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DOI: 10.4018/JCIT.2020100103
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
Copyright©2020,IGIGlobal.Copyingordistributinginprintorelect
ronicformswithoutwrittenpermissionofIGIGlobalisprohibited.
44
Building a Critical Mass of Users for
Digital Healthcare Promotion Programs:
A Teaching Case
Rennie Naidoo, University of Pretoria, South Africa
https://orcid.org/0000-0001-8392-1136
ABSTRACT
Despiterecenttechnologicaladvancements,theslowadoptionpatter
nofdigitalhealthcarepromotion
programscontinuestobeamajorproblemplaguingmanyhealthcareor
ganizationstoday.Thehistorical
teachingcasestudyisindispensableinimprovingourunderstandingo
fthecomplexandmultifaceted
natureofcontemporarydigitalhealthcarepromotionprograms.Thish
istoricalteachingcasepresents
informationaboute-health,thee-
commerceunitofalargemultinationalhealthcareinsurancecompany
.
Theteachingcaseshowshowdespitee-
health’sabilitytopersuadealargeregisteredbaseofusersto
trialitshealthcarepromotionprograms,over90%oftheseregistrants
discontinueduseafterashort
trialperiodofusingthetechnology.Thishistoricalteachingcasefocus
esonthesocialchallenges
involved inpersuadingusers to adopt and continueusing e-
health’smajor healthcarepromotion
innovation:anonlinenutritioncenter.Despiteextensivepromotions
andtheuseofincentives,less
than10%oftheuserbaseadoptedandcontinuedtousethishealthcarep
romotioninnovation.Thecase
reportsonthediscontinuanceamongdigitalhealthcarepromotionuse
rsdespitetheintensiveefforts
toretainthem.Studentsandpractitionerswillgaininsightintothekeys
ocialchallengesinvolved
inachievingacriticalmassofusersfordigitalhealthcarepromotionin
novations.Theteachingcase
requiresimportantdecisionstobemadebystudentsandpractitionersa
boutpresentdigitalhealthcare
promotionprogramsbydrawingon inferences
frompastdigitalhealthcarepromotionprograms.
Finally,thishistoricalteachingcasestudymakesaconvincingcasefor
thevalueofhistoricalinsights
ininformingpresentdaychallengesfacingcontemporarydigitalhealt
hcarepromotionprograms.
KeywoRDS
Adoption, Electronic Health, Healthcare Informatics, Healthcare
Promotion, Preventative Healthcare
INTRoDUCTIoN To DIGITAL HeALTHCARe PRoMoTIoN
PRoGRAMS
Astheglobalpopulationrisesandlifeexpectancyratesaroundtheworl
dcontinuetoincreasedueto
advancesinscienceandtechnologyandimprovementstosocio-
environmentalconditions,healthcare
budgetsarefacingenormouspressure.Onthe21stofNovember1986,t
heOttawaCharterinitiated
theadvocacyofhealthpromotiontoimprovehealthcareglobally(WH
O,1986).Healthpromotionis
Thisarticle,originallypublishedunderIGIGlobal’scopyrightonSep
tember23,2020willproceedwithpublicationasanOpenAccess
articlestartingonJanuary18,2021inthegoldOpenAccessjournal,Jo
urnalofCasesonInformationTechnology(convertedtogoldOpen
AccessJanuary1,2021),andwillbedistributedunderthetermsoftheC
reativeCommonsAttributionLicense(http://creativecommons.org/
licenses/by/4.0/)whichpermitsunrestricteduse,distribution,andpr
oductioninanymedium,providedtheauthoroftheoriginalworkand
originalpublicationsourceareproperlycredited.
https://orcid.org/0000-0001-8392-1136
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
45
basedonthepremisethathealthcarecannotbethesoleresponsibilityo
fthehealthsectorandtherefore
seekstoprovidepatientswithbettercontrolovertheirhealththroughi
nformation,healtheducation,
andlifeenhancingskills(Eriksson&Lindström,2008).Thebenefitof
empoweringpatientsisnot
limitedtothecostreductionofhealthcare,butisalsoariskmitigationfa
ctorfordiseaseaswellas
ahealth-enhancingstrategy.
