Phones for Health: Great Idea, But Where’s the Evidence?

The United Nations Foundation has just released an interesting report on the potential of mobile phone technology for improving the health of people in the developing world. The report is launched at their site. The report assembles descriptions of the use of cell phones to accomplish a variety of different health objectives. Each of the stories is fascinating in its own way, opening up vistas of opportunity. Here are a few reactions.

First, I am pleased that so many trials of cell phones are going forward despite claims by some that providing cell-phone access might be unethical. A few years ago I sat on a committee to which a proposal was presented to distribute free phones to adolescent young women living in southern Africa who were thought to be at risk of HIV infection. The research proposal was to randomly allocate the girls to two groups, one of which would receive HIV prevention messages through the phone and the other would not. Then all the girls would be observed periodically for biological markers of their riskiness of their sexual behavior, including pregnancy and/or sexually transmitted infections and/or HIV. The hope was to demonstrate that cell phones could be used to reduce the riskiness of the girls' sexual behavior, whether it be by increased abstinence, increased condom use or more selective choice of partners. I was frustrated when the other members of my committee rejected the proposal for ethical reasons. Their preconceived idea was that giving a cell phone to a girl in southern Africa would be tantamount to encouraging her risky sexual behavior. It seemed to me that (1) this would be an interesting hypothesis to test in its own right, since a young woman might just as logically use a phone to find employment, excel in school or otherwise avoid risky sex; (2) these young women would soon have cell phones anyway, so providing a free one a few months earlier would not have an appreciable negative impact - and any such impact was more than offset by the potential benefits of the intervention to the subjects and to many others. Much to my frustration I was outvoted and the proposal was rejected. If my colleagues on that committee were correct, enough cell phones have been distributed by these mHealth projects to dramatically increase the risky sexual activity of a great many people. Yet no one seems to be complaining - yet.

Related Experts

Mead Over

Senior Fellow Emeritus

Jenny Aker

Non-Resident Fellow

Second, the report fails to distinguish between anecdotal evidence and rigorous evaluation results, leaving the impression that there are none of the latter. The report often refers to comparisons of process measures before and after a cell phone intervention, but doesn't make comparisons with matched control groups which have not received the intervention. This is particularly disturbing since cell phone interventions are spreading so rapidly anyway and they could so easily be randomized by computer. The benefits of good evaluation would be to provide much more rigorous, and therefore much more believable, measures of the benefits of a given intervention - or the lack thereof. Many attribute the survival of Mexico's innovative Oportunidades program to the fact that it's benefits had been demonstrated so convincingly through randomization that even a new government was obliged by the evidence to continue its support. Without such rigorous evaluations, will cell phone interventions be able to withstand the vicissitudes of government and donor fashion? (One rigorous evaluation of the impact of cell phones is being conducted by Jenny Aker, a post-doc here at CGD.)

Third, this report does not address the issue of how to design incentives for truthful data collection by cell phone. I am particularly interested in the possibility of using cell phones to improve disease surveillance. Some of my ongoing work is on modeling the impact of interventions to prevent or slow the spread of a future pandemic of highly pathogenic influenza. The problem in using cell phones for flu surveillance is that of incentives. How does one induce the general public to accurately report outbreaks of flu? People might under-report for fear that an intervention would be draconian. This fear could be offset with a campaign describing the nature of the intervention and perhaps by rewarding those who report with free cell phone minutes. On the other hand, If one gives away cell phone minutes for reports of flu episodes, people might over-report. The report suggests that these incorrect reports were entirely due to a misunderstanding based on language, when intentional misreporting in hopes of receiving the promised reward may have instead been the problem. So a study of cell phone interventions for health could usefully include a discussion of the merits and demerits of various ways to provide incentives for truthful reporting.

The UN Foundation and the Vodafone corporation deserve our hearty congratulations for having sponsored this report. We hope they will sustain their interest in using cell phone technology to improve the health of the developing world with support for rigorous and nuanced evaluation.

Thanks to Jeff Garland here at the CGD for flagging this report for our attention.