persistent boundaries (or why we should be aware of our assumptions in ict4d)

OXFORD DEPARTMENT OF INTERNATIONAL DEVELOPMENT

Persistent Boundaries

(Or why we should be aware of our assumptions in ICT4D)

Breaking Boundaries: ICT for DevelopmentDepartment of Education

Marco HaenssgenOxford Department of Int‘l Development

13 March 2014

Phone use and rural health in India and China

BACKGROUND

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BackgroundCommon Assumptions About End-User Oriented mHealth

Academics and professionals hope to revolutionise healthcare access through mobile health technology.

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Health information

technologies (HIT), which include

computers, mobile devices, […], have

great potential to promote health and

support healthcare around the world.

(Chan & Kaufman, 2010:300)

“Text messaging demonstrates strong potential as a tool for

health care improvement.” (Cole-Lewis & Kershaw, 2010:3)

“The future of e-health lies in mobile and ubiquitous

computing.” (Kwankam et al., 2009:275)“will have a tremendous impact on emerging

markets by enabling emergency services to reach

end consumers at the right time.” (Manjunath et al.,

2011:4)

“offers a

tremendous

opportunity for

developing countries

and communities to

advance and […] to

save scarce resources

by making health

systems more

efficient. (Qiang et

al., 2012:15)

“mHealth has the potential to transform the

face of health service delivery across the

globe.” (WHO, 2011)

“Harnessing

this technology for

improving the health of

populations would be a step

in the right direction.” (Krishna

et al., 2009, p.

239)

“the shortage of health

workers in rural areas, the

variable quality of care, lack

of patient compliance, and

fraud, will potentially be

mitigated through the

wide deployment of ICT.”

(Lewis et al., 2012, p. 337)

“The developing world stands to massively benefit from the technological advances that have been

made in recent years” (Dimagi, 2013)


BackgroundCommon Assumptions About End-User Oriented mHealth

mHelath proponents’ narratives often (over-)emphasises the potential of technology to revolutionise healthcare.

Technology excites (as it excites us)

(Almost) universal phone ownership

Sharing and lending where there are no phones

The underlying technological platform is neutral

People have a demand for mobile health services

They will have a positive effect on people’s access to healthcare

Inequities between urban and rural areas will decrease

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Euromonitor International (2012, 2013)


EVIDENCE

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EvidenceSample characteristics

Qualitative data has been gathered from a high-variance sample in rural Rajasthan and Gansu.

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Adapted from Google Inc. (2014)


EvidenceOwnership

Phone ownership is widespread, but penetration is larger in China, especially among older population. Smartphones are rare.

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50

40

30

20

10

0

10

20

30

40

50

18-24 25-39 40-54 55+ Male Female

No.

of R

espo

nden

ts (V

illag

e Re

side

nts)

Phone Ownership Among Respondents, by Age Group and Gender

Phone No Phone Age Group Gender

Indi

a (n

=89)

Chin

a(n

=89)


EvidenceUse

Mobile phone use is highly variable in rural Rajasthan and Gansu.

Dominant use of voice communication

Usability limitations especially from middle-aged upwards

Active vs. passive use

Lending restricted to important purposes

Learning (teaching) restricted to fundamental functions

Phone use can be beneficial as well as detrimental

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EvidenceUse

Illustrations from the field: Use of phone features

Which mobile phone functions do you use?

I don’t know any. I just press the “OK” button to receive calls, but I can’t dial numbers. So whenever I want to a make call, my son helps me. Whatever text messages I receive, they are all invisible for me because I don’t know about them and I never see them.

(woman aged 45, phone owner, in Rajasthani village)

[Woman] Generally, I take and make calls, and SMS sometimes. The people whom I contact are relatives and children, to convey holidays greetings or to say hello sometimes. I can’t use other functions of the phone. I do use the phonebook, but not the pictures, I can’t use that. I also can’t use the camera. [Man] I can’t use phones with more functions – the fewer functions, the better.

(married couple, woman aged 42 and man aged 45, phone owners, in Gansu village)

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EvidenceUse

Illustrations from the field: Sharing, but limited use of phone features

Have you ever used the phone of your sons?

[…] We don’t know how to use the mobile, we only know that when someone calls, we put phone near the ear so the sound comes from other side. We can listen to it and when we say something, the other side can listen as well to the sound [of our voice]. We all know how to receive phone calls, this has been taught to us by our sons. They said to receive phone calls, there is a green button on the right side [of the phone keyboard], so when phone rings, we have to press it.

Do you feel comfortable when using the phone?

[…] I am afraid to use the phone, so I only take it when it’s needed, and [afterwards] immediately hand it over to my son – if I accidentally press the wrong button, I will cause money loss.

