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The Duality of Digital Self-Care: Decreasing Health Worker Workloads, While Increasing Access to Care for Clients

Digital technology, when applied well, serves to extend the reach of health workers and to reinforce and enhance relationship-driven in-person care, not to fully replace it.

In 2021, it's hard to remember a time when going into the physical branch of a retail bank to engage with a teller was commonplace. Starting with ATMs (Automated Teller Machines) and evolving to include a slew of increasingly sophisticated e-banking products, the retail banking sector has completely transformed its approach to customer service. Twenty-first century banking is consumer-driven, on-demand and available round-the-clock.

Though the health sector fears a looming human resource crisis, with a projected frontline health workforce gap of 18 million by 2030, it has been slow to adopt similar digital technologies to optimize the use of scarce human resources and to increase the accessibility and convenience of healthcare for clients. It’s long past time for direct-to-client technologies to become an integral part of how healthcare is delivered in the digital age.

For many health conditions, both chronic and infectious, the behaviors and choices that the individual makes on a day-to-day basis such as what to eat, when to take medication or adopt safety precautions, and when it is time to call the provider all happen in the sphere of the client’s own home and depend on their self-management and self-efficacy. Mobile messaging, apps, hotlines and chat services can help the individual make healthy choices in the days, weeks and months between in-person visits with a health provider.

Of course, the underlying goals of banking and healthcare are different: the AI (artificial intelligence)-driven voice-activated menu of many banks is deemed successful if a customer never steps foot in a branch location again, whereas direct-to-client digital health services are not intended to eliminate in-person contact, but rather to drive the right care-seeking at the right time. Often this may mean even more frequent or earlier visits with a health worker to manage a condition before it develops into a costly, late-stage emergency. The ambition is to empower and support clients to effectively manage their own health, but also to create a digital front door to the health system so that appropriate care can be accessed quickly and easily, with greater alignment to client needs. The technology, when applied well, serves to extend the reach of health workers and to reinforce and enhance relationship-driven in-person care, not to fully replace it.

What does digital self-care mean for the frontline health worker and health system?

Digital self-care services can extend the reach of health workers into communities and improve continuity of care in between face-to-face consultations by enabling ongoing dialogue and remote monitoring of patients. This strengthens the bridge between community-based and facility-based primary care. Using new technologies like AI, digital self-care services can automate certain health worker functions (e.g., counseling and reminders), increasing the productivity of health workers and optimizing the allocation of human resources for health. By providing data insights to both health workers and clients, digital tools can help reduce the variability of healthcare outcomes and play an important part in delivering health equity.

Although there is still much to be learned about how digital self-care can improve the functioning of the health system, there is preliminary evidence from low and middle-income countries that digital linkages between health workers and patients helps take care of routine day-to-day questions virtually, making face-to-face visits more efficient and focused on targeted counseling and prioritizing high-risk patients.1,2 Links to care by mobile phone can reduce the need for patients to visit the clinic for routine post-procedure check-ups or test results, benefiting the health worker by making these interactions more efficient while still providing quality care.3,4

Optimizing when, where and how services are delivered

This is the promise of digital self-care: it can contribute to solving one of the great conundrums of universal health coverage—how can we expand coverage to the half of the world’s population currently lacking access to a full range of essential health services, while simultaneously reducing the burden on an overstretched and exhausted health workforce?

The answer lies in balancing a complex push and pull:

  • Convenience, anonymity and ease of access can pull more clients to receive the care that they need, when they need it—including traditionally underserved groups like adolescents
  • Automation, virtual triage and digitally-supported self-care behaviors can push many routine functions away from the frontline health worker, freeing them up to focus on interactions that require their skills and expertise

However, for this approach to work as intended, digital self-care interventions need to take careful account of the needs and preferences of both sets of target audiences—clients and health workers—to ensure that the full system of care delivery is optimized.

This is where many of the emerging digital self-care interventions fall short. Designed to address only the client side of the equation, they don’t pay sufficient attention to linkages to care, or the knock-on effects on health workers and the health system.

If digital self-care is appropriately viewed as an extension of the health system, resources and training will be crucial to make the dynamic interplay between digital and physical services function as intended. For example:

  • Helpdesk agents need to be trained and supported with adequate resources and means to answer questions and make referrals
  • Health workers need to be involved in the design of digital self-care services and appropriately trained on any new roles they need to perform (e.g., enrolling clients or monitoring client-submitted data or queries)
  • Client-facing digital self-care services need to be integrated with health worker-facing case management tools, electronic medical records and health information systems

Ideally, digital self-care exists within a dynamic and adaptable system where clients can choose traditional care or digitally-enhanced self-care depending on their health condition, access to digital tools, comfort with technology, and self-efficacy to undertake self-care behaviors.

Health in Your Hand: A Vision for Collective Action

To strengthen the positioning of quality digital self-care as a strategy to increase healthcare access while supporting the overburdened health workforce, the Johnson & Johnson Center for Health Worker Innovation is collaborating with a network of regional partners around the world— including ARMMAN, Jacaranda Health, mothers2mothers, Praekelt.org, Reach52, UNICEF, VillageReach and Vitalk Health—on research, real-world implementation and advocacy. We call this body of work Health in Your Hand.

Alongside direct funding support to these regional digital self-care initiatives through the Johnson & Johnson Foundation, the Center aims to advance the field by building evidence of the positive health worker and health system impacts of digital self-care, documenting best practices for integrating digital self-care with physical health services, and promoting supportive policies and regulations with relevant government policy- and decision-makers.

The Center’s approach aligns with the Digital Self-Care Framework that was developed by HealthEnabled in collaboration with the Self-Care Trailblazer Group. It draws heavily on HealthEnabled’s extensive experience in digital health as well as the co-author’s professional involvement in both the World Health Organization guidelines development processes for digital health and self-care. As such, Health in Your Hand has been designed to contribute to the collective efforts of many committed organizations working to make self-care a key contributor to universal health coverage.

References

1 Nhavoto JA, Grönlund Å, Klein GO. Mobile health treatment support intervention for HIV and tuberculosis in Mozambique: Perspectives of patients and healthcare workers. PloS One. 2017;12(4):e0176051. doi:10.1371/journal.pone.0176051

2 Thomas BE, Kumar JV, Onongaya C, et al. Explaining Differences in the Acceptability of 99DOTS, a Cell Phone-Based Strategy for Monitoring Adherence to Tuberculosis Medications: Qualitative Study of Patients and Health Care Providers. JMIR MHealth UHealth. 2020;8(7):e16634. doi:10.2196/16634

3 Feldacker C, Murenje V, Holeman I, et al. Reducing Provider Workload While Preserving Patient Safety: A Randomized Control Trial Using 2-Way Texting for Postoperative Follow-up in Zimbabwe’s Voluntary Medical Male Circumcision Program. J Acquir Immune Defic Syndr 1999. 2020;83(1):16-23. doi:10.1097/QAI.0000000000002198

4 Ggita JM, Katahoire A, Meyer AJ, et al. Experiences and intentions of Ugandan household tuberculosis contacts receiving test results via text message: an exploratory study. BMC Public Health. 2020;20(1):310. doi:10.1186/s12889-020-8427-0