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New rural healthcare inequalities as mobile phones replace friendships?

  • Health behaviour research in Thailand and Laos studied how poverty, mobile phones, and social relationships affect access to healthcare in rural populations
  • Researchers documented a broad spectrum of informal mobile phone use during illnesses, even in the absence of specific healthcare interventions
  • Support from family and friends as well as phone use were widespread and improved poor patients’ access to public healthcare
  • Mobile phones were also generally less accessible for the poorest of the poor, which makes them prone to aggravating inequalities in rural areas of low- and middle-income countries
  • Researchers call for caution in health interventions that use mobile phones, as such interventions could drive out other ways of gaining access to healthcare

Thai person using phoneLeading health and development organisations such as the World Health Organization increasingly recognise the risk of “digital inequalities” – that the use of technologies like mobile phones can exclude poor and disadvantaged groups.

A new study led by Warwick University Assistant Professor Marco J Haenssgen has now demonstrated directly how mobile phones can support access to healthcare in developing countries, but at the risk that the poorest are deprived of support. Published in the prestigious journal World Development, the researchers highlight the complexities of technological change and caution against over-enthusiastic medical interventions that aim to promote health through mobile phones.

The researchers conducted a representative health behaviour survey among 69 villages in northern Thailand and 65 villages in southern Lao PDR. Responses from this sample of 2,141 people reflect the broader living conditions and health behaviours of more than 700,000 villagers.

The study found that

  • People in both regions often suffered from non-monetary poverty. Despite widespread poverty, mobile phones were commonly owned – by 97% of households in Thailand and 75% of households in Laos
  • Phones increasingly integrate into people’s health behaviours and fulfil similar functions as the direct support from family and friends during an illness. Social support remained more common, however: two-thirds of patients in rural areas involved other people during their illness, only one-quarter (Thailand) and one-sixth (Laos) of patients used mobile phones when they were sick. Patients who used phones were significantly less likely to be poor
  • After excluding other factors that influence patients’ healthcare access (e.g. age, gender, and how severe an illness is), the study showed that poor people benefit both from phones and from friends’ support. Among the poorest parts of the population, phone users were 84% more likely to access public healthcare, and people receiving support from their families and friends were 105% more likely than poor villagers without such assistance.

The study was conducted together with Nutcha Charoenboon (University of Bristol) and Giacomo Zanello (University of Reading) as part of a larger research agenda that investigates health behaviour in contexts of poverty, precarity, and socio-economic change. The rapid spread of mobile phones is in fact one of the most visible developments that low- and middle-income countries are undergoing, with global teledensity (i.e. mobile subscriptions per 100 people) now exceeding 100%.

The rapid spread of mobile phones worldwide has sparked excitement about the development potential of mobile technology in low- and middle-income countries. The industry group Groupe Speciale Mobile Association (GSMA) currently lists more than 1,000 health-related mobile phone interventions worldwide. However, Dr Haenssgen explains:

“We need to change the medical narrative and stop pretending that mobile phones will automatically make healthcare more inclusive. They certainly have the potential to be vehicles for helpful interventions, but we also need to understand and appreciate the ways in which they consistently create new divisions, especially among poor people in low- and middle-income countries – who are often the primary target group of such health interventions.”

The study thereby provides substance to a recent report by the World Health Organization, in which Director-General Dr Tedros Adhanom Ghebreyesus highlighted that, “We must make sure that innovation and technology helps to reduce the inequities in our world, instead of becoming another reason people are left behind.”

Nutcha Charoenboon, who supervised the surveys in Thailand and Laos, reflects on her research experiences within this study:

“We could see on the ground how the fascinating range of mobile phone usage becomes almost a mirror image of the local context. In health systems with co-payments for treatment, phones are used to access credit; in livelihoods dominated by demanding farm work in irrigated rice fields, phones are left at home and become effectively a landline. Technological interventions, if and when they are necessary, need to accommodate these situations. Solutions developed out of context and without consideration of local realities therefore won’t cut it – however much ‘potential’ they may have.”

Dr Zanello comments,

“Paradoxically, it is the poorest who at the same time benefit most and are most likely to be excluded from mobile phones. This is a real problem. We know from sociological studies that mobile phones can weaken local communities. If they also make healthcare access more individualistic, then poor people who used to rely on traditional local support structures will be left stranded during emergencies.” 

  • The research is published in World Development: Haenssgen, MJ, Charoenboon, N & Zanello, G. (2020). You’ve got a friend in me: how social networks and mobile phones facilitate healthcare access among marginalised groups in rural Thailand and Lao PDR. World Development. doi: 10.​1016/​j.​worlddev.​2020.​105156. Available at https://www.sciencedirect.com/science/article/pii/S0305750X20302837

23 September 20202

NOTES

Photo: Caption: A mobile phone user in Thailand. Credit: Marco J Haenssgen

The study data is publicly available at the UK Data Service:

Haenssgen, M. J., Ariana, P., Wertheim, H. F. L., Greer, R. C., Jones, C., Lubell, Y., et al.(2019). Antibiotics and activity spaces: rural health behaviour survey in Northern Thailand and Southern Laos 2017-2018 [data set]. Colchester: UK Data Service. doi:10.5255/UKDA-SN-853658. Available at http://reshare.ukdataservice.ac.uk/853658/

The Department for Global Sustainable Development was founded in 2015 with a remit to deliver a suite of innovative degree courses which take on the challenge of engaging with the UN’s Sustainable Development Goals in a multi-disciplinary and intellectually enriching environment. The department has grown to encompass 12 undergraduate degree courses and the Institute for Global Sustainable Development which was established in 2017 to foster research that contributes to the sustainable development agenda across the Global North and Global South.

The Economic and Social Research Council (ESRC) is the UK's largest funder of research on the social and economic questions facing us today. It supports the development and training of the UK’s future social scientists and also funds major studies that provide the infrastructure for research. ESRC-funded research informs policymakers and practitioners and helps make businesses, voluntary bodies and other organisations more effective. The ESRC also works collaboratively with six other UK research councils and Innovate UK to fund cross-disciplinary research and innovation addressing major societal challenges. The ESRC is an independent organisation, established by Royal Charter in 1965, and funded mainly by the Government.

The Antibiotics and Activity Spaces project is a study of antibiotic-related health behaviour in rural Thailand and Lao PDR, funded by the Antimicrobial Resistance Cross Council Initiative supported by the seven research councils in partnership with the Department of Health and Department for Environment Food & Rural Affairs (grant ref. ES/P00511X/1, administered by the UK Economic and Social Research Council).

CONTACT

Sheila Kiggins

Media Relations Manager

University of Warwick

07876 218166

s.kiggins@warwick.ac.uk

Dr Marco J Haenssgen

Assistant Professor in Global Sustainable Development

University of Warwick

marco.haenssgen@warwick.ac.uk