She looked 14, but she was pregnant. She wore a big dress probably meant for someone three times her size, as if to conceal her pregnancy. Maybe she just liked the dress. It was not obvious. She looked so sad, but at the same time determined. She caught my attention. Her name was Efua. I met her while working as a country manager to help evaluate the effectiveness of one of Africa’s biggest mobile health technology programs, MOTECH.

The Mobile Midwife component of MOTECH provides relevant health information on pregnancy and childcare in voice SMS to rural pregnant and nursing mothers. The health information is tailored to each woman based on gestation age or the newborn’s age at the time of registration. The MOTECH program operates in some rural districts in Ghana, and I was responsible for establishing a research team to collect routine data from pregnant and nursing mothers using MOTECH. I was also responsible for ensuring the research design was executed as planned, and the science was not compromised in any way. I took on this job after completing my Master’s program in the UK where I had learned about health injustice; health inequalities caused by social determinants. There were three Africans in my class, all from sub-Saharan Africa. I remember how we exchanged looks and sighs when my professor once said, “Africa is where you see health inequalities in all its glory”. She was right.

Developing poor health because you are poor is an injustice. - Cynthia Afedi Click To Tweet

Health inequality simply refers to the differences in health status between different groups of people based on social determinants such as their place of residence, type of employment, level of education and income. The World Health Organization (WHO) defines social determinants of health as the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at the global, national and local levels. How do a wider set of forces and systems shape the conditions and choices of your daily life? How do economic policies, development agendas, social policies and political systems impact your health knowingly and unknowingly? We’re about to delve in.


Efua’s Story: “Health Inequality in All Its Glory”

Efua arrived at the district health office in response to radio advertisements for pregnant women using MOTECH to participate in a focus group discussion, which I moderated. Like every focus group, there is always that one dominant participant who has so much to say as well as that one shy participant who needs encouragement to speak. Efua was the latter. Before the discussion started, the older pregnant women seemed to question why Efua showed up. A few times when I encouraged Efua to speak her mind on a topic, some of the older women giggled. Another time one woman openly said, “Debaadze na onyim? Small girl wo ndwen wo ho”. Meaning, “What does she know? Young girl, you won’t mind your own business”. To this, I issued a stern final warning and threatened to dismiss any participant who disrespected another. That was when I realized Efua was crying. It was obvious Efua was judged for being pregnant at her age. She did not stand up to these women, maybe because in Ghanaian culture, the younger person is always wrong. I briefly forgot the communal lifestyle in rural Ghana. Perhaps, these women knew Efua’s story, but I was yet to find out. After the discussion, I also asked Efua why she came. It seemed she expected the hostility she faced but came anyway. “I wanted the money,” was her response. Efua braced all odds to participate in the focus group discussion because we advertised that each participant will receive GHC 20.00 and lunch.

Mobile Health
A pregnant woman // Credit: Olivia Acland

Efua’s story was “health inequality in all its glory.” She grew up with her mother and four younger siblings in a small shack on a farm her father was contracted to work on. It was not a real farm, she explained, but land someone had bought and needed human presence on to serve as security. Her dad was an alcoholic, and spent all his money drinking. Her mother planted vegetables on the land, but the farm was too far away for her mother to afford daily transportation to the market to sell her produce. So, she sold them cheap to nearby neighbors. The family’s diet was hardly balanced. When anyone got ill, Efua’s mother fed them tomato light soup and prayed for healing.

A year earlier, Efua’s mother had sent her to the district capital to work as a house-help for another family. Efua was illiterate, poor and vulnerable; a man in her new home sexually abused her for several months, and in exchange bought her a cheap cell phone. When she became pregnant, she was sent back to her mother’s shack. Efua was blamed for seducing a grown man and accused of lying about who was responsible for her pregnancy. She registered for MOTECH with her cell phone and learned through the Mobile Midwife that she had to prepare for her childbirth. She was now saving money for a home birth. “Why? Is it not free to deliver at the hospital?” I quizzed. At least, the benefits of skilled delivery at a hospital was part of what MOTECH was teaching. However, that choice was more complicated for Efua.

