Journal of Public Health Policy

, Volume 37, Supplement 2, pp 167–200

The impact of digital technology on health of populations affected by humanitarian crises: Recent innovations and current gaps

  • Sandra Mesmar
  • Reem Talhouk
  • Chaza Akik
  • Patrick Olivier
  • Imad H. Elhajj
  • Shady Elbassuoni
  • Sarah Armoush
  • Joumana Kalot
  • Madeline Balaam
  • Aline Germani
  • Hala Ghattas
Open Access
Original Article

DOI: 10.1057/s41271-016-0040-1

Cite this article as:
Mesmar, S., Talhouk, R., Akik, C. et al. J Public Health Pol (2016) 37(Suppl 2): 167. doi:10.1057/s41271-016-0040-1

Abstract

Digital technology is increasingly used in humanitarian action and promises to improve the health and social well-being of populations affected by both acute and protracted crises. We set out to (1) review the current landscape of digital technologies used by humanitarian actors and affected populations, (2) examine their impact on health and well-being of affected populations, and (3) consider the opportunities for and challenges faced by users of these technologies. Through a systematic search of academic databases and reports, we identified 50 digital technologies used by humanitarian actors, and/or populations affected by crises. We organized them according to the stage of the humanitarian cycle that they were used in, and the health outcomes or determinants of health they affected. Digital technologies were found to facilitate communication, coordination, and collection and analysis of data, enabling timely responses in humanitarian contexts. A lack of evaluation of these technologies, a paternalistic approach to their development, and issues of privacy and equity constituted major challenges. We highlight the need to create a space for dialogue between technology designers and populations affected by humanitarian crises.

Keywords

digital humanitarian refugee health 

Introduction

In 2016, 37 countries are facing humanitarian crises. The UN Office for the Coordination of Humanitarian Affairs (UNOCHA) estimates that 88 million people are in need of humanitarian assistance globally.1 The recent influx of refugees into Europe highlights the political, social, and economic complexities that result in displacement both within and across borders. Traditional and social media coverage of these events has increased awareness of the plight of refugees, and highlighted how digital technologies have become essential tools for humanitarian workers and affected populations alike.2

Digital technology allows for storage and analysis of large amounts of data using electronic devices.3 Since the response to the Haiti earthquake in 2010, in which social media, text messages, and satellite imagery played an important role,4 the use of digital technology in humanitarian action is now viewed as both “essential and inescapable.”5 Such technologies underpin the functions of many humanitarian actors, including data collection, data analysis, information dissemination, coordination, advocacy, and fundraising. Networks of technicians have also been established to provide data analysis and geospatial technical assistance to humanitarian organizations.6

The potential of digital technologies to support the health and social well-being of populations affected by humanitarian crises lies in their use to better understand complex situations and the needs of the affected communities, facilitating humanitarian response efforts, and engaging the affected populations in the response.5 Our objectives were to (1) review the current landscape of digital technologies used by humanitarian actors and affected populations, (2) examine their impact on the health and well-being of affected populations, and (3) consider the opportunities for and the challenges faced by users of these technologies.

Methods

We conducted a systematic literature search to identify reports of the use of digital technologies to improve health assistance, health, or its determinants in populations affected by humanitarian crises. These populations were defined as people exposed to natural disasters, war, armed conflicts, or rescue missions, including displaced populations, refugees, forced migrants, or evacuated populations. Digital technologies refer to both hardware and software applications such as (but not limited to) mobile and desktop computers, telemedicine, telehealth, eHealth, and mHealth. We included studies or reports dating from 2005 to 2015 that aimed to improve the health of displaced populations or to facilitate the health work of humanitarian organizations. We excluded news articles, blogs, media reports, theoretical models of technology, and disaster planning documents, monthly and weekly updates from humanitarian agencies, and opinion pieces as well as reports about economic migrants. We also excluded initiatives that focused on shelter, water, sanitation and hygiene improvements, as they generally focused on the engineering of infrastructure, and were more than one degree removed from health.

We searched Medline (our strategy is included in Supplementary Material), Embase, Global Health, PyschInfo, Popline, and the Association for Computing Machinery (ACM) Library for published literature, and used Google to locate reports of projects for displaced populations, digital technology, disaster context, and health. We included peer-reviewed articles, books, book chapters, periodic reports, one-time reports, and websites published between 2005 and 2015. No language restrictions were placed on the search. We imported the articles and reports retrieved into Endnote X7 and removed duplicates. Two researchers conducted title-abstract and full-text screening independently according to the inclusion criteria outlined. Figure 1 presents the resulting review flow chart.
Figure 1

Flow chart for the review of the literature on digital technologies to improve health in humanitarian crises

Results

The findings of this landscape review are structured according to an organizational framework illustrated in Figure 2. They are divided into technologies used by humanitarian actors and those used by populations affected by crises. Digital technologies are used in humanitarian programming to facilitate various functions of the preparedness for, response to, and recovery from emergencies, supporting health assistance and health and its determinants.7 We identified a set of digital technology initiatives used largely by those affected by humanitarian crises and that can impact the various determinants of health including income, education, social support, access to healthcare services and others.8
Figure 2

Digital technology can play a role in facilitating humanitarian action and improving the determinants of health.

