Mobile Health Technologies Are Essential for Reimagining the Future of Water, Sanitation, and Hygiene

ABSTRACT.

The new Lancet Commission on water, sanitation, and hygiene (WASH) hopes to reimagine and guide global WASH efforts. This comes at a time when unequal living conditions and global disparities in response and recovery have been highlighted by the COVID-19 pandemic and recent large impact trials have delivered mostly disappointing results suggesting the need for radically more effective interventions to improve global public health. We find ourselves at an inflection point in global WASH with an opportunity to build new approaches with potentially more equitable, cost-effective, and scalable solutions. Mobile health (mHealth) technology is an important and innovative tool for WASH advances. Yet, the use of mHealth has not been equally distributed in terms of its benefits nor is its impact guaranteed. In resource-constrained settings, where technology can increase inequalities, special attention should be paid to structural and systemic hierarchies during the development of mHealth programs along with the acknowledgment and understanding of how these systems can reinforce the systematic exclusion of those most vulnerable. The WASH sector needs to adapt to a future that is innovative and inclusive with a commitment to rethinking the resources needed to enhance scope and impact. We highlight urban sanitation in Brazil as a case study to demonstrate that mHealth can support and enhance publicly funded infrastructure and to help reimagine WASH for postpandemic and beyond.

The Lancet announced a new Commission on water, sanitation, and hygiene ^{1, 2} (WASH) with the goal to reimagine global efforts in WASH and to support the WASH sector to meet current and impending environmental challenges such as climate change and urbanization. They also argue that WASH is a central pillar for gender equality and social and environmental justice. ¹ This is prescient as the world has seen how dramatically inadequate and unequal living conditions are across cities, nations, and the globe amid the COVID-19 pandemic. ^{3, 4}

The majority of the world lives in urban settings, ⁵ where insufficient and unequally distributed resources disproportionately affect the growing low-income population. As a result, one in seven people on earth lives in urban communities often called slums, ⁵ characterized by a lack of access to basic needs such as water, sanitation, solid waste services, and secure housing. The COVID-19 pandemic exposed the vulnerability of those living in these settings to infectious disease spread, and has exacerbated disproportionate health and economic burdens in these communities. ⁴ The global health community has an opportunity to innovate away from traditional approaches for WASH that have not addressed systemic inequities ⁶ and move toward supporting and enhancing cost-effective, scalable, sustainable, and community-derived solutions.

The COVID-19 pandemic highlighted WASH challenges of low-income urban populations where demographic density, poor housing conditions, and lack of access to clean water and adequate sanitation made preventive hygiene and social distancing practices impossible. ^{4, 7, 8} Urban areas often have greater WASH coverage ⁹; however, densely populated, poor urban communities experience substantial disparities in distribution, quality, and continuity of these services; often the result of historical and systemic racism and oppression. ^{10, 11} Often these sanitation systems are not adequate nor safely managed ¹² with an estimated > 1.8 billion households in need of fecal sludge management services ¹³ and most wastewater produced in cities in low- and middle-income countries being untreated before discharge. ¹⁴ Poor sanitation puts residents at risk of disproportionate exposure to emerging and reemerging infectious disease which is pertinent with increasing globalization, urbanization, and climate change and the risk extends beyond the boundaries of these communities. ^{15, 16}

Beyond the need for publicly funded infrastructure investments and professionalized WASH service delivery, numerous challenges exist that reduce the potential return on these investments. They include quality and consistency of services, user behavior change, communication between users and service providers, and community participation, which are key to realizing the benefits of WASH. As recently highlighted by mostly disappointing results from large impact trials, there is a need for radically more effective WASH interventions to improve global public health, ¹⁷ reflected in calls for “transformative” WASH. ^{1, 17, 18} For urban sanitation interventions, poor relationships between users and providers, and lack of collective action, stakeholder engagement, and sustained behavior change are all barriers to impactful sanitation solutions. ^{15, 19 – 22} Collective and individual behavior change is required for urban sanitation solutions to function, be sustainable, and provide the greatest health benefits. ²¹ Solutions to address barriers to effective urban sanitation interventions also need to be scalable to achieve greater impact.