Overtheyears,ICTbegantobeintegratedintohealthsystemsandservi
cesworldwide.During
the1990s,e-commerceemergedandenablednewways toconduct
transactionsvia the Internet.
eHealthwasalsoenabledby theInternet.The termeHealthrefers to
theuseof informationand
communication technologies to improve health and the health
care system (Oh, Rizo, Enkin &
Jadad,2005).TheInternetreferstothegloballyconnectednetworkofc
omputers.Althoughtheterm
InternetisusedinterchangeablywithWorldWideWebor‘theWeb’,th
eWorldWideWebrefers
tomultimedia-
baseddocumentsthatcanbeaccessedonline,overtheInternet(Lupton
,2014).This
becameknownastheWeb1.0eraortheso-
calledbrochurewebera.TheWeb1.0erabeganrapidly
in1990sbecauseoftheavailabilityofbrowserswithuser-
friendlygraphicalinterfaces.TheWorld
Wide Web had become avaluable channel for accessing and
seeking health information. Rapid
improvementincommunication,hardwareandsoftwaretechnologie
salsoledtonewandbetterhealth
serviceofferingsviatheInternet.Bytheearly2000s,therewasanotice
ableshiftintheuseofthe
webandthedevelopmentofweb-
basedapplications.ThiswastermedWeb2.0andinvolvesusers
creating,organizing,sharing,critiquingandupdatingcontent.Web2.
0connectspeopleandcontent
inuniqueways.Web2.0facilitatesan‘architectureofparticipation’–
adesignthatencouragesuser
interaction,empowermentandcommunitycontributions.PopularW
eb2.0applicationsincludeFlickr,
Wikipedia,Facebook,MySpace,TwitterandYouTube.Bythemid-
2000s,Healthcare2.0emerged
totakeadvantageofthenetworkofWeb2.0applicationsandservicesd
eliveredthroughtheWeb
platform.Health2.0usessocialnetworkingsites,blogs,email
listservices,onlinecommunities,
podcasts,search,tagging,videos,andwikistopersonalizehealthcare
andtocollaborateandpromote
healtheducation(Lupton,2014).
Recentadvances
inprocessor,memory,anddiskstoragecapacityhavemadedigitaldev
ices
relativelyinexpensiveandaccesstoonlineplatformshavebecomemo
reubiquitous.Consequently,
increasinglysmallerdigitaldevicesfromthepersonalcomputertothe
tablettosmartphonestowearable
computersarebeingbeenusedinhealthcare(Lupton,2015).m-
Healthormobilehealthisdefined
astheuseofmobiledevices,suchasmobilephones,patientmonitoring
devices,personaldigital
assistants(PDAs),andotherwirelessdevicestosupporthealthpractic
es(Bert,Giacometti,Gualano&
Siliquini,2014).Forexample,trackingdevicescanbeusedtomonitor
apatient’scalorieconsumption,
exerciseandmetabolicrate.Thesedevicesarebeingintegratedwithso
cialmediatoprovidesupport
andmotivation.ExpertspredictthattheWebwillevolveintoWeb3.0o
rthe‘SemanticWeb’(Giustini,
2007).TheSemanticWebaimstoimproveuponthemeaningfulnessof
informationontheWebthereby
improvingcooperationbetweendigitaldevices,healthcarepractitio
nersandpatients.