Adapted from Inter-agency Standing Committee’s Humanitarian Program Cycle and Determinants of Health from Health Canada7,8

Table 1 summarizes the number of articles or reports we found through the systematic search for different types of digital technologies, defines these technologies, and categorizes them by user (humanitarian versus affected population).
Table 1

Types of technologies retrieved, their definitions, and articles/documents that refer to these by user of technology

Type of technology

Number of articles/documents retrieved by user of technology

Technology

Definition

Humanitarian organization

Displaced population

Digital classrooms/instant classrooms

Digital story telling

A tool kit with built-in 3G network, loaded with e-books, HD hand-held cameras, graphic design and video software, documentaries, movies, arts and crafts materials, projector, Games, and one built-in stage for musical and theatrical representations

 

242,51

Digital communication

Communication between agencies and decision making

229,66

 

Electronic health records

An electronic version of a patient’s medical history and records, maintained by the health care provider over time, and may include administrative and clinical data relevant to the persons’ care

45,3739

 

Electronic voucher (e-voucher) cash cards

Mobile network operators work with humanitarian organizations to provide financial mobile money services where vouchers are given and can be topped up at recharge machines using landline connection

 

318,43,50

Gaming

The use of digital games that take place in both reality and virtual reality

111

 

GIS

A system that allows for the portrayal of multiple layers of data on interactive maps

125,9,10,18,22,2426,32,48,59

160

Hand-held electronic data entry

Input biographical data to identify those in need

518,20,21,49,64

 

Low-cost computers

Credit card sized computer that can be inserted in monitors or small motherboards preloaded with educational material and act as information portals to access education in areas with intermittent internet access

 

118

Portable medical equipment

Medical devices that have been redesigned to be compact and portable

133

 

Robotics

The use of programmable machines

230,31

 

Social media

Websites and applications that allow content sharing to create a network of shared users

412,13,27,28

146

SMS (and radio talk, radio and television talk shows)

Text messaging service information is given on early warning alerts and local assistance numbers

134

15

Spatial decision support system (SDSS)

Interactive system that assists decision making while taking into account spatial dimensions

261,67

 

Spoken Language Translation in the medical domain

Translates spoken language to healthcare providers

141

 

Surveillance Systems

The collection, analysis and interpretation of health data to guide interventions in real time

813,1517,35,36,63,65

 

Website

A group of webpages that are connected to each other and can be accessed through the internet

25,40

 

3D Printing

Low-cost digitally fabricated prosthetics and fabrication laboratories equipped with laser cutters, vinyl cutters, milling machines, 3D printers, and scanners

147

147

Total

47

Technology Used by Humanitarian Actors

Table 2 summarizes the technologies used by humanitarian actors and aid workers, the context in which they have been deployed, their purpose, impact, and at what point in the humanitarian program cycle they have been used (preparedness, response, or recovery).
Table 2

Digital technology used by humanitarian actors, aid workers, and healthcare providers, its purpose, and impact

Type of technology

Name of technology

Organization/Country and context technology deployed

Purpose of technology

HPC stagea

Impact of technology

Digital communication and coordination technologies

Syria Regional Refugee Response29

Governmental Agencies, Academics

NGOs, UN agencies/MENA countries hosting Syrian refugees

Portal where multiple stakeholders can view resources to be able to communicate and share information to improve decision making

Response

Not reported

Google Hangout66

N/A/Japan 2011 earthquake

Response

Not reported

Electronic health records

N/A38

UNRWA/Palestinian refugees in Jordan

Evaluation of chronic disease control interventions by primary healthcare centers

Preparedness Response

Recovery

Not reported

Refugee Assistance

Information system37

UNHCR and partnering humanitarian agencies/Iraqi refugees in Jordan

Monitoring and evaluating the health status of Iraqi refugees registered with UNHCR

Preparedness Response

Recovery

Not reported

Japan’s Health Management

System5

Japan’s National Institute of Public Health/Japan’s post 2011 earthquake

Maintenance of electronic health records in cases of disasters on a cloud-based system

