OXFORD DEPARTMENT OF
INTERNATIONAL DEVELOPMENT
Persistent Boundaries
(Or why we should
be aware of our
assumptions in ICT4...
BACKGROUND
3 February 2014Phone use and
rural health in
India and China
Page 2
Background
Common Assumptions About End-User Oriented mHealth
Academics and professionals hope to revolutionise healthcare...
Background
Common Assumptions About End-User Oriented mHealth
mHelath proponents’ narratives often (over-)emphasises the p...
EVIDENCE
3 February 2014Phone use and
rural health in
India and China
Page 5
Evidence
Sample characteristics
Qualitative data has been gathered from a high-
variance sample in rural Rajasthan and Gan...
Evidence
Ownership
Phone ownership is widespread, but penetration is larger in
China, especially among older population. S...
Evidence
Use
Mobile phone use is highly variable in rural Rajasthan and Gansu.
 Dominant use of voice communication
 Usa...
Evidence
Use
Illustrations from the field: Use of phone features
Which mobile phone functions do you use?
I don’t know any...
Evidence
Use
Illustrations from the field: Sharing, but limited use of phone features
Have you ever used the phone of your...
Evidence
Use
Illustrations from the field: Limits to teaching
Have you ever taught your parents how to use the mobile phon...
Evidence
Healthcare seeking
If people are able to access and use the mobile phone, it can become
part of their strategies ...
Evidence
Healthcare seeking
Illustrations from the field: Facilitating healthcare access
Which kind of emergency happened ...
Evidence
Healthcare seeking
Illustrations from the field: Facilitating healthcare access (non-owner)
How do you make calls...
Evidence
Healthcare seeking
Illustrations from the field: No facilitating role of the phone
Who takes care of you when you...
Evidence
Healthcare seeking
Illustrations from the field: Summoning assistance
How long does it normally take you to go to...
CONCLUSION
3 February 2014Phone use and
rural health in
India and China
Page 17
Conclusion
Revisiting the assumptions
Assumptions of common mHealth narratives are easily violated.
 Ownership not a good...
Conclusion
Implications for the design of mhealth applications
The violation of common mHealth assumptions (ubiquity, easy...
Conclusion
Implications for the design of mhealth applications
But there is a case for mhealth in rural, resource constrai...
Conclusion
Summary
Need to understand technology users and their coping strategies
before developing mHealth solutions
mHe...
Conclusion
Emerging questions
Besides the research questions posed here, promising avenues of
future research are emerging...
Thank you.
Questions?
marco.haenssgen@hertford.ox.ac.uk
3 February 2014Phone use and
rural health in
India and China
Page ...
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Persistent Boundaries (Or why we should be aware of our assumptions in ICT4D)

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Marco’s presentation will shift the focus from health workers to the potential recipients of mobile-phone-based health services. Focusing on upstream elements of mHealth, Marco will explore patterns of mobile phone use and healthcare-seeking behaviour, drawing on fieldwork insights from rural India (Rajasthan) and China (Gansu). The evidence suggests that common assumptions of mHealth proponents are easily violated; that is, mobile phone ownership is not ubiquitous and does not necessarily reflect mobile phone use, people do not necessarily share mobile phones freely amongst each other, they are not necessarily keen and excited technological learners, and they do develop mobile phone-aided coping strategies that may compete with mhealth. While both contexts offer, at least in theory, the potential for mobile technology to break boundaries, the presentation will emphasise the importance of understanding upstream factors of mHealth before deploying technological solutions in order to provide effective solutions and to avoid the potential exacerbation of healthcare inequities.

