Getting health information to internally displaced youth in Afghanistan: can mobile phone technology bridge the gap?

Introduction

Despite improvements over the past two decades in reproductive, maternal, newborn and child health (RMNCH), Afghanistan continues to rank among the most disadvantaged countries globally for many health indicators^1,2. Child and maternal mortality remain critical public health issues, with higher rates in rural settings compared to urban³. Though some newborn and child health statistics have improved, immunization and nutrition indicators lag behind other countries regionally and vary markedly^3–5 between provinces and urban and rural settings. Total fertility rate (TFR) among Afghan women, which contributes to maternal mortality, is also high at 5.3 children per woman, and age at first birth is low (median 20.1 years) with 12% of girls ages 15–19 years initiating childbearing³. Modern contraceptive method use to space or limit pregnancies has stagnated over the last decade, with only 20% of married women reporting modern method use³.

Afghanistan has a “youth bulge” with more than half of its population younger than 19 years; youth aged 15 to 24 years comprise 22.2% of the population⁶. As these youth enter adulthood, marry, and begin their families, they constitute a key target for RMNCH interventions aimed to improve health and reduce maternal and child mortality. They are also an important audience for health-related information, particularly around RMNCH. However, reaching Afghan youth with needed RMNCH information is challenging, as multiple barriers limit young peoples’ access to formal health services^7,8.

Internally displaced persons (IDPs), including youth, experience additional challenges to obtaining essential health-related information and services. Years of armed conflict, natural disasters like drought and flooding, and widespread poverty have led to large-scale migration of intact family units both within and from Afghanistan^9–11. As of 2018, nearly 2.6 million of the estimated 35.5 million people in Afghanistan were internally displaced^9,10. The factors that contribute to internal displacement also reduce health service access. A 2018 United Nations Refugee Agency (UNHCR) report documented that up to 42% of Afghan IDPs are unable to access health care, with those in urban areas having slightly better access than those in rural settings¹². Key reasons for limited health care access were high cost and perceived low quality of available healthcare¹².

More information is needed on alternative ways to reach displaced youth with health information, particularly in fragile settings. Several programs have succeeded in reaching various audiences with health information through platforms that use mobile phone technology across multiple global contexts^13–17. The exponential growth of mobile phone technology has created opportunities to connect people with information at a scale previously unfathomable and Afghanistan is no exception. Mobile phone coverage is increasing within Afghanistan, in terms of number of users and use among target populations, including women and youth. In 2014, Afghanistan had an estimated 12 million mobile phone subscribers, and a 2018 estimate reported subscriptions at 22.0 million^18,19. A 2012 survey of Afghan women revealed that 80% had mobile phone access: 48% of women owned a mobile device and 32% could borrow one when needed²⁰.

To optimize exposure to RMNCH-related information and programming to create demand for health services, a greater understanding is needed of current exposure to and preferences for information channels and content among critical target audiences, such as IDP youth. The objective of this study was to measure current and preferred RMNCH information channels, content and media preferences, and to explore the feasibility of using mobile phone technology to reach IDP youth in Afghanistan with RMNCH information.

Methods

Results

A total of 462 IDP youth were recruited to participate in the survey. Ten of the 462 declined participation (2.2%); one person consented but refused to answer the remaining survey questions and data from one further participant was dropped because of incomplete interviews, leaving 450 total study participants from Kandahar, Nangarhar, and Takhar Provinces, including 225 male and 225 female youth. Characteristics of non-responders are not available as once a person declined to participate, no further information was recorded.

Just over half of female IDP youth were married, compared to 39% of their male counterparts (Table 1). Nearly all participants were born in Afghanistan. One-third of male and nearly half of female IDP youth reported currently living in their birth province. About two-thirds of male IDP youth had any formal education, compared to just under one-fifth of female youth; education levels varied markedly by province²².

Mobile phones as a source of health information

IDP youth were asked how likely they would be to use a free mobile phone-based system to receive RMNCH information. Nearly all respondents, regardless of sex or province, said they would be somewhat or very interested in such a system (Figure 1).

Figure 1. Likelihood of use of free mobile-phone based information on reproductive health among IDP youth, by sex and province, Afghanistan, 2017 (n=450).

Participants were further asked if the phone-based system should deliver information through recorded messages or if they would prefer to speak with a live person. Except for males in Kandahar who were evenly split on the options, most respondents stated a preference for speaking with a live person rather than hearing a recorded message (Table 7).

Table 7. Preferred way to receive health information through a mobile phone-based system, by sex and province, IDP youth Afghanistan 2017.

Media	Kandahar		Nangarhar		Takhar
	Men (n=75) %	Women (n=74) %	Men (n=75) %	Women (n=76) %	Men (n=75) %	Women (n=75) %
Hear a recorded message	52.0	12.2	16.0	1.3	12.0	17.3
Speak with a live person	48.0	82.4	80.0	90.8	85.3	73.3
Don’t know	0.0	5.4	4.0	7.9	2.7	9.3

Discussion

Results from this study add to limited information on the potential use of mobile phone technology to disseminate health-related information in fragile settings like Afghanistan. To our knowledge, this study is among the first to explore this topic among IDP youth.