Preparedness and Response

Not reported

Geographical information system

Activity Info18

WASH Mercy Corps UNICEF/Displaced populations in Mali Somalia and DRC

Multiple stakeholders can view resources to be able to communicate and share information to improve decision making

Response

Not reported

Strategic Needs Analysis Project

(SNAP)22

Assessment Capacities Project provides this service to be accessed by NGOs and governmental agencies/Portrays areas of conflict in Syria

Documenting intensity of conflict and number of people in need of aid in Syria and surrounding countries

Response

Not reported

Ushahidi60

Victims of violence and Ushahidi/Natural disasters such as those in Haiti, Chile, and Pakistan

SMS, Twitter, Facebook, and Flicker were used to provide OCHA a live crisis map showing the movement of people, health logistics, and security allowing for communication between agencies. This allowed general population to input data, enabling two-way communication

Response

Not reported

Libya Crisis Map5

OCHA/Crisis in Libya

Response

Rich data was integrated into the United Nations’ (UN) official Who-is-doing-What-Where (3W) aiding coordination.

Led to the launch of the Digital Humanitarians Network

N/A48

Humanitarian agencies/Haiti Earthquake

Response

Not reported

N/A59

Governmental agencies and NGOs/Haiti cholera outbreak

The use of mobile SIM card reports was used for risk assessment of cholera outbreak (by tracking population movements) and notification of those in high-risk zones for disease containment and risk aversion

Response

Estimates of population movements during disasters and outbreaks can be delivered rapidly to organizations and with potentially high validity in areas with high mobile phone use

Humanitarian OpenStreetMap

Team (HOT)25

NGOs/Ebola outbreak in West Africa

Assessment of the risk of Ebola outbreak and notification of those in high-risk zones through portrayal of resources and sharing information between stakeholders

Response

Not reported

N/A26

UNHCR/N/A

Tracking the distribution of aid and incidence of communicable diseases

Response

Not reported

N/A24

NGOs/Japan 2011 earthquake

Directed supplies according to the demands of communities affected by the 2011 earthquake. Supplies were matched with needs via website

Response

Not reported

HumanNav5

World Food Program and

International Federation of Red Cross (IFRC)

UNHCR/N/A

Evaluation of security and road safety of delivery routes and the effectiveness of vehicles

Response

Not reported

N/A9

Academics/2004 Tsunami in Aceh

Conducting vulnerability models and spatial decision support systems to create models that help predict the outbreak and spread of diseases

Preparedness and Response

Tsunami mortality rate in Aceh estimated by demographic models was similar to official figures (131,066 and 128063, respectively)

N/A10

N/A/Dadaab refugee camps in Kenya

Risk assessment of cholera outbreaks in order to notify and create models that help predict the outbreak and spread of diseases

Preparedness and Response

Not reported

GIS and type of spatial decision support system (SDSS)

N/A67

Academics/N/A

Decision-making and problem-solving tool to help inform and coordinate where to evacuate crisis victims from the scene of the incident

Preparedness

Not reported

Hand-held devices and data entry

Support to Life18

Support to Life/displaced and refugee populations in

Turkey, Pakistan, and Georgia

Social workers identify and input data of individuals displaced due to disasters to generate a photo identification card with a barcode to assess and monitor food security and mortality rates

Response

Not reported

Last Mile Mobile Solutions49

UNICEF/Displaced populations in Iraq

Response

IOM’s Displacement Tracking and Monitoring (DTM) unit conducted registrations covering 3,587 households representing 14,448 individuals in UN House and 4,314 households representing 14,520 individuals in Tomping, South Sudan

Biometric Technology20

International Organization for Migration/Displaced populations following disaster South Sudan

Response

The aggregation of data from SMART surveys allowed for the evaluation of mortality and nutrition indicators from conflict affected lands

Digital surveying using Computer Assisted Personal Interview (CAPI)21

Oxfam/Post Typhoon in Philippines and in Thailand

Responses can be recorded during interviews on hand-held devices with the aim to achieve food security and sustainable income

Response

Timely and accurate data entry, which allowed for efficient data monitoring as well as tracing accountability while maintaining data security.

Potential for coding errors, heightened security risks for data collectors, weather challenges, and inequalities in technological literacy

N/A: Survey on handheld devices64

Academics/Tsunami in southern Thailand

Risk assessment to compare the preparedness behaviors of households with and without special-needs members

Preparedness

Loss of livelihood was significantly associated with 3 mental health outcomes: post-traumatic stress disorder, anxiety, and depression.

After the 9-month follow-up survey, prevalence rates of symptoms of post-traumatic stress disorder, anxiety, and depression among displaced persons decreased.

