Exploring the potential of digital devices in accessing health care services among the population of an urban slum

INTRODUCTION

Digital devices have gained widespread adoption in our modern societies. In most countries, devices such as mobile phones have seen an exponential rise in rates of ownership as countries develop and incomes rise.^[1] These devices such as mobile phones, televisions, and personal computers have started to find application in many fields to improve our day-to-day lives, ranging from communication, entertainment, education, and notably healthcare.

Unfortunately, owing to widespread economic differences and disproportionate growth among urban and rural areas, India has witnessed the appearance of slums in every major city. The residents of these slums are one of the most disadvantaged groups in our urban areas. Several communicable and non-communicable diseases are prevalent in these slums,^[1] with the issues at the forefront being diseases such as diabetes, hypertension, and infections such as dengue. This population faces issues in accessing even the most basic healthcare. With the advent of digital devices, the field of healthcare has been given a “digital boost.”^[2] The devices may help us to significantly improve access to healthcare services and therefore health-related outcomes for the residents of the urban slums.^[3]

The COVID-19 pandemic presented various issues for the residents of the slums - Studies have shown that the residents who had better access to online information and devices had better knowledge and practices of combating COVID-19.^[4]

Mobile health or mHealth applications have been given a boost owing to the pandemic, and many countries, including India, has deployed these applications. Overall, mHealth applications such as Aarogya Setu were seen by/f the public as useful tools for combating the pandemic.

Telemedicine is another field gaining popularity, but adoption is limited by available infrastructure. It can help in combating non-communicable diseases by generating awareness regarding them. There is readiness among the people for mobile consulting in delivering healthcare services in the slums, thus, telemedicine can prove to be a boon for the slum residents as it can help them avail medical consultation conveniently from their homes.

In this study, we will explore the accessibility to and usage of digital devices, primarily mobile phones, by the residents of the urban slums in our field practice area, along with how these may have helped in the health care of the urban slum population. We will also explore methods to make health services available to them via harnessing the untapped potential of digital devices.

MATERIAL AND METHODS

This cross-sectional study was conducted in an urban slum located in the catchment area of the urban health training center established by the medical college, over a period of 4 months from September to December 2023. Full approval from the institutional ethics committee was received before initiating the study.

A total of 111 households existed in the area, of which 104 were available at the time of conducting the study. Seven households were found to be locked/unoccupied and were hence excluded from the study.

A house-to-house interview was conducted with a validated questionnaire developed to collect information from each family, all data being recorded on the questionnaire using the interview method by the investigator. One member from each household, having attained at least 18 years of age, was selected as the informant for this study. Informed consent was taken from all the participants after duly explaining to them the details of the study.

All data were entered into and analyzed using Microsoft Office Excel. Statistical parameters of frequencies, percentages, and Chi-square test were utilized, using which the significance of association was determined. Open-ended responses were compiled and presented in the form of narratives.

RESULTS

We sampled a total of 104 households/families that were present in the area encompassing the boundaries of the urban slum. We found that a majority, i.e., 92 (88%) of the families were in possession of at least one digital device, which was a mobile phone [Figure 1]. Only 12 (11%) families reported not possessing any digital device, while merely 17 families (16%) reported ownership of a television.

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Figure 1:

Number of devices in a household.

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Out of the 12 families that reported not having a mobile phone, 5 stated that they had never owned one, while the remaining indicated that they had owned mobile phones previously, but due to the devices breaking down and further financial constraints, they were unable to purchase new ones.

The average expense of Rs. 270 per month per family (Standard deviation – 138.74) was incurred for making calls and accessing the Internet on their mobile phone.

A total of 58 families (55%) presented with a history of having suffered a disease/health issue in the past 1 year [Figure 2].

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Figure 2:

Conditions affecting individuals in various households.

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A total of 38 families (36%) stated that they utilized a digital device for seeking help regarding their health issue [Figure 3].

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Figure 3:

Purpose of utilising devices (n=38).

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None of the families had ever utilized teleconsultation (video call) to talk to a doctor. Furthermore, none of them had ever utilized a digital mobile application to connect with a doctor.

A total of 17 (16%) of the families gave a positive response when asked if they had ever registered on a health-related app, of which 16 (15%) families stated that they have downloaded Aarogya Setu, while 1 stated that they use Nikshay Tuberculosis (TB).

