mHealth, or mobile health, is one of the most exciting and innovative areas in global health; the ubiquity of mobile phones in sub-Saharan Africa and elsewhere has led many to pin their hopes on the technology to improve health outcomes, educate children and adults about the scourges of HIV and malaria, and connect individuals with virtual health care providers. There’s a sense that mHealth can’t go wrong.
Unfortunately, it seems that it can. Paradoxically, providing sexual health information to young adults via mobile phones in Uganda increased the incidence of risky sexual behavior and infidelity, according to a recent paper by Julian Jamison, Dean Karlan, and Pia Raffler of Innovations for Poverty Action (IPA).
In Uganda in 2009, Google, the Grameen Foundation, and MTN (a cell network provider in Uganda analogous in its ubiquity to AT&T or Verizon in the United States) collaborated on a project to create a health information messaging service, which allows individuals to send specific questions via text messaging. The multi-lingual service, which allowed users to ask questions in English or Luganda (an official language widely spoken in Uganda), used an algorithm to respond with a targeted answer based on the topic.
IPA, a non-profit founded by Karlan in 2002, “evaluates what works in fighting poverty using the most rigorous methodology available: the randomized controlled trial,” worked with the Google consortium to randomize sixty villages: half received “high-intensity marketing campaign by a professional marketing firm” and half received no special information (though the text messaging service was available to everyone).
The researchers hypothesized that having access to private, objective, and reliable sexual and reproductive health information would increase knowledge, change attitudes towards safe sex practices, and lead to more safe sex and less unsafe sex (which included infidelity).
Their results were surprising and discouraging:
We find no increase in health knowledge regarding HIV transmission or contraception methods, and no change in attitudes. Rather than seeing reductions in risky sexual behavior, we actually find higher incidence of risky sexual behavior, and more infidelity, although more abstinence as well. Overall, individuals perceive their behavior as being riskier, which could be an indication of better probabilistic assessments but is also likely a result of the riskier (self-reported) behavior and possibly a desire to answer the surveyor in a particular way.
Infidelity increased from 12% to 27% in the treatment group, and men showed a statistically significant increase in the number of sexual partners, from 0.63 to 1.04.
Why is there a higher incidence of risky sexual behavior and more infidelity among users of the service? The authors don’t have conclusive data, but suggest that “sexual sorting” may have occurred; women, having learned about the risks of unsafe sex, demanded safe sex (and, failing that, denied sex altogether). Men, who perhaps didn’t want safe sex, found another girl to have risky sex with, cheating in the process.
In this case, it seems that the conventional wisdom is wrong: providing health information in and of itself doesn’t appear to be enough to promote safe sexual practices; as the authors conclude,
…it would be appropriate to learn from this study that the mere introduction of an information technology, designed by development experts, but left to individuals to self-direct in terms of their usage, does not necessarily lead to the socially desired impacts set out in the original intention of a program.