Apartfromthecreationofdigitalcontentbyhealthcareuserswhenthe
yuploadinformationto
theInternet,sensorsembeddedinhealthcaredigitaldevicesandphysi
calhealthcareenvironmentsare
alsogeneratingmassivedatasets(NevesStachyra,Rodrigues2008;P
anesar,2019).Thesemassive
datasetsarereferredtoas‘bigdata’.Cloudcomputingtechnologiesar
ebeingusedtofacilitatethe
production,storageandsharingofthesebigdatasetstoprovidedigital
healthcaresolutions(Darwish,
Hassanien,Elhoseny,Sangaiah&Muhammad,2019).Artificialintel
ligenceandmachinelearning
arebeingused touncoverhiddenconnectionsandpatterns in
thesemassivedatasets toprovide
evidence-
baseddigitalhealthcaresolutions(Panesar,2019).Today’shealthcar
eICTecosystemis
muchmorecomplexandinvolvesnetworkproviders,networkoperato
rs,digitaldevicesuppliers,
platform,contentandapplicationsproviders,healthcarecompanies,
healthagencies,governments
andpatients(Fransman,2007).Theterm‘digital’isnowbeingemploy
edtodescribepaper-based
elementsthathavebeentransformedintodigitalformats,andthedevic
es,communicationnetworks
andsoftwareapplicationsthatusetheseformats.
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
46
ICTshaveplayedacrucialroleinprovidingadigitalplatformforpubli
shinganddisseminating
healthalertsandinformationtothegeneralpublic,scientistsandhealt
hcareprofessionals.eHealth
innovations like electronic health records, computer assisted
prescription systems, and clinical
databases have already directly benefited many patients and
holds great promise for the future.
Digitalplatformsareplayingandwillcontinuetoplayacrucialroleinh
ealthpromotion.eHealth
innovationsareexpectedtoempowerandprovidecost-
effectiveapproachesforpatientcareandtohelp
governmentagenciesandhealthcareorganizationstocopewiththech
allengesofincreasinghealthcare
costs.However,theevidenceshowsthatthelevelsofuseruptakeforma
nyoftheseinnovationsare
currentlyverylowandthatthediffusionofmanyoftheseeHealthinnov
ationsisbeingimpededby
anumberofsignificantbarriers(Oderanti&Li,2018;Gugglberger,20
18;Parasuraman&Colby,
2007).Despitethetechnologicaladvancementsandthepotentialofdi
gitalhealthpromotiontotackle
theglobalhealthcrisis,someresearchersarguethatthattherecontinue
stobeacrisisindigitalhealth
promotiondelivery(vanGemert-
Pijnen,Nijland,vanLimburg,Ossebaard,Kelders,Eysenbach&
Seydel,2011;KeshavarzMohammad,2019).Thekeychallengesaren
ottechnologicalbutsocial.
Healthcare promotion innovations have earned a reputation for
diffusing relatively slowly
comparedtootherhealthcareinnovations(Rogers,2002;Rogers,201
0;Greenhalgh,Robert,Bate,
Macfarlane&Kyriakidou,2008).Itmaybesimplistictoassumethatst
rongmonetary,andother
formsofincentivesforprevention,willresolvethecomplexproblemo
fconsumerhealth(Reichheld
&Schefter,2000;Jost,2007).Despitethemixedviewsabouttheeffica
cyofhealthcarepromotion
programsintheliterature(Adam&DeBont,2003;Bandura,2004;List
er,West,Cannon,Sax&
Brodegard,2014),informationandcommunicationtechnologiesare
deemedtobeimportantenablers
inhealthcareservices(Larkin,2001;Schraefel&Churchill,2014;Sul
aiman&Wickramasinghe,
2014;Orji&Moffatt,2018).However,healthcarepromotionprogram
sarequitecomplex(Solberg,
Kottke,Conn,Brekke,Calomeni&Conboy,1997),yettheycontinuet
obehandledpoorlyandfail
todeliveronanticipatedbenefits(Ward,2013;Ginter,Duncan,&Swa
yne,2018;Greenhalgh,2018).
Tomanagethiscomplexity,somescholarshavesuggestedthatthesein
terventionsneedtoaddress
thesocialchallenges(McLeroy,Bibeau,Steckler,&Glanz,1988;Gre
en,Richard,&Potvin,1996;
Iyengar&Nair,2000;Schlosser,2002;PorterandTeisberg,2006).