Timely and accurate data entry, efficient data monitoring, traced accountability, maintained data security

Healthcare provider communication technologies

Website: Ethnomed40

Healthcare providers/Seattle, USA

Familiarizing healthcare providers with the cultural beliefs and health issues of refugee communities to improve quality of care given to refugee populations

Preparedness

Response

Recovery

Not reported

Medical spoken Language

Translation41

British primary healthcare providers/Somalia

Improving communication between healthcare providers and Somalian refugees to improve the quality of care they receive from healthcare providers

Preparedness

Response

Recovery

Not reported

Humanitarian Aid Education technologies:

Youtube5

Healthcare providers in Boston/Syria crisis

Educating doctors in Syria on how to preform lifesaving surgeries

Response

Not reported

SMS, Social Media: MAMA34

Women’s Refugee Commission

Social Media and Development Company/India

Providing humanitarian workers with SMS’s and Facebook posts that aim to train healthcare providers and public health practitioners on care provision during crisis

Response

Not reported

IFRC Website5

IFRC/N/A

Training volunteers on basic courses through the website

Preparedness

Response

Recovery

Not reported

Gaming: MiRTE11

N/A (simulation)

Mixed reality triage and evacuation game developed to train users on how to respond to crises and improve decision making by healthcare providers and humanitarian workers during times of mass evacuation

Preparedness

Evacuation time and redundant visits decreased. However, this was a scenario-based evaluation

Humanitarian aid supporting services

Portable Medical Equipment31

Not mentioned/healthcare providers conduct field work during crises for refugee populations in remote areas

Making health services more accessible during emergencies

Response

Not reported

Cellophone33

Medecins Sans Frontières/N/A

Phone application that runs optical tests to test for tuberculosis by analyzing bodily fluids and to measure blood parameters relevant to HIV patients

Response

Not reported

3D printing47

Refugee Open Ware/Zaatari Camp, Jordan

Making health services more accessible during emergencies by 3D printing umbilical cord clippers

Response

Not reported

Robotics

UN/Aid Necessities Transporters31

 N/A

Improving the delivery of humanitarian aid in hard to access areas

Response

Not reported

Unmanned aerial vehicles30

UNOCHA/Haiti & Philippines after Typhoon Yolanda

Demonstrating the scale of the damage and recovery status; rescue and relief through scanning buildings for survivors and mapping those that could not be located due to rubble with infrared cameras

Response

Not reported

Social Media and Geolocation

N/A14

Philippines Government/Typhoon in Philippines

Compiling and analyzing data regarding the effects of crisis, creating evacuation and emergency response models that help predict the outbreak and spread of diseases

Preparedness

Not reported

N/A: social media and geolocation12

Academics/New York Hurricane Sandy

Preparedness and Response

Not reported

Cholera Surveillance system13

Academics/Refugee camps in Kenya

Risk assessment of cholera outbreak to create models that help predict outbreak and spread of disease. The system understands temporal developments and carries out correlations between outbreaks mentioned in Twitter and official sources

Preparedness and Response

Not reported

Artificial Intelligence for Disaster Response (AIDR)28

Academics/2013 Pakistan Earthquake

Aggregating tweets, filtering them, and presenting them in an easy-to-use manner to improve communication and decision-making between agencies

Response

In the 2013 Pakistan earthquake, AIDR was able to differentiate between informative and noninformative tweets to improve response

CrisisLex27

Academics/Chilean earthquake of 2010

Hurricane Sandy as climate change related events

Aggregating and filtering tweets in order to present them in an easy-to-use manner. Providing a list of terms that can be used when broadcasting during crisis communication between agencies

Response

Not reported

Surveillance systems

Type of Real time Surveillance system65

Houston Department of Health and Human Services/Hurricane Katrina

Collecting information through web-based forms from evacuees seeking health services inside shelters: demographic information, vital signs, chief complaints, disabilities, chronic conditions, past medical and surgical histories, medication history, exposure to substances or toxic materials, clinical laboratory results, follow-ups recorded, discharge notes, and diagnoses, dialysis requirements, and free text entries for any other information

Preparedness

Response

Recovery

The surveillance system was able to detect a number of communicable diseases such as (1) respiratory infections, (2) bloody diarrhea, (3) chicken pox and (4) watery diarrhea. The system also allowed for the monitoring of referrals to healthcare providers

Type of Real time Surveillance system17

Mississippi Department of Health (MDH) and the American Red Cross (ARC)/Mississippi Post Hurricane Katrina

A symptom-based, case reporting method was developed and distributed to shelter staff, which was linked with health professionals by a toll-free telephone service. Hotline staff investigated potential infectious disease outbreaks, provided assistance to shelter staff regarding optimal patient care, and helped facilitate the evaluation of ill evacuees by local medical personnel

Preparedness

Response

Recovery

The system was able to record 8,800 patient encounters. Additionally, outbreaks of psychological and gastrointestinal diseases were detected

N/A15

Center for disease control/Haiti Earthquake

NGO camp clinics voluntarily submitted reports of observed conditions on a daily basis. Improved communication between agencies and decision making

Response

Infrequent and inconsistent reporting between NGOs.

