DigiHelp

The core problem we want to address is limited and disproportionate access to health information impacting marginalized communities globally, especially those living in rural areas. This leads to low health literacy (HL) and potentially poor health as a consequence. While there are numerous interventions aimed at reaching out marginalized communities through digital technologies, many have not been successful beyond external financial support due to failure to take into account contextual factors influencing the real-world implementation of the digital literacy (also known as e-health literacy) programs. 

Unfortunately, HL disproportionately affects individuals globally. For example, in the USA, low HL is associated with racial/ethnic minority status, elderly, poverty, inadequate health insurance coverage, low formal educational attainment, and high self-reported health problems (Kutner et al., 2006). One study in Tanzania revealed that only 32.9% of respondents had adequate HL on a one-health problem linked to humans, animals and the environment, with more literacy in males (Muhanga and Malungo 2018). Despite the ongoing efforts to improve HL in Tanzania, marginalized communities such as rural and peri-urban dwellers, women and persons living with disabilities are left behind because of their positions in the society. Traditionally, health information has been conveyed to communities orally or in printed formats, which are economically, environmentally and socially unsustainable due to high costs, carbon footprint (for printed format) and cannot reach the whole community. While digital health promotion works globally (Xie 2011; Noll et al., 2018; Gürkan and Ayar 2020; Hong 2021; Holst et al., 2022; Kajuna 2022b), internet connectivity in rural and peri-urban Tanzania remains challenging due to a lack of access. Where available the cost is prohibitive. More innovative and low-cost approaches such as DigiHelp are needed to increase community coverage, and hence, better contribute to sustainable development goals (SDGs), especially SDG 3 (Good Health and Wellbeing). Nevertheless, the implementation of e-HL programs needs to full take into account contextual barriers and opportunities for effective and sustainable implementation programs. This is the focus of our proposed solution.

We will advance the Transactional Model of Electronic Health Literacy (TMeHL), which defines electronic HL (eHL) as “the ability to locate, understand, exchange, and evaluate health information from the internet in the presence of dynamic contextual factors, and to apply the knowledge gained for the purposes of maintaining or improving health” (Paige et al., 2018). The model emphasises on four interconnected literacies but from low to high: (1) Functional eHL- basic skills in reading and writing (typing) about health to effectively function on the internet, (2) Communicative eHL- the ability to collaborate, adapt, and control communication about health with users on online social environments with multimedia (3) Critical eHL- the ability to evaluate the credibility, relevance, and risks of sharing and receiving health information on the internet, and (4) Translational eHL- the ability to apply health knowledge gained from the internet across diverse ecological contexts. Improving HL enables citizens to play an active role in improving their health and that of their communities. We will use our own developed and pilot-tested e-health literacy (e-HL) program to develop and evaluate implementation strategies suitable to the Tanzanian context. 

Our innovation is an eHL programme that employs digital technology to effectively, efficiently and sustainably deliver health information for improvement of HL (hence health) of marginalised communities in a low-income country. Our programme (DigiHelp) is a web and mobile application that consists of a dashboard where viewers can navigate various pages containing information about each domain (in our case disease) uploaded. The messages initially in hardcopies, are obtained from government approved documents, carefully reviewed and digitised into forms easy to be understood by the general public. The final content is an animated storyline in English and national languages, accompanied by quizzes to enable further learning. The resulting apps can be found via the internet or accessed via Wi-Fi in InfoSpots using locally stored village servers. The dashboard screenshot of the DigiHelp platform has been attached to this application. More information about the DigiHelp development and preliminary evaluation can be found elsewhere (Noll et al., 2018; Holst et al., 2021), 

Our solution serves rural communities in sub-Saharan Africa (SSA). Globally, rural dwellers, especially those living in rural areas are disadvantaged in the sense that they have limited access to important services, including health information services, making them prone to infectious diseases (including epidemics). Even within particular settings disparities exist. For example, public health emergencies including infectious disease outbreaks are increasingly evidenced in being closely related to constructed social dynamics, thereby affecting women, men and other genders differently. Even where notions of equality are embraced, ongoing inequality and unfairness survive, where historical disadvantages intersect with cultural factors such as sex, gender, age, ethnicity, faith and economic status (Vissandjée 2017). Despite the increasing evidence on existing inequalities and inequities in accessing health information there are limited effort in promoting eHL as a basis for individual and global health. Our eHL implementation strategy is geared to benefit various marginalised populations taking a gender lens by bring the different parties in co-developing strategies for eHL program implementation to suite the local contexts. This solution will address health issues, prevent disease transmission and consequently contribute to global health.