Thiscaseisaboutthedifficultiesinvolvedindigitalhealthcarepromot
ionprogramsattaininga
criticalmassofusers.Asstudentsexplorethecasetheywillberequired
toaddressthemanysocial
challenges raised by digital healthcare promotion programs.
This case highlights the challenges
experiencedbye-Health,thee-
commercechannelforHealthInsuranceCompany(HIC),anditsOnlin
e
NutritionCenter.AfterabandoningtheOnlineNutritionCenter,some
15yearsago,HICisrevisiting
whetherornottopursueadigitalstrategyforthepromotionofnutrition
amongitscustomers,given
thelatestadvancesintechnology.Beforeproceeding,theExecutiveh
asconcludedthatareviewof
thepastOnlineNutritionCenterinitiativeisneeded.Theybelievethat
suchanassessmentofthe
pastcouldprovidevaluableinsightsandlessonslearnedtoinformthei
rdecisionaboutthefuture.
SeTTING THe STAGe
Introducing the e-Health Case Study
TerryRossiburst intohisoffice,walkeddirectly
tohisdeskandslumpedintohischair.Hehad
justarrivedfromanother
toughExcomeeting.Thecommitteewasconcerned that
the“wellness
innovations”deliveredontheWebhadsofarappealedtoonlyaminorit
yofcustomersandnotthe
highnumbersthathadbeenpromisedbye-
Health.Atbest,thehealthcarepromotionprogram,the
onlinenutritioncenter,wasservingasacomplementarychannelforas
mallcaptiveaudience.Terry
wonderedhowhewasgoingtoimprovetheperformanceoftheonlinen
utritioncenter.Terryknew
that ifhewere toconvince theExco that
thishealthcarepromotionprogramwasa success, this
programwouldhavetoattainacriticalmassofusers.Hewasconsiderin
gthestepshecouldtaketo
ensurethate-Healthbuiltacriticalmassofusers.
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
47
CASe DeSCRIPTIoN
e-Health’s Nutrition Centre
E-
HealthistheindividualbrandnameofthewebsiteforHealthcareInsur
anceCompany(HIC)(Figure
1).HICiscomposedoftwootherbusinessunits:WellnessScienceCo
mpany(WSC),acompanythat
providedwellnessandloyaltyprogramsforcustomers,andBritishHe
althcareInsuranceCompany
(BHC)whichfocusesonoffering“consumer-
engagedhealthcareproducts”forUK’sprivatemedical
insurancemarket.TheaimofWSCistoprovidememberswithtoolsto“
preventdiseaseandimprove
theirwell-
being”.WSCwaslaunchedin1997inresponsetothegrowingtrendtow
ardsahealthier,
moreactivelifestyle,basedonthepremisethathealthierlifestylescou
ldtranslateintolong-termsavings
onhealthcarecosts.WSCprovidesmemberswithaccesstoselectedhe
althandfitnessfacilities,and
createsstrongincentivesfortheircustomerstousethem.Membersare
persuadedtoearnincentive
pointstoimprovetheirwellnessstatus.Thegreaterthestatus,themore
accesstobenefits,suchas
discountedtravelandleisureprices.WSCalsoprovidesallsortsofinc
entivestousee-Healthand
e-
Health’sNutritionCenter(Figure2).Bytheendof2005,HICwascove
ringmorethan1.8million
lives(Figure6)whileWSCwascoveringmorethan1.2millionlives(Fi
gure7).Atthesametime,
e-Health’sregistereduserbaseexceeded430,000(Figure8).
TheNutritionCentrewasconceivedin2002.Theobjectivewastoprov
ideanonlinemechanism
thatpromotedhealthyeatinghabitsamongWSC’smembers.Thedesi
gnprocesswasmanagedby
awellnessnutritionpanel,composedofdieticians,cliniciansandnutri
tionacademics.Therewasa
hugeemphasisondesigningthetoolwithastrongscientificbasis.