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  • According to my latest count, there have been 950 active mhealth projects worldwide, some countries having more than 30 initiatives. There is a lot of excitement around mhealth, and here are just some examples of the common narrative. According to the various authors and organisations here, mhealth is basically going to revolutionise global healthcare, and all we need to do is to harness the technology that is already at our fingertips, because the infrastructure for mobile-phone-based service delivery is already there. Compelling argument, or is it not?
  • So let me just tell you very briefly how I have been trying to tackle these research questions.
  • In total I visited 15 sites for my interviews within Udaipur and Rajsamand district. Among the interviewees, the majority were phone users, which reflects larger trends of phone ownership in this state. Overall, 70% of the respondents owned a phone, but I think there were only one or two who didn’t have a single phone in their households.
  • Ownership – clearly not ubiquitous, so some blind spots, but generally high (all that shouldn’t surprise us, but this isn’t the indicator we rely on, anyway)Implications of acquisition patterns – some gifted, some bought for work, some handed over because no use, some because liking phonesPopulation groups remain excluded from phone useElderly’s use in Rajasthan more limited than in GansuPhone design can mitigate (though not overcome) exclusionLandline users in China
  • Rajasthan: ARPU < 100; 75 / 5 / 20 (Voice / Text / Data)Gansu: ARPU < RMB 50; 90 / 4 / 6
  • All of these 5 As have slightly different determinants (e.g. the channels of communication, the ability to be used within lending arrangements) and come in as a function of technological
  • My point here is not that the nobody uses phones or that mhealth is worthless, but I mean to stress the diversity of people and to stimulate thinking about those that should be the main target group of mhealth, namely people in poor health and poor health access conditions
  • So I would advise to first look at these elements and only then decide whether and how an mhealth intervention can add value
  • Persistent Boundaries (Or why we should be aware of our assumptions in ICT4D)

    1. 1. OXFORD DEPARTMENT OF INTERNATIONAL DEVELOPMENT Persistent Boundaries (Or why we should be aware of our assumptions in ICT4D) Breaking Boundaries: ICT for Development Department of Education Marco Haenssgen Oxford Department of Int„l Development 13 March 2014
    2. 2. BACKGROUND 3 February 2014Phone use and rural health in India and China Page 2
    3. 3. Background Common Assumptions About End-User Oriented mHealth Academics and professionals hope to revolutionise healthcare access through mobile health technology. 3 February 2014Phone use and rural health in India and China Page 3 “Text messaging demonstrates strong potential as a tool for health care improvement.” (Cole-Lewis & Kershaw, 2010:3)
    4. 4. Background Common 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 3 February 2014Phone use and rural health in India and China Page 4 Euromonitor International (2012, 2013)
    5. 5. EVIDENCE 3 February 2014Phone use and rural health in India and China Page 5
    6. 6. Evidence Sample characteristics Qualitative data has been gathered from a high- variance sample in rural Rajasthan and Gansu. 3 February 2014Phone use and rural health in India and China Page 6 Adapted from Google Inc. (2014)
    7. 7. Evidence Ownership Phone ownership is widespread, but penetration is larger in China, especially among older population. Smartphones are rare. 3 February 2014Phone use and rural health in India and China Page 7 50 40 30 20 10 0 10 20 30 40 50 18-24 25-39 40-54 55+ Male Female No.ofRespondents(VillageResidents) Phone Ownership Among Respondents, by Age Group and Gender Phone No Phone Age Group Gender India(n=89)China(n=89)
    8. 8. Evidence Use 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 3 February 2014Phone use and rural health in India and China Page 8
    9. 9. Evidence Use 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) 3 February 2014Phone use and rural health in India and China Page 9
    10. 10. Evidence Use 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) 3 February 2014Phone use and rural health in India and China Page 10
    11. 11. Evidence Use 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 2014Phone use and rural health in India and China Page 11
    12. 12. Evidence Healthcare 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 3 February 2014Phone use and rural health in India and China Page 12
    13. 13. Evidence Healthcare 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) 3 February 2014Phone use and rural health in India and China Page 13
    14. 14. Evidence Healthcare 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) 3 February 2014Phone use and rural health in India and China Page 14
    15. 15. Evidence Healthcare 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) 3 February 2014Phone use and rural health in India and China Page 15
    16. 16. Evidence Healthcare 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) 3 February 2014Phone use and rural health in India and China Page 16
    17. 17. CONCLUSION 3 February 2014Phone use and rural health in India and China Page 17
    18. 18. Conclusion Revisiting 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 3 February 2014Phone use and rural health in India and China Page 18
    19. 19. Conclusion Implications 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 3 February 2014Phone use and rural health in India and China Page 19
    20. 20. Conclusion Implications 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 3 February 2014Phone use and rural health in India and China Page 20
    21. 21. Conclusion Summary 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 3 February 2014Phone use and rural health in India and China Page 21
    22. 22. Conclusion Emerging 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? 3 February 2014Phone use and rural health in India and China Page 22
    23. 23. Thank you. Questions? marco.haenssgen@hertford.ox.ac.uk 3 February 2014Phone use and rural health in India and China Page 23

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