Sokoine University of Agriculture (SUA) is a public university established in 1984 in the United Republic of Tanzania. The university offers a wide range of programmes to undergraduate and postgraduate students. It also researches and provides consultancy and community outreach in various disciplines, including veterinary medicine, public health, food safety, animal science, agriculture, information communication technology, forestry, wildlife, tourism, food science, consumer studies, education, and social sciences. The university has a long and positive experience in leading small projects to large programmes funded by various sources (national and international), including Wellcome Trust, NIH, USAID, EU, DANIDA, NORAD, World Bank and many others. In addition, SUA has important policies, regulations, and guidelines for managing grants effectively, efficiently and ethically. During the Pilot 1 project, SUA led a component in implementing and evaluating the DigiHelp, with Prof. Helena Ngowi as the principal investigator (PI). H. Ngowi has long and positive experience in managing research grants ranging from 50,000 EUR to 1,600,000 EUR funded by various organizations, including DANIDA, BMBF, DFG and EU. She has successfully managed individual projects and research networks (for example, CYSTINET-Africa consortium (BMBF Nov 2016 to Dec 2023). In the proposed implementation research, SUA will bring onboard partners who she has worked with in the pilot study of DigiHelp project. These include Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania, Tanzania National Institute for Medical Research (NIMR), and the Basic Internet Foundation (BIF) in Norway.

Muhimbili University of Health and Allied Sciences is a premier higher learning institution in health and allied training, research, consultancy, and public services in Tanzania. The University has robust digital infrastructures and expertise for digital health transformation. The university promotes community engagement and adherence to the Principles of Digital Development. Through the co-creation approach, the existing e-HL promotion platform and the content will be scaled up in order to contribute to the attainment of national and global priorities. 

The Tanzania National Institute for Medical Research is empowered to handle all health research institutions in Tanzania. NIMR plays a central role in coordination, monitoring and promotion of health research and provides a linkage between health research generators and the users. In addition, NIMR implements a number of medical research (including health systems research). In the DigiHelp, NIMR Muhimbili Research Centre will participate in various aspects of the project, including further development of e-HL education contents for the various diseases, co-supervision of research and involvement in short-term training of the target communities.

The Basic Internet Foundation is a foundation under the University of Oslo in Norway, which engages in projects around the world in the fields of access to internet, education, health care, and women entrepreneurship. The main goal of the foundation is to enable free access to information for every human by closing the digital divide. During the DigiHelp Pilot 1 (funded by Norwegian Research Council 2017-2020), BIF was the lead organisation. In the currently proposed solution BIF will provide technical support for successful utilization of the e-HL program in Tanzania.

The DigiHelp intervention was evaluated between 2019 and 2020 in nine villages in the Iringa district, southern Tanzania. It provided free access to community information spots (InfoSpots) and integrated an eHealth education platform with health messages regarding HIV/AIDS, TB, T. solium cysticercosis and taeniasis targeting intervention villages (n = 6). A non-randomised pre-post-controlled study design was used to assess the effects of the intervention on knowledge (Holst et al., 2022), the prevalence of cysticercosis in pigs and associated transmission risk factors (Kajuna et al., 2021; Kajuna et al., 2022a). At 12 months after the intervention, knowledge about HIV/AIDS, TB, and cysticercosis and taeniasis was 10.2% (95% CI 5.0%-15.4%), 12% (95% CI 7.7%-16.2%) and 31.5% (95% CI 26.8%-36.2%) higher in the intervention group than in the control group, respectively. In all 4 aspects (transmission, symptoms, treatment, and prevention), an increase in knowledge was observed across all the 3 diseases. The participants who reported using the InfoSpots in the 12-month assessment further increased their understanding of the target diseases for a 6.8%-13.9>#/span### higher mean proportion of correct answers compared with the participants who did not use the InfoSpots (Holst et al.,2022). Similarly, there was a significant increase in pig confinement and improved pig pens attributable to the intervention in 70 pig-keeping households (38 control, 32 intervention) assessed for these factors. The total population reached at the evaluation time was 600 (60.3% females).