Providing accurate, concise RMNCH information is important to the health of young men and women and a key step to improving uptake of RMNCH interventions. Such information has been traditionally delivered through health providers, and more recently, through lay persons trained as CHWs, consistent with reports from participants in this study. A key challenge with health care providers being the primary RMNCH information channel is limited access to such providers experienced in many low- and middle-income countries, including Afghanistan. Even when services are available, costs and perceived low quality can impede health service uptake¹². Women in Afghanistan have the added challenge of needing permission and money for payment from male relatives to obtain health services³. These barriers can intensify for IDPs, particularly the recently-displaced, as they are unfamiliar with health facilities in their new location and some may fear discrimination based on IDP status²³.

Lay CHWs are an important health information source, particularly in more rural, remote settings, and findings from this study reflect the value participants place on CHWs as a RMNCH information channel. Notably, CHWs were named frequently in Kandahar, despite sampling most of the IDP youth from urban locations in that province, potentially reflecting individuals recently displaced from rural areas. However, persistent challenges such as competing demands and high turn-over among CHWs can limit their effectiveness to reach male and female youth in some settings²⁴. Moreover, for youth displaced to urban settings, CHWs are not a viable channel as the urban health system does not have a formal CHW cadre²⁴.

Mass media campaigns are another health information strategy with evidence for increasing health-related knowledge, attitudes, and to a lesser extent, health behaviors^25–27. Regardless of effectiveness, use of media like print, radio and television requires reasonable access among the target audience. Our findings suggest that low literacy precludes using print media to disseminate health information, and RMNCH information delivered through radio and television would miss large numbers of youth in these IDP communities. Youth in Kandahar were more likely to report television use, likely reflecting the predominantly urban recruitment sites for this province and thus both access and acculturation to this channel among youth living in an urban location²⁸. Though we did not measure duration of displacement, anecdotal information indicated that some participants had been resettled for five years or more, potentially resulting in different norms around media use and health care access compare to those more recently displaced.

It is notable that some male youth reported need for RMNCH-related information, in some cases exceeding the proportion of female youth requesting the same information for certain topics. We posit this difference may reflect limited reliable information sources accessible to young men coupled with their awareness of becoming the primary health decision-maker upon marriage³. Just under half of youth in this study were already married; thus, these topics are germane to this population. On-demand channels, as well as programming specifically targeting male IDP youth, are worthy of further investigation.

Although few participants spontaneously listed mobile phones as a preferred health information channel, most reported being likely to use a free mobile phone-based intervention. Given low literacy levels in Afghanistan, options for a mobile phone information system are limited to voice delivery, either through pre-recorded messages or speaking with a live person, with the latter strongly preferred by youth in this study^20,29. With high reported mobile phone access among participants, such a system seems potentially feasible and likely accessible to more youth than other communication channels.

There is limited reported evidence on the use of messaging strategies for mobile phones other than SMS, and to date, there is no published evidence on the use of mobile phone-based health promotion interventions in Afghanistan¹⁴. Authors of a 2017 systematic literature review on mHealth strategies in low- and middle-income countries found that most intervention strategies used SMS-based messaging, though a few incorporated social media apps, such as Facebook®, and one program in Papua New Guinea employed the use of voice messages and an interactive information hotline to promote youth-friendly sexual and reproductive health information for young people ages 15 to 24¹⁴. While studies and project reports have documented successful implementation of mobile health strategies, predominately SMS messaging, a 2019 review notes a number of important barriers, including telecommunications infrastructures, costs, literacy and language barriers, among others, that will require careful consideration, planning and assessment as future interventions are developed and evaluated³⁰. Designing and implementing a mobile phone-based RMNCH information program targeting youth must also consider potential challenges to reaching young people, particularly female youth. It will also need to be tailored to the information needs of subpopulations, which differ by geography, with substantial differences in education and literacy, in particular, among male IDP youth across provinces. Although mobile phone access among Afghan women is high and growing, social norms that require women to seek permission to use phones and privacy concerns when phones are shared within families are important considerations²⁰.

Geography, ethnic diversity, limited transportation infrastructure and insecurity make conducting population-based research in Afghanistan challenging. While this study provides useful information on health information sources and preferences of youth from three provinces, several limitations require interpreting findings with caution. The youth in these analyses self-identified as IDP during enrollment; however, we did not collect information on reasons for displacement and length of time in current residence. Thus, this sample of youth may be quite heterogenous by displacement characteristics. although efforts were made through use of a random-walk method to reduce sampling bias in this convenience sample, it remains a non-probability sample;³¹ the extent to which findings reflect the broader population of IDP youth in these provinces is unknown. Information collected on exposure to media and health-related information was gathered through self-report and are subject to problems with recall.

Although findings from this study are exploratory, we believe that mobile phone-based programming, if appropriately marketed, presents a promising channel to reach IDP youth. Further research is needed to more thoroughly document feasibility, as well as to understand the most cost-effective mobile phone platforms to use. It will also be important to refine content for various RMNCH topics and channel selection to target specific segments of these sub-populations. We recommend that mobile phone-based RMNCH programming be developed and tested specifically for youth, with purposive inclusion of IDP populations in multiple settings to ensure cultural congruence and acceptability. The resulting interventions should be rigorously tested for cost-effectiveness to help guide national policy for youth programming amidst budgetary limitations and increasing insecurity.

Data availability