Google Inc. and the Grameen Foundation set out to improve awareness of sexually transmitted diseases and reduce risky behavior in rural Uganda through text messaging. Instead, the program spurred infidelity.
Participants in the project texted questions on sexual health topics to a service set up by Google, Grameen and the local mobile-phone provider. Using its search technology, Google worked with Grameen to develop a way to pick up key words in the texts and reply with templated answers. Infidelity jumped to 27 percent from 12 percent of those involved in the project, one of the findings of a soon-to-be published Google-funded study by Innovations for Poverty Action, a non-profit organization.
The unexpected result exposes kinks in the growing field of mobile health, which is bringing together technology companies, wireless carriers, drug makers and non-profit organizations to explore applications ranging from diagnostics to disease tracking. They see the potential to improve the health of more people using mobile phones, with subscriptions at about 96 percent of the global population, more than twice the number of Internet users.
"Along with the successes, there have been some definite failures," John Tippett, who spent 18 years working on software development at Microsoft Corp. and is now director of mobile health innovation at the Washington, D.C.-based Grameen Foundation, said in an interview. "As an industry, we're not crawling anymore, but we're not quite running yet."
With the program in Uganda, which began in 2009, infidelity may have risen as women became more aware of the risks of cheating and insisted on going for testing with their husbands, said study author Dean Karlan, an economics professor at Yale University in New Haven, Connecticut. Some men resisted, leading women to deny them sex, which the men then sought from other women, Karlan said.
Mobile health still holds promise in the world's poorest nations, where it offers an inexpensive way to reach many people, even in rural areas. Cellular penetration in developing countries is at 89 percent, the International Telecommunication Union, a United Nations agency, said in a February report.
Using mobile technology may also help health systems cut spending through remote patient monitoring, better adherence to drug regimens and lifestyle improvements that may prevent chronic diseases from developing. Such measures could help reduce costs by almost 100 billion euros ($130 million) in the European Union by 2017, according to a report yesterday by PricewaterhouseCoopers and GSMA, a mobile operators industry group based in London.
Vodafone Group Plc, the second-largest wireless carrier, in December said it is working with U.K. drug maker GlaxoSmithKline Plc (GSK) to develop a pilot program to increase vaccination coverage in Mozambique using mobile technology. Glaxo, based in London, sells vaccines including Rotarix for rotavirus and Pediatrix for childhood illnesses.
Vodafone, based in Newbury, England, has also implemented a program in Tanzania using its M-PESA text-based payment service for treatment of fistula, or chronic incontinence after giving birth, which affects more than 2 million women in Asia and Africa. Since the program began, the number of surgical interventions to treat fistulas at a hospital in Tanzania has risen to 601 last year from 162 in 2009, according to Vodafone.
Results from various programs show phone technology is better suited for some initiatives than others.
The Google-funded study found that people's usage of the texting service from mobile-service provider MTN Group Ltd. (MTN) dropped by more than half the peak level after a three-month period of heavy advertising by a professional marketing firm. While some of them may have forgotten about the service, they may also have been turned off by the algorithm-based program that didn't always supply appropriate answers to their questions, especially in the local Luganda language, Yale's Karlan said.
Designed differently, other projects have seen success. A program in Uganda involving an SMS-based quiz on HIV and AIDS and reminders of free screening led to a doubling in test uptake.
"Unlike before, there's now an almost zero-cost way of giving and receiving information," Karlan said. "It just requires the creativity and ingenuity of development and health experts to figure out how to use this technology and design better programs."
Google is no longer involved in sexual health projects, and current health efforts focus on tracking diseases such as flu and dengue using search technology, according to Kelly Mason, a spokeswoman for the Mountain View, California-based company.
Mobile-health programs work best where the objectives of the users match those of the project organizers, Tippett said.
In the Uganda project, "the men didn't have the goal to have safer sex, even though the women did," he said.
Better suited to mobile technology are projects to improve maternal health, where pregnant women want to deliver a healthy baby, or with sick patients who want to be reminded to take their medication, according to Tippett.
Even in those areas, many details need to be worked out. Grameen's work in developing countries has shown that in most cases, users prefer voice messages over text messages, while other features such as preference for a man or woman's voice, whether they prefer that voice to sound like a doctor or a peer, how often they want those messages, and the length of each message, vary by population, Tippett said.
Those accumulated experiences have enabled Grameen to build template-based platforms that can be adapted for each new project. Because the software is open-source, they can be taken to any country.
There are discussions under way about bringing a program in India funded by Johnson & Johnson (JNJ) -- sending reminders to HIV patients about taking medication and tips on healthy living --to the developed world, he said.
"Our hope is that by building these common pieces and letting others build on top of those, they can more quickly try out things and figure out what works and improve the overall industry," Tippett said.