Out of those interviewed, 19 families (18%) utilized their digital devices for some health-related purpose during the COVID-19 Pandemic- 18 families (17%) made use of the device for directly calling a doctor after getting affected with COVID-19, only 1 family made use of the device for enquiring about COVID-19 vaccination.

For the association between suffering from a health condition and utilizing digital devices for healthcare access [Table 1], P-value obtained is 0.017 (i.e., <0.05), which was calculated by utilizing Chi-square test. Thus, there exists a statistically significant association between suffering from a health condition and using the digital device for accessing health services. However, at the same time, it indicates that the utilization of devices for preventive and promotive services is low.

A total of 61 (58%) of the families stated that they received health related information or reminders in the form of text messages from the government, out of which 58 (55%) stated that they had received messages regarding COVID-19 vaccination, 1 family received messages regarding Blood testing services, 1 family received messages regarding Maternal health services and 1 received text messages containing reminders regarding their child’s vaccination. Out of the 104 families sampled, 37 (35%) reported that they knew mobile phones could be utilized for availing health services.

A directory was created using the phone numbers of the informants collected while conducting the study. We plan to deliver messages containing information relevant to health-related issues such as the diseases prevalent in the area, their prevention and control, details of health camps being organized in their area, etc.

Those who do not possess mobile phones were attached to their neighbors who had phones and were instructed to utilize their mobile phones for accessing the text messages that will be delivered to them, which will result in better health outcomes for the residents.

DISCUSSION

The study found a very high ownership of digital devices among the families residing in the urban slum, with a majority (88%) of the families reporting being in possession of at least 1 digital device. The devices may help us to significantly improve access to healthcare services and therefore health-related outcomes for the residents of the urban slums.^[1]

These results are in accordance with prior studies^[2] conducted in an urban slum area that found that 87% of the individuals own mobile phones. Other studies^[3] have also shown the number to be between 75% and 99%. A study^[4] carried out in an urban slum in Thailand reported that 59% of the respondents used a smartphone to access digital information. These results point to the fact that even among the slum residents, mobile phones have achieved satisfactory adoption and usage in everyday life, despite them being underprivileged, which would have led us to assume that the ownership rates might be quite low.

An average expenditure of 270 rupees per month on recharging the mobile phones, i.e., subscribing to prepaid plans, is reported by the families.

To determine the diseases and conditions affecting them, a study^[5] carried out in the urban slums of Bengaluru found that 31% of the population reported some morbidity. Anemia was found to be increasingly prevalent, with 71% of adolescent girls reporting the same. Consensus is that the families residing in urban slums would suffer from a greater percentage of diseases than the urban population due to a lack of proper sanitation and other-related factors. In our study, 58 families (55%) reported suffering from an illness/health issue in the past year. Anemia is the most prevalent, mainly affecting females. Fever and diarrhea were also reported [Figure 2]. It is likely that the actual prevalence is much higher, as these data were self-reported by the interviewees; thus, the potential patients have probably never been tested for the same or lack awareness regarding the disease.

Out of the 58 families, who reported suffering from a disease in the past year, 27 (25%) said that they utilized a digital device for seeking help regarding that health issue. Some respondents said that they utilized the device to call the doctor, seeking advice, while 7 families stated that they used their phones to book appointments with the doctor, a number which is strikingly low-leading to needless loss of a day’s income to the families where the working members are daily wage laborers. Two families reported using the device to contact the pharmacy to enquire about the availability of required medicines, which is a practice that the urban slum residents can be encouraged to adopt.

Telemedicine is another field gaining popularity, but its practicality rests largely on the infrastructure,^[6] if adequately available, it can help in combating non-communicable diseases by generating awareness regarding them.^[7] None of the families said that they have ever utilized teleconsultation, and no one said that they ever used an app to connect with the doctor. There seems to be a general lack of awareness and motivation among the residents of the urban slum to utilize teleconsultation. As per a study, most of the teleconsultation (mConsulting) services in other countries, which are state-supported, are free of cost.^[3] These services can also prove to be cost-effective for healthcare providers by saving travel and other associated costs.^[8]

The COVID-19 pandemic presented various issues for the residents of the slums, with social distancing being an impossible task for them.^[9] Studies have shown that the residents who had better access to online information and devices had better knowledge and practices of combating COVID-19.^[4] Mobile health or mHealth applications have been given a boost owing to the pandemic, and many countries, including India, have deployed these applications.^[10,11] There is readiness among the people for using mobile consulting in delivering healthcare services in the slums, thus telemedicine can prove to be a boon for the slum residents as it can help them avail medical consultation conveniently from their homes.