Mobile technology may have provided Efua with the tools to make the right health decisions, but her circumstances left her with little choice.

I learned that hospital delivery is a decision you make early-on in pregnancy. It is mandatory to attend antenatal clinics, provide hospital requirements for birth (dettol, powder, soap, baby cloth, etc.), and arrange transportation for labour day and postnatal care visits. Even what you wore on those clinic days as a new mum was a big deal.  Pregnant women who could not afford these external costs simply forfeited. By saving money for a traditional birth attendant, Efua was being brave. But what if she suffers hemorrhage during childbirth? What if there are complications with the baby? What happens then? Traditional birth attendants can be helpful in certain circumstances, but the obstetric dangers of childbirth are more manageable in a hospital under the care of skilled professionals. Mobile technology may have provided Efua with the tools to make the right health decisions, but her circumstances left her with little choice. Just like that, Efua was at risk of maternal mortality or morbidities, just because she was born poor.


Health Inequalities: The Ladder Analogy

 Many of us are not that different from Efua. Socioeconomic restrictions have forced us to make poor health choices once or multiple times. Whether it’s skipping a dental appointment because you are broke, taking unprescribed drugs in lieu of a doctor’s visit, buying cheaper waakye from a seller with poor hygiene, or ignoring the expiry date on tinned tomatoes. If you – a health literate person – can do this, how about people with low health literacy who may not know any better? Everyone suffers low health literacy with one health condition or another, but the ability and capacity to even access accurate written or recorded health information that can inform good health decisions depends on socioeconomic status. How about people aware of their poor health circumstances but lack the power and ability to change their environment? A typical example are children who are treated for malaria and sent back to the very mosquito-infested homes that made them sick in the first place. Health inequality affects everyone; so think of it as a ladder. Those at the bottom are more impacted than those above them. What is particularly alarming, however, is the widening inequality gaps.

Mobile Health - Health Inequality Ladder

Poor economic policies and development agendas indirectly make us suffer poor health in diverse ways. In Ghana, economic growth and poverty reduction efforts are not equally distributed across the nation, and have allowed the richest groups to pull ahead, while the poorest have been left behind. For example, the poorest 20% of Ghanaians earned only 5.2% of the national income, while the richest 20% earned 48.3% (almost half) of the national income in 2006. Likewise, 62% of the Ghanaian population live in rural areas, but only 31% have access to electricity. The physician-to-population ratio in Accra is 1:5000, compared to 1:92000 in the Northern region for instance. Growing public health efforts have helped narrow the gap between the rich and poor for vaccination coverage, sanitation and child stunted growth. Nonetheless, the inequality gaps continue to widen for income, under-5 mortality (mainly due to malaria), skilled delivery and access to clean water. And so, health inequalities continue to worsen in Ghana as poorer and less educated people living in resource-poor settings continue to have poorer health.

In the public health community, health inequality is considered a “wicked problem”—that is, a problem that is complex, difficult to define and with no immediate solution. The common question then is who is to blame for health inequalities? When the more important question is how can we reduce it?


The Potential of Mobile Health Technology

That said, all is not lost. The extensive market penetration of mobile phones in Africa over the last few decades, coupled with advanced operating system technologies have broadened the capacity, scope and reach of health programs that run on mobile/portable devices. These programs are called mobile health ( mHealth) interventions, and the evidence for their effectiveness is growing.

In developed countries, some mHealth programs enable health practitioners to monitor patients remotely and manage patient risk factors, thus decreasing the frequency of hospital visits and hospitalizations. Likewise, some mHealth programs expand the consumer health domain, allowing patients to actively engage in- and self-manage their health behaviors. In developing countries, mHealth programs like MOTECH offer an opportunity to reach populations facing risks and health inequalities; populations who otherwise would be difficult to reach with traditional in-person programs. MHealth programs are also emerging as important health tools, and some studies have shown promising impacts of such programs to increase access to health information, enhance service productivity, and improve health behaviors.