Nevertheless, the solution is still iterating as its uptake for routine implementation by the community and existing public or other supportive systems after the expiration of the donor funding in 2020 has not been established. Therefore, it is important at this stage to co-develop implementation strategies for the solution that take into account the local context so as to ensure effectiveness and sustainability. This is the core for our current solution.

We are applying to Solve with hope to be linked with interested parties who can support our initiative technically and financially. For example, technically through development of business models to enhance sustainability of our innovation, and financially to enable us implement and evaluate (further pilot-test) the implementation strategies for our solution.

DigiHelp is innovative as it uses digital technology to disseminate health education messages, especially to rural communities, which are by their nature marginalised. The DigiHelp can be out-scaled easily, enabling wider dissemination of health education information to communities as opposed to printed material or face-to-face delivery of health information (current approach). This is because the web-based mode of information delivery is not restricted to time, and with the current rapid increase in the use of digital devices this approach becomes increasingly popular in Tanzania. The web-based health information sharing brings many parties, ranging from private to public sectors, which makes the societal cost more effective. The DigiHelp innovation can be adapted to other low- and middle-income countries (LMICs) with similar conditions. 

DigiHelp seeks to use an innovative low-cost digital solution to promote health literacy on the WHO's One Health and contribute to SDG 3: Good Health and wellbeing. We complement it with the socio-technical systems (STS) approach (e.g., Muringani and Noll, 2021) to treat Health as complex adaptive systems involving both social and technical aspects and interactive processes between actants (actors, artefacts and actions). Our theory of change (TOC) adapts the United Nations Development Programme (UNDP) model and includes aspects from WHO (2016). We take the log frame, representing inputs, activities, outputs, outcomes and impacts of innovation as embedded within a context or social environment of a project, organisation and society. We argue that this is not deterministic on its own but goal oriented, therefore, shaped by human agency, such as the entrepreneur or innovator, who introduce innovations that transform society but is constrained by the social environment, and must overcome it (Schumpeter, 1934). We identify this wicked problem as inaccess to digital health information, exacerbated by the existing contextual barriers but access could be enhanced by a number of enablers existing in the context. We also understand that e-HL is more than access to e-H information, but also how the individuals interpret and make use of the information within a multitude of personal, inter-personal and contextual noises. Therefore, we propose a digital health intervention with resources including crucial activities and inputs:

Activities:

·        Enhancing the existing DigiHelp solution

·        Addressing barriers to the uptake of the solution

·        Managing the project

 Inputs: 

·        Leadership, organisational and human capabilities: Our team has the prerequisite capabilities, and led by a woman, Prof Helena Ngowi, transforms a largely patriarchal social context.

·        Technological capabilities: DigiHelp is a scientifically proven concept at the technology readiness level (TLR) between 5 and 7 depending on the defined context. It is, therefore, a minimum viable product (MV) that can be pivoted for scale-up.

·        Social capabilities- Co-creation with users in the first pilot created social capital, an essential determinant for Health.

·        Financial capabilities – Our innovative and sustainable business model will ensure digital health innovations' success and scale-up in low-income communities (Noll, 2016).

Arguably, above resources will achieve the expected results: 

 Outputs:

·        Digitised health messages in English and local languages

·        Connected ten new schools and ten new villages with Information spots (InfoSpot)

·        Digital literacy workshops in schools and communities.