(focus group, older men aged 55 and 60, non-owners, in Rajasthani village)

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EvidenceUse

Illustrations from the field: Limits to teaching

Have you ever taught your parents how to use the mobile phone?

Yes, we taught them how to make and receive calls, how to send text messages.

Do your parents understand these basic feature at the first attempt?

No, we have to teach them 5-6 times.

Are they were confident after they learned these features, or do they still feel hesitant

to operate their phones?

No, they are usually scared of wasted balance, which is why they don't use the

phone unnecessarily.

(3 young male respondents aged 18, 20, 22 in Rajasthani village, owners)

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EvidenceHealthcare seeking

If people are able to access and use the mobile phone, it can become part of their strategies to navigate the healthcare system.

Phones enter healthcare seeking where feasible and deemed necessary Access Assistance Appointments Assurance Advice

But facilitation does not follow automatically Elderly people Restricted social networks Savvy vs. basic use

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Illustrations from the field: Facilitating healthcare access

Which kind of emergency happened did you encounter and how did you use the mobile phone?

Recently my father and I had an accident but we couldn’t make a call because our phone didn’t have reception. So we received help from another person to call the ambulance and finally we could reach the hospital. There we could call to our home and inform our family about the accident.

When you go to the hospital, do you call there first?

First I give a call to the doctor and ask whether he is available or not.

(man aged 22, owner, in Rajasthani village close to town)

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Illustrations from the field: Facilitating healthcare access (non-owner)

How do you make calls in emergencies?

I call from my neighbours’ mobile phone.

[…] Did you get ill recently, and what did you do then?

Last Diwali, I suffered from a very bad fever. I called my mother so that she would take me to the hospital.

Did the mobile phone play role in this process?

Yes, it made this easy. If I didn’t have the phone, then definitely I would have had to take help from my neighbours.

How far do your parents live from here?

2-3 hours from here by bus.(woman aged 28, non-owner, in Rajasthani village)

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Illustrations from the field: No facilitating role of the phone

Who takes care of you when you are ill?

Myself. And I wouldn’t go to hospital. I have some common medicines at home or I get some from the pharmacy in [the district capital of] Huining. We have 2 buses to Huining in the morning, going back in the afternoon. It takes 1 hour to Huining and costs 12 yuan [GBP 1.30]. If it’s a common cold, I take some drugs that help, I do not go to the hospital.

(woman aged 51, phone owner, in Gansu village)

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Illustrations from the field: Summoning assistance

How long does it normally take you to go to village hospital?

40 minutes if you walk there. Or you can call the village doctor to come here, he can come here by motorcycle in 20 minutes. […] He comes here almost everyday, and he comes to whoever calls him […]. Almost all people have the village doctor's phone number.

Are there people who do not have the number, who would go to the neighbours and ask for the number or borrow their phones?

Yes, our neighbour who caught by cold came over to borrow mine. They did not have the number of village doctor, and I dialled the number for them on my phone, and the doctor came here after calling. These visits generally does not raise the fees, they wouldn’t ask for the visiting fee, and only charge for the drugs and diagnosis.

(man aged 50, phone owner, in Gansu village)

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CONCLUSION

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ConclusionRevisiting the assumptions

Assumptions of common mHealth narratives are easily violated.

Ownership not a good proxy for use

Use not determined by devices – reliance on voice

People not necessarily keen learners / teachers

Sharing only for important purposes and within limited networks

People are creative and active problem solvers

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ConclusionImplications for the design of mhealth applications

The violation of common mHealth assumptions (ubiquity, easy sharing, enthusiastic and curious users, passive recipients, inevitable positive impacts) can have implications for design and deployment.

Mhealth may:

be rendered ineffective by digital exclusion and passive use

compete with local coping strategies

potentially aggravate inequitable healthcare access

suffer from insufficient demand and technological learning

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ConclusionImplications for the design of mhealth applications

But there is a case for mhealth in rural, resource constrained areas. This can involve, for example,

India Snake bite responses “Household health activists”

China Medication information and order-placement Elderly as target recipients

Both Real-time information about health staff availability One-button emergency call-back

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ConclusionSummary

Need to understand technology users and their coping strategies before developing mHealth solutions

mHealth can break boundaries, but not every problem should be solved with ICT first

Under flawed assumptions, mHealth may add little or even increase inequities

Deployment of services requires (intensive and continuing) training of users

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ConclusionEmerging questions

Besides the research questions posed here, promising avenues of future research are emerging.

Who will be the winners of the upcoming “upscale battle”?

Who gains most from the mHealth hype?

How can we integrate new solutions into existing systems while avoiding patchwork?

Are similar trends likely for other sectors of mobile service delivery, e.g. mobile education and mobile money?

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Thank you.

Questions?

[email protected]

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