Despite the potential of mHealth programs, not all modes (e.g. mobile apps, web, social media, SMS/text, or hybrid programs) can be accessed equally by all groups. While mobile application programs like MyFitnessPal may work well in urban areas with increased access to internet, SMS voice messages may be ideal in rural areas where there is limited internet access. From Efua’s story, we also learn that the impact of mHealth programs can be limited by social determinants such as poverty, literacy, language and cultural barriers. On the macro level, poor electricity, telecommunication systems, and inadequate structural resources affect how people interact with effective mHealth programs. The effectiveness, impact and accessibility of mHealth programs are reduced by the same.

Mobile Health Technology - Health Inequality Ladder

To mitigate such social determinants, it is important to design non-disruptive mHealth programs that fit the mobile technology culture of target groups in specific settings. Firstly, it is important to leverage on the existing mobile technology infrastructure. In resource-poor settings for instance, simplified mHealth programs like clinic appointment reminders, health information texts and supportive messages, can make timely health support more accessible to a wider rural population at a cheaper cost. Furthermore, SMS/text-messaging interventions such as the MOTECH Mobile Midwife messages can be delivered via cellular phones and does not require the more expensive smartphones with internet access. Secondly, behavior theory and communication strategies can guide the development of algorithms which can help target and tailor the content of mHealth programs to populations with unique health and social needs. Targeting is used to select a population based on common characteristics like language, tribe, gender, and so on, while tailoring helps to create individualized materials which engage with and provide feedback based on unique and individualized characteristics. Rather than depending on “one-size-fits-all” programs, a combination of targeting and tailoring can be used to address barriers related to language, health literacy and cultural beliefs unique to populations facing health inequalities.


Reimagining Efua’s Story: How Better Designed mHealth Programs Can Improve Odds


From Efua’s story, I began to imagine many ways mHealth programs can be improved to help people like her. I have three major suggestions for improving on the MOTECH Mobile Midwife program (or similar mHealth programs targeted at populations facing health inequalities). Firstly, I will redesign the program to focus on  behavior theories, specifically aimed at perceived severity of obstetric dangers and self-efficacy to overcome access challenges. Efua understood many things from the MOTECH program, but her estimation of obstetric dangers and ability to overcome her access challenges were poor. Providing specific information would have increased Efua’s confidence in pursuing alternative plans to delivering at home. Secondly, I would further tailor MOTECH messages beyond gestation age to include some demographic and socioeconomic identifiers, that helps select vulnerable people like Efua for more help. Lastly, I would employ two-way communication and engagement strategies about MOTECH to increase the extent to which target users engage with the program. Although MOTECH Mobile Midwife was a one-way communication program (users cannot communicate back via the same channel), many studies have shown more engagement and effectiveness with two-way communication programs with feedback loops.

Developing poor health because you are poor or live in a low-resource area is an injustice. Health inequality is unacceptable, and any effort to reduce health inequality gaps should be explored further. While mobile health technology is a necessary solution to health inequality, it is insufficient on its own for addressing Ghana’s health inequalities. Instead, it needs to be coupled with citizen advocacy and government’s equitable developmental efforts to expand education, create employment and infrastructure. With such a holistic approach, mobile health technology holds the potential to reduce health inequalities, especially among populations facing health risks.

If you are a citizen, research and take advantage of ways mobile technology can improve your health. If you are a tech entrepreneur, take this article as a cue to venture into creating viable tech-based solutions to healthcare and population health in Ghana; mobile health technology is certainly the future. If you are a health educator, always think of how mobile technology can improve the area you are teaching. If you are a telecom company, consider supporting mHealth startups in Ghana as a social responsibility to improving health.

A pregnant woman smiling (not Efua) // Credit: Olivia Acland

Cynthia Afedi Hazel is a public health professional with expertise in behavioral health science, mobile and digital health technology, and economic evaluations. She holds a BSc in Biochemistry and Biotechnology from KNUST and a MSc in Public Health Policy from Durham University. Cynthia is currently a Doctor of Public Health candidate at the University of Colorado Denver, where she has helped to develop various technology-based behavioral health programs including an app to help pregnant women eat healthy and return to pre-pregnancy weight after birth.

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