TheNutritionCentreprojectteamaimedtoestablishanintegratednutr
itionprogrammeusing
‘scientificguidelines,periodicreviews,anddatacollection’.Meanw
hiletheclinicalteamwhowere
nowdrivingtheprojectselectedapanelthatconsistedofthreenutritio
nacademicsfromthevarious
UniversitiesaroundSouthAfrica.Thispanelwastaskedtoreviewthed
esignoftheapplicationand
provideguidance.Theywerealsoinvolvedinanumberofworkshopsw
iththesoftwaredevelopment
team.Thedesignofthetoolhadtogettheirstampofapprovalspecifical
lyonthe“scientificbasis”.
Figure 1. HIC’s organisation structure
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
48
Despitethisaim,thereweredifferentopinionsamongthepanelmembe
rsaboutcertaintopics,such
asthefibrecontentofahealthydiet,andsoon.
AtthetimetheNutritionCentrehadnotputinanyspecificprogramstha
tinvolvedmembers
goingtoconsultregistereddieticians.Whilememberscouldgoandsee
adieticiantherewasnothing
inplacethat“pushed”memberstodieticians.Sotheonlywaythatmem
berscouldgetnutritional
informationinitiallywasviacommunicationthroughthemagazine,e
mailandtheweighlessprogram.
Howevertheweighlessprogramdidnotappealtoeverybodybecauseit
wasobviouslyseenmoreas
aprogramspecificallyforpeoplewhowantedtoloseweightandtheobj
ectiveoftheonlinenutrition
centrewastoappealtoabroaderpopulation.Thepanellistshadthevie
wthattheteamneededto
createanonlinedieticianandthedevelopmentteamweretransfixedby
thisconcept.Itsoonoccurred
tothepanelthatjusttheconceptofprovidinganonlinemealplannerfor
auserwasacomplicated
task.Userinputswererequiredforgender,activity,height,weight,wa
ist,andbloodtype,among
otherinputs.Thetoolalsohadtorelyontheself-
reportedmeasurementsoftheusertoestablishthe
effectivenessoftheproposeddiet.
Whenusingtheonlinenutritioncentreatacoffeeshop,theuserremotel
yoperatestheirnutrition
self-
assessmentformsothatthesystemcouldprovidethemwithamealplan
recommendation.In
thisprocesstheusercapturesarangeofinputsrelatedtotheircurrentw
eight,age,height,andwaist
measurementsintothesystem.Thus,itenablestheuserscontrolbyacti
ngatadistance.Therationale
isthatthereisnoneedtoscheduleanappointmentwiththeirdietician.
WhiletheNutritionCenterdidattractusers,itwasnotaspopularasthea
pplicationsthatwere
concernedwiththemembers’healthplans.Themonthlymanagementr
eportindicatedthatapplications
relatedtohealthplanissues,suchastheonlineclaimstrackerapplicati
on,wereusedasmuchas
threetimesforeverysingleuseofthenutritioncentre.Pageimpression
swereonaveragefewerthan
3000perweek.
ThesurveyresultsreportedinFigure3showsthatdespitethehighlevel
ofawarenessasespoused
bythediffusionofinnovationtheory(Rogers,2010;Ward,2013),and
agreementbyusersonthe
utilityandeaseofuseasespousedbythetechnologyacceptancemodel
(Davis1989;Holden&Karsh,
2010),discontinuanceoftheNutritionCenterremainedextremelyhig
h.
Figure 2. Screen shot of e-Health’s landing page (2004 website
redesign)
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
49
Promoting the Adoption of Healthcare Promotion Programs
Terry’sstrategytomarkettheNutritionCentreresultedinenticingma
nyuserstoregistertotrial
thetechnology.Thecampaignspromotedthecompany’svisionof“im
provingpeople’shealth
andenhancingtheirlifestyles”inanonlineenvironment.TheNutritio
nCentrewaspromoted
invariousmediums:
• Healthcare Insurance Fact
File:TheNutritionCentrewaspromotedinthefirm’sfactfile.