While 17 families (16%) said yes to ever being registered on a health-related app, 16 families said that they have downloaded Aarogya Setu. The application proved to be useful for contact tracing by the authorities during the COVID-19 pandemic,^[12] the low rates of adoption among the residents of the urban slum point to difficulty in effective contact tracing for suspected COVID cases among them. Overall, mHealth applications such as Aarogya Setu were seen by the public as useful tools for combating the pandemic, with 72% reporting it to be useful.^[13]

Only one family stated using the Nikshay app, which caters to Tuberculosis, and they also received reminders on the application regarding completing the due course of treatment.

Maternal and child health is an important issue in these slums, where almost every mother is anemic and child malnourished. mHealth interventions have proved to be helpful in tackling these issues.^[14] Campaigns such as text messaging are effective in educating mothers about improving their child’s nutrition and raising awareness about contraceptive methods.^[15,16] Child vaccine coverage has also been improved among all age groups via these messaging campaigns.^[17] Ensuring a safe delivery and subsequently adequate breastfeeding of the infant will ensure proper growth and development of the child and help in reducing infant mortality in these slums.

Most of the respondents in this study were uneducated homemakers, who were not aware of the mHealth applications and denied ever hearing about these applications, such as Aarogya Setu. This leaves the door open for utilizing information campaigns targeted at these housewives and educating them about the mHealth applications, hence improving their health status in essential areas, one such area being maternal and child health, as studies have shown that mHealth interventions can improve access to maternal and child health care services.^[18]

A study^[15] recording the benefits of utilizing an audio-based mHealth application among marginalized women found that women possessed better knowledge regarding modern spacing methods and reported utilizing the application for gaining knowledge on child nutrition and giving their child energy-dense foods. Therefore, mHealth apps specifically targeted towards women can benefit them immensely by educating them on topics such as Maternal and Child nutrition.

With regards to receiving health or vaccine/immunization-related text messages or reminders from the government, 61 (58%) of the families gave positive responses. A majority (55%) of the families interviewed stated that they had received text messages regarding COVID-19 vaccination. Due to widespread illiteracy, they were unable to read the content of the messages themselves and often relied on their children to read it out to them.

One study found that the preferred mode of receiving information was phone calls, and majority preferred to receive information in their own language,^[19] texts received in the English language were likely not read.

One family each stated receiving messages on blood testing, mother and child health services, and reminders regarding child vaccination, indicating that targeted text campaigns in these areas are essentially non-existent or have limited databases. Thus, this points to the opportunity of exploring audio messages and picture-based informatics rather than simple text messages to this group.

Thirty-seven families (35%) stated that they were aware of the potential of using mobile phones for availing health services, with the most utilized utility being calling the doctor. Out of those that gave a positive response, the most common reason cited for not availing health services despite being aware is “Being uneducated” and hence not possessing the skills or confidence to navigate through the rather complex interface of the mHealth applications to extract any meaningful health-related benefits. Others stated that they did not prefer to use digital devices for health-related issues and would rather show up at the hospital/doctor’s office directly.

A statistically significant association (P < 0.05) was found to exist between suffering from health conditions and utilizing digital devices for better health outcomes, indicating the importance of devices in tackling health conditions. This also indicates that the people are primarily utilizing devices for curative purposes, rather than preventive, because they do not seek health facilities when they are apparently healthy, thus missing out on disease screening and preventative health activities.

Taking into account, the scenario of high ownership but dismal usage of digital devices for seeking preventive, promotive, and curative services, an initiative was launched to establish a directory of all the residents of the urban slum. A complete family folder of the area is created, along with a listing of details of the beneficiaries and their contact numbers.

A program of teleconsultation and counseling, along with sending healthcare-related messages, preferably audio, in the local language to generate awareness regarding preventive and curative measures to combat diseases, health camp services started on a pilot basis. All the residents of the urban slum were sensitized to the procedure and benefits of this mHealth initiative.

CONCLUSION

The study concludes that the utilisation of digital devices for availing health related benefits among the residents of the urban slum is low, despite the fact that device ownership is high. This points to vast untapped potential in launching targeted mHealth interventions to benefit the residents of the urban slum, along with making them aware about the benefits of the same.