During the COVID-19 pandemic, mobile health (mHealth) technology applications for population health have proliferated ranging from remote health service provision, ²³ to health promotion campaigns ²⁴ and to informing COVID-19 disease prevention and control strategies. ²⁵ mHealth can provide a radical shift in how we think, act, and succeed in WASH, as we harness new communication modalities to coordinate action, inform consumers, change behaviors, provide actionable feedback, and problem solve. ²⁶ Worldwide, there are > 5 billion mobile phone users; yet, the application and benefits of mobile technology have not been equally distributed. ²⁷ mHealth applications have the capacity to address social and environmental justice issues. In terms of equity, the technology can gather large amounts of data directly from the underserved populations in need of sustained WASH solutions ²⁸ and enhance the inclusion of vulnerable populations in the participatory construction of these solutions. ²⁹ mHealth strategies have been successfully applied to a wide variety of public health problems ^{30, 31} including use for WASH-related conditions such as diarrheal disease surveillance, ³² enhancing child health and caregiver attention to WASH conditions, ³³ and addressing COVID-19 response in Africa. ^{34, 35} There is growing evidence that mHealth may improve gender inequality ³⁶ and address urban environmental injustice in many settings. ^{29, 37, 38}

However, evidence is limited about successful integration of mHealth applications and their effectiveness for environmental health interventions—especially in urban communities where this work is critical. ^{39 – 42} Potential examples of mHealth deployment ^{43 – 45} to meet urban sanitation challenges are highlighted in Figure 1 and include interactive messages, uploading and geotagging of pictures to report and record the location of environmental issues, and user-provider feedback loops. ²⁶ In many settings, evidence shows that mHealth approaches can be highly cost-effective and scalable. ^{46, 47} In contrast to technology-based approaches to WASH that disregard the “lived experience of poverty,” ⁴⁸ mHealth may enable people to document and voice their own experiences and perceptions of the sanitation problems in their communities.

Figure 1.

Overview of urban sanitation challenges and opportunities for mHealth tools. This figure appears in color at www.ajtmh.org.

Yet, none of the potential benefits are guaranteed without focused and intentional mHealth development and delivery. Global challenges for mHealth delivery and implementation include user engagement and sustained use over time. ⁴⁹ Additionally, in resource-constrained settings, where technology can increase inequalities, be used to oppress, or lead to a reliance on a neoliberal model for provision of privatized services, special attention should be paid to the process and approach for development of mHealth programs and applications along with the acknowledgment and understanding that these systems can reinforce the systematic exclusion of those most vulnerable. ^{50 – 52} Effective implementation and scalability of new technologies can be severely limited without key stakeholder involvement. Community-engaged and community-empowered approaches are needed to inform user-centered design of new technologies as well as best practices for implementation and broader dissemination. Responsibility and accountability for change, however, does not lie with these stakeholders, but rather with governments. We need to encourage the WASH sector to adapt and commit resources to build thoughtful and inclusive approaches that will lead to a better understanding and enhance the development of mHealth in efforts to support the reimagining of WASH.

Such tools may have the greatest potential for achieving impact in settings with high smartphone access and data connectivity and persistent sanitation problems typical of transitional economies where inequality is extreme. Brazil, a setting where 86% of the population is considered urban and most of the population has access to cell phones, offers an opportunity for learning and leading in how integration of communication technologies into WASH service delivery can enhance collective action and problem solving. Although 90% of Brazil is reported to have access to basic sanitation, only 48% of the total population is connected to a networked sewer and approximately 58% of the urban population. ⁵³ Dramatic regional, municipal, and community-level disparities exist in access to a range of health and infrastructure services increasing health disparities, which are the result of historic, multi-dimensional, socioeconomic, and racial inequalities. ^{54 – 57} In densely populated informal and semi-formal urban communities of Brazil (often called favela communities), access to networked sewers is unevenly distributed and inadequate, which can result in environmental deficiencies such as flooding, contact with open sewers, and is associated with disease spread. ^{58, 59} Despite these challenges, Brazil is a leader in the development of cost-effective, simplified water and sanitation systems for densely populated urban settings called condominial water and sewerage systems. ⁶⁰ In Salvador, Bahia, Brazil, the installation of >1,000 km of condominial sewer network pipes ⁶⁰ resulted in city-wide health impacts including reduced intestinal parasites ⁶¹ and childhood diarrhea. ⁶² Yet, barriers for sustained success and expansion of the networked sewers remain in Brazil and they include community and household challenges, technical barriers, as well as challenges with governance. ⁶³ These challenges also result from limited community participation and difficulty in adopting the behaviors and practices required for such systems. ⁶⁰ Tackling urban sanitation challenges in densely populated communities through user-centered design of mHealth programs has not been a large focus but may have the potential to improve engagement, functioning, and sustainability of such systems. Furthermore, community-derived mHealth solutions to enhance urban sanitation for networked sewer systems can be adapted, expanded, and transferred to other situations that face barriers common in many urban sanitation settings.

Early evidence from building and piloting mHealth tools has demonstrated the potential for anytime and anywhere access to service, often overcoming barriers for those that are underserved. The application of mHealth tools in densely populated urban communities and the widespread use of cell phones among Brazilians in low-income communities may enable successful mHealth approaches in Brazil. Integrated communication technologies to drive improved WASH services in urban settings are largely untapped but given the need to maintain high-quality services to deliver value for money and protect public health, we foresee a future where the strengths of human connectivity and critical infrastructure can create the resilient systems of the future.