This limited the system as it made it difficult to create meaningful geographic disease trend maps

Internet-based forms16

Academics/Hurricane Katrina, Georgia

Internet-based surveillance forms for evacuation shelters and an internet-based death registry. District epidemiologists, hospital-based physicians, and medical examiners/coroners electronically completed the forms to improve communication between agencies and decision making

Response

As a result of multiple users and multiple clinics submitting forms through the system, both noncommunicable and communicable diseases were detected, and data on mortality were provided

N/A35

Academics/Hurricane Ike, Galveston, and Chambers counties

Health outcome evaluation focusing on mental health by structured telephone interviews assessing immediate effects of Hurricane Ike (damage, loss, displacement).

Response

The data collected enabled the assessment of mental health morbidity after the crisis. Diseases detected included posttraumatic stress disorder, depressive episodes, and generalized anxiety disorder. Furthermore, it allowed the identification of underlying factors such as lack of clean clothing, money, transportation, water, food, and electricity

Phone calls63

Academics/southeastern/Southern Pennsylvania evacuation emergency preparedness for special needs.

Risk Assessment to compare the preparedness behaviors of households with and without special-needs members

Preparedness

Not reported

Fax, e-mail, or telephone36

The Louisiana Department of Health and Hospitals, Office of Public Health (LAOPH)/Louisiana

Monitoring of chronic and nonchronic diseases for risk assessment

Response

Forms submitted were further reviewed, and patients that warranted further investigation were contacted by telephone. 74 % of the patients contacted were then referred for further follow-up by the office of public health

aHumanitarian program cycle.

Humanitarian crisis preparedness

Five initiatives were found that use technologies in preparedness, of which geographical information systems (GIS) has been a major game changer. GIS now underpins risk assessments, vulnerability models, and spatial decision support systems (SDSS) that predict outbreak and spread of diseases.9,10,63,64 Examples include disease surveillance systems that assess disease risk during natural disasters, and emergency preparedness of households with specific health needs.63,64 These systems have been found to enable continuity of care throughout a disaster.63,64

Another important element of preparedness is training. Game-based simulation exercises have been used to improve humanitarian responses and reduce evacuation time [See Table 2; mixed reality triage and evacuation (MiRTE)].11

Humanitarian crisis preparedness and response

Five technologies linked preparedness to response and were used mostly in the context of natural disasters and conflicts. Social media and geolocation technologies inform decision-making and are used by humanitarian personnel to compile and analyze location data to create evacuation and emergency response models.12, 13, 14

Surveillance systems based on social media were used to assess emerging disease risk, such as cholera-related tweets (Twitter) as an indicator of cholera outbreak in refugee camps in Kenya.13 This innovative data compilation method allows a temporal analysis of such data and, when combined with GIS and SDSS, can enable the prediction of disease outbreaks and their mortality quite accurately.9,13 Surveillance of web-based fora allows clinics run by NGOs in camps to submit reports of numbers of cases of disease observed, among vulnerable populations.15 This aids risk assessment that can improve communication between agencies and support decision-making.16,17 Finally, use of cloud-based electronic health records can successfully recover health records in case of disasters and damage to physically held records and local databases (See Table 2; Japan’s Health Management System).5

Humanitarian crisis response

We identified thirty technological initiatives that primarily serve humanitarian responses. Data entry with mobile devices is now widely used to facilitate the registration of displaced individuals, to conduct surveys, identify those in need of assistance, and to capture data on issues such as food security, vaccination rates, and mortality. (See Table 2; Last Mobile Solutions).18, 19, 20 Accurate and timely data entry supported efficient data monitoring and provenance while maintaining data security. Practical challenges, however, include potential for coding errors, heightened security risks for data collection teams, weather challenges, and inequalities in technological literacy.21

Geographic information systems (GIS) are used to portray areas of conflict through the creation of live crisis maps that document the intensity of conflict and identify the number of people in need of assistance. They are used for demand-based responsive supply for displaced populations and to create warnings (See Table 2; Ushahidi).5,22, 23, 24 GIS can also be used to track population movements, to identify those in high-risk zones in cases of disease outbreaks, and to send text messages containing health information that can be sent to those proximal to an outbreak area.10,25 Technologies that combine GIS and social media have made it possible for humanitarian organizations to aggregate posts and broadcast information to public officials or to rescue and relief organizations (See Table 2; Artificial Intelligence for Disaster Response Crisis Lex).18,26, 27, 28, 29