The fact filewasabooklet thatprincipalmembers receivedannually
toexplainhowtheir
healthplanworks.
• Healthcare
Magazine:TheNutritionCentrewasalsopromotedinahealthcaremag
azine.When
comparedtothedifferentawarenessmediumsthemagazineappearedt
obethemosteffectivein
promotingtheonlinechannel.Themagazineconsistentlyfeaturedarti
clesexplainingthebenefits
oftheNutritionCentretomembers.
• Email Newsletter
Campaigns:Theseemailsweretobecomeavitalcomponentoftheemai
l
promotioncampaignforpromotingtheNutritionCentre.
Other avenues for promoting the Nutrition Centre were
employers, brokers and the call
centreagents.
• Incentive
Points:Memberswereremindedthattheycouldearnpointsbyinteract
ingwiththe
onlinechannelandspecificallytheWellnessapplications.Itwasspeci
ficallytheabilitytoreap
rewardsfromcertainbehaviour,andgoingonlinetogatherrewards,su
chascheapergymnasium
fees,cheaperflightsandholidayaccommodations,thatledtoasignific
antincreaseinthenumber
ofregisteredusers.
Figure4showsthatasaresultofthesepromotions,asmanyas60%ofthe
registered
userbaseregisteredtousetheNutritionCentre.Despiteeffortsatprom
otingtheNutrition
Centre, However, Figure 5 shows that over a short period of
time as many as 90% of
registrantsneverreturnedtousetheNutritionCentre.Thisisinstarkco
ntrasttothehealth
insuredmemberbasechurnor lapse rateof3
to4%.DespiteTerry’sefforts toattaina
criticalmassofusers,theNutritionCentrewaseventuallydisbandedb
ecauseofthehigh
userdiscontinuance.
Figure 3. Nutrition center survey. Source: Bataleur, Customer
Satisfaction Survey.
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
50
PoST IMPLeMeNTATIoN ReVIew: LeSSoNS FRoM THe PAST
Thefollowingproblemscontributed to
theslowuptakeandnegatively impacteddiffusionof the
NutritionZone.
Lesson 1: The Constraining Role of Broader Socio-economic
Structures
TheInternethighwayasastopforonlinewellnesstoolsisnowcompeti
ngwiththemoreresilient
structureofourroadnetworks.Eversincethegrowthofcarsalesandthe
subsequentgrowthofsuburbs,
growthwhich roadnetworkshadencouraged, fast
foodorganisationshavegrown into sprawling
multinationalsbyexploitingprimelocationswithin
thesehighwaynetworks.Evenindeveloping
countries likeSouthAfricaand in factmanyothercountriesaround
theglobe,corporations like
Figure 4. Share of active nutrition center users. Source: Internal
Report - Statistical analysis of retention.
Figure 5. Leaky bucket problem – losing users over time.
Source: Internal Report - Statistical analysis of retention.
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
51
McDonaldshaveexportedthevaluesandtastesoftheirlocalculture.W
iththishomogenisationof
internationalfastfoodculture,countrieshavenotonlylosttheiridenti
tyintermsofhow,whereand
whattheyeat,buttheyhavealsoexposedthemselvestomajorhealthris
ks.
Asaresultofthepervasivenessofthesebroadersocialstructuresinmo
dernsocietybehavioural
changesaredifficulttomakeevenwiththeguidanceofapractitionerle
taloneviaadigitalhealthcare
promotiontool.ThefollowingexcerptbyoneofHIC’swellnesspractit
ionersdescribesthechallenge:
Behaviourchangeisanextremelycomplicatedthing.Itis.Imean,ever
ybodywhohasbeenon
aweightlossprogramknowsthatyoucanbeasdisciplinedand,youkno
w,withexerciseaswellfor
twoorthreeweeksandifyouskiptheweek,youhavetostartfromscratc
h.Imean,peoplegointothe
behaviourchangeforsixmonths,andtheyleaveandthentheyhavegott
ostart,andthentheyhave
lostallthatmotivation.So,ifpeopleloseinterest,thethingis,ifthey,ift
heyhadlearnedwhatthey
wantedtohere,theywouldactuallycomebacktokeeponmotivating.B
ecauseweneedtosustain
thatdevotion.Iftheyhavelostinterest,theyarealosstothecause;theya
rebacktooldbehaviour.