Outcomes

·        Increase uptake of health knowledge

·        Participation of marginalized populations, including women in the project and community

·        Increased digital connectivity and literacy in schools and the communities

 Expected impacts:

·        SDG 3 -Good Health and wellbeing by improving health literacy

·        SDG 5 -Gender equality and 10-reduced poverty by empowering marginalized communities.

·        SDG 9 -Industry, innovation and infrastructure through a scalable and sustainable digital solution with spillover social and economic benefits.

·        SDG 10- Reduce poverty

by reducing the digital divide and increasing meaningful connectivity.

There will be buy-in from stakeholders to successfully implement the solution.

Impact goals

SDG 3 -Good Health and wellbeing by improving the knowledge of One Health: 

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Indicator(s) - 

SDG 5 -Gender equality and 10-reduced poverty by empowering women, youth and communities.

Target(s) - 

Indicator(s) - 

SDG 9 -Industry, innovation and infrastructure through a scalable and sustainable digital solution with spillover social and economic benefits.

Target(s) - 

Indicator(s) - 

SDG 10- Reduce poverty

 by reducing the digital divide and increasing meaningful connectivity/participation.

Target(s) - 

Indicator(s) - 

Our programme (DigiHelp) is a web and mobile application (app) that consists of a dashboard where viewers can navigate various pages containing information about each domain (in our case disease) uploaded. The messages initially in hardcopies, are obtained from government approved documents, carefully reviewed and digitised into forms easy to be understood by the general public. The final content is an animated storyline in English and national languages, accompanied by quizzes to enable further learning. The resulting apps can be found via the internet or accessed via Wi-Fi in InfoSpots using locally stored village servers. More information about the DigiHelp development and preliminary evaluation can be found elsewhere (Noll et al., 2018; Holst et al., 2021),

The steering team has nine full-time government employees from five institutions (4 in Tanzania, 1 in Norway). All participated in the DigiHelp pilot 1 project. The members will devote sufficient time (15-30%) to work for the pilot 2 project. The project members are Prof. Helena Ngowi (veterinary-public health, Tanzania), Dr Felix Sukums (digital health transformation, data governance, and technology, Tanzania), Dr. Bernard Ngowi (medical epidemiology, Tanzania), Prof. Josef Noll (digital technology, Norway), Dr Jonathan Muringani (digital society, Norway), Dr. Flora Kajuna (Tanzania Livestock Training Agency), Alphoncina Kagaigai (health economics and M&E, Tanzania) and Wisam Mansour (digital transformation, Norway). 

Overall, the project ran for 5 years.

Although the Non-discriminating access for Digital Inclusion (DigI) project was a three-year project (2017 - 2020), the final evaluation in Tanzania was completed in early 2022 due to the COVID-19 pandemic that started in Tanzania in early 2020.  The main objective of the project was to establish pilots for the InfoInternet access. It was a one-time off funding by the Research Council of Norway (Visjon2030 portfolje). 

Free access to information presents the basis for a scalable solution of digital access for everyone in the society.

The DigiHelp team adheres to the principles of diversity, equity, and inclusion (DEI) as defined by the MIT Solve and global community. 

For the diversity, the overall objective of the DigiHelp project is gendered in the sense that it is directed to ensuring access to basic internet by all people, with particular consideration of marginalised populations. In addition, the steering team has an excellent gender representation, with four females and five males, two nationalities and consisting of senior and early-career researchers as well as leaders from the public sector. Any further recruitment of personnel of any level (e.g., researchers and supporting staff) will take into consideration diversity (gender, age, ethnicity, and physical ability).

Our equity consideration is directed to fair treatment for all at all levels, recognizes that different individuals may need different levels of support to achieve equal outcomes. This spirit has been considered and it will be considered throughout the project phases from planning through to evaluation. A Collaboration Agreement (CA) entered during the pilot 1 project has been very valuable in this endeavor. The CA is usually updated to accommodate new developments.

The inclusiveness will go further and foster a sense of respect to all and encourage feedback loops through implementation of strong monitoring and evaluation throughout the project phases. Regular meetings of the project team ensures that any deviations are quickly handled. 

Not applicable at this stage.

Not applicable at this stage.