When humanitarian response is initiated, GIS can evaluate the security, road safety, and effectiveness of vehicles, to inform logistics, coordination, and evacuation. In addition, unmanned aerial vehicles have been used to deliver humanitarian aid in hard to access areas and to map survivors (See Table 2; UN Aid necessities transporter).30,31

Digital technologies such as the internet, SMS, and social media are also used to deliver training for healthcare providers during crises.3234 Portable medical devices enable physicians to run tests32,33 (See Table 2; Cellophone) including eye examinations, tests for tuberculosis, and the identification of biomarkers for HIV positive patients.

Preparedness, response, and recovery

Surveillance systems enable information gathering about displaced populations or evacuees.65 Data aggregation and analysis are used to detect communicable diseases, and to support follow-up on damage, loss, mental health diagnoses, and chronic conditions.15, 16, 17,35,36

In addition to the resilience provided by cloud-based electronic health records, they aid the monitoring and evaluation of health status of registered refugees over the longer term, potentially improving continuity of care, especially in protracted crises (See Table 2; Refugee Assistance Information System).37, 38, 39

Technologies intended to overcome language and cultural barriers include websites and spoken language translators to increase communication and familiarize healthcare providers with cultural beliefs of refugee populations (See Table 2; Ethnomed).40,41

Affordable training and education applications can cover all stages of humanitarian programming. The International Federation of the Red Cross, for example, trains its volunteers via an online platform that provides modules and a space for online dialogue and peer review.5

Technology Used by Populations Affected by Humanitarian Crises

Although technological initiatives used by displaced populations do not have direct health objectives, they can have indirect effects on health and its physical, social, and economic determinants (See Figure 2). Table 3 summarizes these technologies, the context in which they have been used, their purpose, impact, and the determinants of health that they address.
Table 3

Digital technology used by displaced populations, its purpose, and impact

Type of Technology

Name of Technology

Organization/Country and Context Technology Deployed

Purpose

Determinant of Health

Impact of Technology

Digital classrooms and digital story telling

Voices beyond walls-digital storytelling42

Voices beyond Walls/Palestinian refugee camps in the West Bank, East Jerusalem, and Jordan

Support for post-traumatic stress disorder

Strengthening peace and reducing community tensions

Education

Social support networks

Healthy child development

Not reported

Ideas Box51

UNHCR and Vodaphone Foundation/Displaced children in Syria, Jordan, Lebanon, Iraq, Turkey, Central African Republic, Sudan, Kenya, and Democratic Republic of Congo

Improving sense of security, inclusion for those who are illiterate. Improved information security and risk prevention from rumors and misinformation

15 % increase in attendance rates in Kenyan schools

Electronic voucher (e-voucher) program

WFP E-voucher program43, 44, 45,50

World Food Programme/Displaced populations in Kenya, Philippines, and Lebanon

Refugees have the liberty of utilizing cash resources for needs such as shelter, food, health (access to antenatal care), pharmaceuticals, water, sanitation, hygiene products, and cash transfers

Income and social status

Health services

Improved financial literacy of refugees.

Improved food security. A significant difference in food consumption was observed where recipients had 78 % increase in food consumption scores versus 49 % in non-recipients. 

Created 1300 jobs and led to 3$ million dollars investments in capital expenditure and increased benefit to Lebanese economy and food products sector.

Creates dependence on vouchers, with potential for exacerbations in the status of beneficiaries in case of disruption of transfers

Support to Life18

Support to Life staff/Displaced population Turkey

Improving living conditions as well as promoting environmental health

Physical environmental

Not reported

Low cost computers

Raspberry Pi18

UNICEF/Syrian Refugees in Lebanon

Computer is preloaded with health content and libraries of health videos to improve health literacy. Provides refugees with solutions for provision of healthcare, protection from violence and abuse, and education on human rights. Aims to teach basic computing skills

Education

Social support networks

Health child development

Not reported

SMS

Trilogy emergency relief application and community outreach program (TERA)5

IFRC/The 2010 Haiti earthquake and the 2004 Indian Ocean tsunami

Inquiries received are forwarded and shared with community members and used to create interactive live radio and television programs with the aim of improving coordination and risk communication during natural disasters to save lives and property

Physical environment

Social support network

Not reported

Social media

Facebook/Twitter46

UNHCR/Syrian Zaatari camp in Jordan

The accounts are information hubs for camp residents such as schedules for distribution of aid, available job opportunities, and access to services, weather forecast warnings and preparedness, with the aim of improving communication, advocacy, and health promotion

