ICTworks

Engaging and mobilizing communities to be agents of their own health outcomes is one of the foundational tenets of primary health care, and a major opportunity area for digital health. This was reiterated in the 2018 Declaration of Astana, which said, “Through digital and other technologies, we will enable individuals and communities to identify their health needs… and play an active role in maintaining their own health and well-being.” Digital health offers a powerful opportunity to connect clients and communities to health workers and health systems.

Direct-to-client digital health services using mobile messaging, chatbots, call centers and help desks, mobile applications, and websites are also an important enabler of universal health coverage because they can serve as a first point of access when frontline health workers are scarce, and promote continuity of care between health worker visits.

At the J&J Center for Health Worker Innovation, we’re particularly interested in this area of work as a strategy for addressing the projected shortage of frontline health workers by 2030. But we’re facing a deceptively simple challenge – what do we call it? The laundry list of mobile messaging, chatbots, call centers, apps, websites… is descriptive, but doesn’t exactly roll off the tongue!

What Meaning is Behind Our Current Terminology?

In any emerging field, agreeing on specific and shared terminology is critical to promote shared understanding and efficient communication. These words and phrases do matter – they serve as the keywords that we use to scour the internet for our peers and the academic literature for relevant implementation experience and evidence. They can also have strong connotations about the primary target audience, the goals of the work, and how to measure success.

Let me give an example. When J&J first started working in low- and middle-income countries over a decade ago, the lack of smartphone adoption and high cost of mobile services meant that very simple, typically one-way, push messaging services using SMS or voice were really the only option. They were either described matter-of-factly based on the technology in use (e.g., “text messaging” or “voice messaging“) or based on the goals of the program (e.g., “adherence messaging“, “reminder messaging“).

The most common phrase used to describe this cluster of activity was “mHealth behavior change communication“. With a very limited capacity to solicit or track any kind of user engagement, these services were the digital equivalent of a poster or pamphlet or magazine article. The goal – clearly embodied in the name – was to drive adoption of healthy behaviors, and the typical evaluation would analyze changes in the knowledge, attitudes, and practices of participants.

Sometimes these direct-to-client mobile messaging services were called “demand generation” programs, reflecting a goal of increasing the demand for health commodities and services (often antenatal care visits). The logical marker of success was increased care-seeking behavior by participants.

These programs arose from the paradigm of preventive and promotive health, focused on communities.

There were, in parallel, a different set of nascent digital health services arising from the paradigm of curative healthcare services, focused on individual patient management. These “telemedicine” programs aimed to enable health workers to conduct remote consultations with patients or specialist peers, or in the case of “remote patient monitoring” to maintain continuity of care between in-patient visits for better longitudinal disease management.

A decade ago, these early efforts were quite distinct.

A Blurring of mHealth Solution Boundaries

Now, in 2021, the world looks very different. Smartphone usage is at record highs, accompanied by growing technical literacy and declining data costs in low- and middle-income countries. The explosion of natural language processing and artificial intelligence means that programs are now able to provide a personalized and engaging conversational interaction with clients at scale.

Automated triage systems can parse incoming messages and route high-risk clients to a health worker for individual support. We’re no longer talking about either health promotion or delivery of healthcare services because technology solutions can do both.

What New Words Do We Use?

The WHO Classification of Digital Interventions gives a great sense of the range of functionality that digital health services can provide, but doesn’t help with a simple phrase because many platforms can now cater to all of the use cases on the client side, and many on the health provider side to boot. The recent Digital Square Global Goods Guidebook doesn’t have a category that caters to direct-to-client services (and RapidPro is not currently listed).

In my own writing I used the term “virtual services” to contrast with in-person health services, but found the term was not widely used in the literature or by norm-setting bodies like WHO. Mothers2mothers recently used the term “eServices“. Others are homing in on the use of artificial intelligence and clustering all AI-powered digital health solutions together, regardless of the target audience or goals of the work.

WHO Digital Self-Care Terminology

Another new-to-me term is “digital self-care”, grounded in the WHO definition of self-care and with a recently-released framework from the Self-Care Trailblazers Group.

It has a lot to commend it, with an emphasis on community agency and empowerment, and the ability to capture a full range of health activities from promotion and prevention through to active disease management and palliative care.

However, the term places full emphasis on the actions of clients and communities, even though these digital solutions can only offer safe and high-quality care when they incorporate strong linkages to health workers and health systems.

This terminology shortcoming can result in real-world consequences: health workers and health system managers may be excluded from the upfront design of digital self-care services, or programs may underestimate the amount of health worker training required to enable them to interact with digital self-care solutions.

Frequently, program evaluations fail to look at the implications of digital self-care services for health workers and health systems. (It is particularly confusing to note that a “demand generation” program of five years ago might be labelled a “digital self-care” program today – should this be expected to increase or decrease attendance at health facilities?).

Perhaps most importantly, the emphasis on self-care rather than service delivery means that these kinds of solutions may be excluded from government planning towards universal health coverage, even though they must inevitably form an important part of primary and community health in the digital age.

Is There a Better Term Than Digital Self-Care?

With these limitations to the term “digital self-care,” I wonder what other words we could use to describe the use of digital tools for engaging clients and communities, without excluding health workers and health systems?

Please share your opinion in the comments. I welcome a discussion on what terms other organizations are using. Is “digital self-care” the growing consensus, or are there strong alternatives to consider? I will happily join you in finding a good phrase we can all use for this important work.

By Dr Joanne Peter, Johnson & Johnson Center for Health Worker Innovation