a top obstacle preventing people from fully benefiting from digital health. There is no anticipation of a complete reduction in the cost of data. However, there is the need for a negotiated arrangement to make access to online health services and applications relatively cheaper.
The Ghana Ministry of Health should engage mobile phone service operators to explore tailored services that support vulnerable communities to access digital health applications.
Reducing digital health inequality will take time. However, short-term policy interventions such as social support systems can ensure that people can leverage digital health tools effectively regardless of a person's education, income, and geographical location.
Social support systems provide the emotional and informational needs that rural communities and persons with disabilities can rely on in their use of digital health technologies. Setting up information support centers and capacity-building initiatives for those in need is an excellent example of social support.
As someone working in digital health, I believe we can take proactive measures to reduce digital health inequality through policies and program interventions. The digital health challenges mentioned in this article are consistent with the calls to action from the United Nations that raise concerns that digital health technologies are entrenching inequalities.
I put forward the recommendations above to provide a foundation for governments, academia, and civil society organizations to understand digital health inequalities in Ghana.
We need a holistic and socially inclusive approach to integrating technology into existing health systems. For digital health tools to be inclusive, the needs of end-users must be considered and integrated into the planning, design, and implementation of any digital health interventions.
West African Lead, ALMA Youth Advisory Council/Zero Malaria Champion
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Dear Digital Diary,
I realized that there is an unquestionable comfort in being misunderstood. For to be understood, one must peel off all the emotional layers and be exposed.
This requires both vulnerability and strength. I guess by using a physical diary (a paper and a pen), I never felt like what I was saying was analyzed or judged. But I also never thought I was understood.
Paper does not talk back.Using a daily digital diary has required emotional strength. It has required the need to trust and the need to provide information to be helped and understood.
Using a daily diary has needed less time and effort than a physical diary as I am prompted to interact through mobile notifications. I also no longer relay information from memory, but rather the medical or personal insights I enter are real-time behaviours and experiences.
The interaction is more organic. I also must confess this technology has allowed me to see patterns in my behaviour that I would have otherwise never noticed. I trust that the data I enter is safe as it is password protected. I also trust that I am safe because my doctor and nutritionist can view my records in real-time.
Also, with the data entered being more objective and diverse through pictures and voice recordings, my treatment plan has been better suited to my needs.
No more elephants in this room