Employment

Access to health services

Not reported

3D printing

Refugee open warefare47

Refugee Open Ware/Residents of Zaatari camp in Jordan

Refugees who have suffered injuries in wars are trained to use 3D printing labs to learn how to print prosthetic body parts. Empowers refugees to be involved in the process of creating solutions to the problems they deem to be important

Health services

Personal health practices and coping skills

Biology and genetic endowment

Not reported

Education, social support networks, and healthy child development

Low-cost computers and digital classrooms have increased access to education (including health education) for affected populations in low resource settings. Information portals with preloaded content enhance access to information that addresses human rights, protection from violence and abuse, and computing skills (See Table 3; ideas box).18 By learning collectively through creative media expression and by supporting those who are illiterate, technologies such as digital storytelling provide children with a sense of social inclusion and community interaction to promote mental health, well-being, and healthy child development (See Table 3; Voices Beyond Walls).42 Feedback from users of such programs suggests the use of simpler activities prior to complex forms of expression. This might mean role-play, dance/movement, and story boarding around topics not tied to struggles of displacement.42

Use of SMS during natural disasters can facilitate social support networks. To save lives and property, one initiative received inquiries through SMS and created interactive live radio and television programs for risk coordination and communication (See Table 3; TERA).5

Improving income, social status, access to health services, and the physical environment

In emergencies, electronic voucher programs have played a pivotal role and gained recognition as a dignified form of humanitarian assistance that gives affected populations the liberty to use cash for what they deem important (i.e. food, shelter, health, pharmaceuticals, water, sanitation), thereby improving income, social status, and access to health services (See Table 3; WFP’s e-voucher program).43,44,50 E-voucher programs have also been used to remunerate those who have helped clear municipal waste from public areas after natural disasters, thus improving living conditions as well as promoting environmental health.43,45

Social media platforms such as Facebook and Twitter pages for refugee camps allow information sharing among camp residents (See Table 3; Zaatari camp Facebook page).46 These platforms have been used for information dissemination about services provided in camps (including health), scheduling of aid distribution, advertising available job opportunities, and for weather forecast warnings.46

Personal health practices and coping skills

Thus far, the technologies mentioned have been integrated in marginalized populations with outcomes indirectly impacting health. Whereas personal fabrication technologies have the potential to empower those who have been injured in conflicts, perhaps to 3D print their own prosthetic body parts (See Table 3; Refugee Open Ware).47

Discussion

Although many digital technologies do not have direct health objectives, they may have indirect effects on health and its physical, social, and economic determinants. For technologies used by humanitarian actors, our framework categorizes initiatives by the stage in the humanitarian program cycle. We recognize that this limited view of humanitarian action may not apply in protracted emergencies where the lines between preparedness, response, and recovery are blurred. Phases overlap, sometimes for decades, such as is the situation in many long-term crises.

Our results highlight the fact that digital technologies facilitate communication, coordination, and the collection and analysis of large amounts of data, enabling timely responses in humanitarian contexts, particularly sudden-onset disasters. The impacts of these technologies most often include their ability to: assess risk and identify the number and location of people with specific health needs, including health services and assistance; to maintain health records; and to enable follow-up, continuity, and improve quality of care. They have also provided a platform for the remote training of healthcare professionals and humanitarians, particularly in hard to reach locations, plus facilitated the coordination and logistics of humanitarian assistance with implications for the determinants of health.

The rise of internet activism around issues of social justice, human rights, education, health equity, and sustainable environments are likely to continue to raise awareness, and pave the way for social change and for health promotion for affected populations.

Our attempt to examine the impact of these technologies on the health and well-being of crisis-affected populations has, however, been hampered by the lack of impact assessment in the design and use of these technologies. Here we identify several gaps and concerns with current digital humanitarian practices:

Lack of evaluation

While surveillance systems have been routinely evaluated, including their impact on health outcomes, very few evaluations exist of other uses of digital technologies in humanitarian contexts. Although many technologies promise social change, evaluation models have not been integrated in humanitarian intervention technologies and remain underdeveloped.46 Most other technologies discuss purpose and lessons learned with no other evaluative framework.48 Specified criteria for assessment were often described, but for many technologies, we found neither methodologies nor evaluation reports.18,4951,63 Where methods were described, deficiencies included shortcomings in the reporting of denominators and response rates.15,63 The elusive nature of displaced populations as well as uncertainty and unpredictability of events may be underlying reasons discouraging investments in evaluation.5,43,46 Rigorous monitoring and evaluation should, however, be conducted to inform funding priorities, and enhance learning for the design of future digital initiatives, as well as to provide an understanding of pathways by which these initiatives can improve health. Process, impact, and outcome indicators would need to be integrated at all levels of design.

