Persistent Boundaries (Or why we should be aware of our assumptions in ICT4D)
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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
3 February 2014Page 2
Phone use and rural health in India and China
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)
Phone use and rural health in India and China
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)
Phone use and rural health in India and China
EVIDENCE
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Phone use and rural health in India and China
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)
Phone use and rural health in India and China
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)
Phone use and rural health in India and China
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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Phone use and rural health in India and China
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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Phone use and rural health in India and China
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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Phone use and rural health in India and China
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)
3 February 2014Page 11
Phone use and rural health in India and China
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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Phone use and rural health in India and China
EvidenceHealthcare seeking
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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Phone use and rural health in India and China
EvidenceHealthcare seeking
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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Phone use and rural health in India and China
EvidenceHealthcare seeking
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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Phone use and rural health in India and China
EvidenceHealthcare seeking
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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Phone use and rural health in India and China
CONCLUSION
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Phone use and rural health in India and China
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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Phone use and rural health in India and China
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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Phone use and rural health in India and China
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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Phone use and rural health in India and China
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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Phone use and rural health in India and China
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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Phone use and rural health in India and China
Thank you.
Questions?
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