Malala Yousafzi rightly said, “we cannot all succeed when half of us are held back.” She was talking about women and girls.

The Middle East and North Africa (MENA) exhibits a gender divide in both digital technology access and use, and in health, with implications for digital health, despite its potential to expand the reach of health services and information to marginalized and vulnerable groups[1].

This gender divide is rooted in cultural norms, gender roles, biases, traditions as well as differences in power dynamics between men and women. In fact, data shows that the percentage of women making decisions about their own health does not exceed 40%[2]. The gender gap is also shown in women’s access to mobile internet, with 83% of women in MENA having access to mobile internet compared to more than 20 million remaining completely disconnected.

The MENA region ranks third lowest in terms of women’s access to the internet[3]. These gaps threaten the global agenda of ‘leaving no one behind’ and the achievement of the Sustainable Development Goals (SDGs)[4].

To address this gap, two multi-component digital health interventions in Lebanon and Jordan provide early lessons and a call to action to ensure that women are not left behind by digital health interventions intended to help them.  Lebanon and Jordan host the highest number of Syrian refugees who fled the Syrian civil war in MENA[5], the majority of which were women and children[6]. The refugees reside primarily in underserved areas and fragile settings, overstretching the health system of both countries.

Digital to decentralize knowledge and power to women

“More pregnant women visiting our primary healthcare center are now asking about the antenatal care (ANC) services and tests they can access,” said one of the midwives enrolled in the Gamification, Artificial Intelligence and Health Network for Maternal Health Improvement (GAIN MHI).

GAIN MHI is an interventional research project led by the Global Health Institute at the American University of Beirut, aiming to improve maternal health by enhancing the uptake of ANC services among disadvantaged and refugee women in Lebanon.

GAIN MHI employs a context-specific digital health intervention. It is composed of gestational-age specific educational and awareness messages in Arabic, sent by text and voice message over WhatsApp to women and their spouses. The intervention is complemented by a professional development mobile app that uses gamification and artificial intelligence to tailor capacity strengthening for midwives and obstetricians.

Strengthening voices and choices for family planning 

One client attending primary care in Jordan explained, “I live 30 minutes away from the health center and it takes me time to find a taxi or bus and costs me at least 3 Jordanian dinars. It would be great to obtain FP-related information through an application or a website while I am home, not worrying about leaving my children home alone”.

Through a participatory approach and guided by formative research[7],[8], we developed a digital health intervention to promote contraceptive use and access to family planning services among disadvantaged communities in Lebanon and Jordan.

The intervention consists of a mobile application and website (https://m-ayla.org/) that provides evidence-based and culturally adapted information in local language on contraceptive choices and methods. It also provides support for continued use of contraception through follow-up messages and reminders. The intervention is complemented by training packages on effective couples counselling for midwives and doctors.

Ensuring that no woman is left behind: lessons learnt for the development of gender-sensitive digital health interventions

The implementation of these interventions has provided learnings on gender dynamics. To overcome the challenges encountered in these projects, it is recommended that initiatives:

  1. Conduct gender analysis at the beginning and end of all digital health interventions meant to benefit women. Consider multiple vulnerabilities and intersectionality of gender, refugees, socio-economic status, etc.
  2. Develop and design digital health interventions (technology and content) targeting women through participatory design with a focus on gender and cultural sensitivity and reducing the gender divide, accounting for social determinants of health, including education and literacy levels, etc.
  3. Raise awareness among both women and men on the importance of empowering women to make informed decisions related to their own health for their benefit and the benefit of their husbands and children
  4. Consider the risks and develop gendered mitigation strategies for external factors (e.g., COVID-19, economic crises, etc.)

Finally, Nawal Al-Saadawi, a leading Egyptian feminist, writer, activist, and doctor said, “women are half the society. You cannot have a revolution without women. You cannot have democracy without women. You cannot have equality without women. You can’t have anything without women.”

Therefore, we will not have equity in digital health if we do not place women at the core of all digital health interventions – at a minimum those interventions that are meant to benefit their health.

[1]Mehl, G., & Labrique, A. (2014). Prioritizing integrated mHealth strategies for universal health coverage. Science, 345(6202), 1284-1287.

[2]UNICEF (2021). Situational Analysis of Women and Girls in the MENA and Arab States Region: Pillar 1 Health and Wellbeing Key Messages and Recommendations.

[3]GSMA (2021). The Mobile Gender Gap Report 2021

[4]Sinha, C., & Schryer-Roy, A. M. (2018). Digital health, gender and health equity: invisible imperatives. Journal of Public Health, 40(suppl_2), ii1-ii5.

[5]UNHCR (2022). Operational Data Portal Refugee Situation.

[6]Ibid.

[7]Al-Sheyab, N. A., Al Nsour, M., Khader, Y. S., Yousif, H., Alyahya, M. S., Taha, H., … & Amiri, M. (2021). Midwives and women’s perspectives on family planning in Jordan: human rights, gender equity, decision-making and power dynamics. Heliyon, 7(8), e07810.

[8]Yousef, H., Al-Sheyab, N., Al Nsour, M., Khader, Y., Al Kattan, M., Bardus, M., … & Amiri, M. (2021). Perceptions Toward the Use of Digital Technology for Enhancing Family Planning Services: Focus Group Discussion With Beneficiaries and Key Informative Interview With Midwives. Journal of Medical Internet Research, 23(7), e25947.