Our review of web-based technologies for health promotion suggests that given the complex settings in which health technologies are deployed and disseminated, evaluations of health outcomes and impacts may be very difficult.52 Humanitarian health innovations, however, might adopt action-oriented research frameworks that integrate evaluation of the design, development, and deployment processes. Health promotion research models such as the Spiral Technology Action Research and the e-Technology Participatory Action Research, emphasize the importance of engaging and working with user communities to identify and clarify the goals of the technology and of reporting back to inform its design iteratively.53,54

A paternalistic approach

Most technologies cited in this review are tailored to meet the needs and functions of humanitarian organizations; to be top-down paternalistic innovations. Within this approach, there is an inherent assumption that humanitarian actors collect data to understand populations’ needs, without explicit involvement of the target population.55,56 Big datasets, however, do not necessarily lead to improved response, particularly if data management and analysis capacities are insufficient.56

Even when technologies are intended to be used by affected populations (See Table 3), involvement is often superficial. It usually takes place in the data collection phase, not in data analysis and interpretation. We only found one initiative47 that included the affected population in the design process. Data were rarely made available as a resource for the affected communities themselves. Even with more inclusive design processes, a balance must be struck between designers creating products in a paternalistic manner and the use of potentially invasive participatory design methods which may overburden communities in the process.57 Technology designers need to gain a deeper understanding of the population’s context, health beliefs, and use of technology. Over-reliance on technology raises resilience challenges. Will health be detrimentally affected instead of improved?55 Despite pressure to introduce and experiment with new technologies, these should be balanced with alternatives for action.

Issues of privacy and equity

As technology continues to facilitate the work of organizations that respond to humanitarian crises, issues of privacy and equity need attention. People caught in humanitarian crises fear having their personal information leaked or their location identified. They raise questions about privacy and fears of being tracked.43 Data security and privacy should engender trust of the affected communities, to protect the vulnerable and ensure their rights to assistance.56

The political blockade of information, such as internet censorship and surveillance, as well as intermittent or nonexistent access to internet and mobile data connections can hinder technologies and information dissemination.46 Unequal access to technology therefore remains a key challenge. Socioeconomic, age, and gender gaps in technology use and access are well known.5 They further magnify disparities in access to information relevant to health.5

Similarly, inequities at national levels, where local organizations and governments in low-income countries face challenges in accessing financial, human, and technological resources, reinforce unequal power relations.5 Crowdsourcing might redress this imbalance, by diffusing knowledge ownership beyond humanitarian actors. Where government disaster responses have led to the rise of new decentralized crisis mapping platforms, this may be the foundation for greater community participation in humanitarian action.56,58

Recommendations and conclusions

Rigorous evaluation of digital technologies in humanitarian crises must be integrated into design and deployment, to strengthen the evidence base for decision-making, including their impacts on health. Increased awareness of the criticisms and potential risks of digital technology use in humanitarian contexts is needed to ensure that technology is used responsibly.

Future work must strive to create a space for dialogue between technology designers and the populations affected by humanitarian crises to achieve increasing relevance and sustainability of innovations.62 Care should be taken to ensure that participation is not just a token. Indeed, the culture of technology use by affected populations is on the rise. In many cases, the affected populations are the innovators. They should be supported as they adapt and appropriate digital technologies to their own needs.

Supplementary material

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Supplementary material 1 (DOCX 13 kb)

Copyright information

© Macmillan Publishers Ltd 2016

Authors and Affiliations

  • Sandra Mesmar
    • 1
  • Reem Talhouk
    • 2
  • Chaza Akik
    • 1
  • Patrick Olivier
    • 2
  • Imad H. Elhajj
    • 3
  • Shady Elbassuoni
    • 4
  • Sarah Armoush
    • 5
  • Joumana Kalot
    • 5
  • Madeline Balaam
    • 2
  • Aline Germani
    • 5
  • Hala Ghattas
    • 1
  1. 1.Center for Research on Population and Health, Faculty of Health SciencesAmerican University of BeirutBeirutLebanon
  2. 2.Open LabNewcastle UniversityNewcastle upon TyneUK
  3. 3.Department of Computer and Communications Engineering, Faculty of Engineering and ArchitectureAmerican University of BeirutBeirutLebanon
  4. 4.Department of Computer Science, Faculty of Arts and SciencesAmerican University of BeirutBeirutLebanon
  5. 5.Center for Public Health Practice, Faculty of Health SciencesAmerican University of BeirutBeirutLebanon

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