That,thatiswhatIhavelearned,youknow,throughexperience.
Lesson 2: Intense Competition for the Customer’s Attention
Thereareothermarketmechanismsoutsideof thehealth
insurancefirmthatarevyingfor the
consumer’sattention.Thecontentdeliveredbythemediaplaysacentr
alroleinhowconsumers
constructtheirvaluesandrulesofbehaviour.Inaneconomicsystemth
atfocusesonthenarrow
dictatesofprofitability,obesityhasbecomebigbusinessfortheverys
ystemthatinfluencedit.
Indeed,consumersareoverwhelmedbythevarietyofdietschemesand
weight-lossadviceand
productsthatareavailableinthemarketplace.Furthermore,foodisani
mportantfactorinour
day-to-daysocialpractices.
Lesson 3: The Relativistic View of Dietary Science
Eventhedieteticpracticeitselfissubjectivewithdifferentschoolsoft
houghtmakingdissimilarclaims
aboutthebestapproachforweightloss.Forinstance,somefocusoncal
oriereduction;othersfocus
onthetypesoffoodgroups(protein,carbohydrate,fat)suchaslowGI(
glycaemicindex),andthe
useofsupplementsandsoon,allservingtoconfusetheconsumer.The
NutritionExpertdescribed
thedifferentperspectivesimplicatedinthedesignoftheonlineNutriti
onCentreasfollows.
Therewere a lot of challenges Imeanwithin anypanelyouaregoing
tohavediffering
opinions.Although theyareallexcellentacademics in
theirownright therewasofcoursea
certaindegreeofnotnecessarilyconflictbutdifferencesofopinions
incertainaspects.You
couldcertainlypickupthedifferentslantsintheirparticularfieldofint
erestsandorpassion.
Soforexampleonewouldconstantlybeharpingaboutfibreorlentilsan
dtheotheronewould
beharpingonaboutyouknowvariousdifferentangles.Sotakingthesci
enceandtranslatingit
intoaninteractivetoolwasquiteachallenge.
Lesson 4: Delegating Tacit and Uncodified Knowledge to
Technology
Havingbeenapracticingdietician,theNutritionExpertsuggestedtha
tbecausefoodandeatingisa
veryemotiveissue,the“real-
world”dieticianoftenhastoplaytheroleofapsychologist,partcoach,
partfriend,andpartdietician.Adieticianalsospendsanenormousamo
untofeffortinmotivatinga
patient.Andevenduringthefollow-
upsessions,thedieticianbecomesthemotivatorandthecounsellor.
Thelimitationsofdelegatingtheroleofthedieticiantotheself-
servicetoolaresuccinctlydescribed
bywayofexamplebytheNutritionist.
Thosearethekindofthings,thesmallnuancesthatareimportant,tobea
rinmindbecauseofthe
factthatthiseatingissomethingwealldoeverydayanditishighlyemot
iveandsohighlyeffected
bythetypeoflifethatyoulead.Sotherearesomanyfactorsandnoteven
necessaryreallytobe
writtendown.Youknowyoujustpickthesethingsup.It’sreallyaboutg
atheringinformationand
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
52
thentailoringit.Becauseweknowwithcompliance,withanykindoflif
estylechange,themoreyou
personaliseit,themoresuitableitistotheperson’slifestylethemoresu
ccessyougoingtohave.
Theadvantagesofgoingtoadietician,yougointoaprofessionalenviro
nment,youarehaving
thatcontactwiththedieticianwhocanreadyouandbuildarelationship
withyouandbecomea
partnerinthisprocess...Ithinkattheendofthedayit(theonlinetool)isn
osubstituteforthathuman
contact…WhatImeanisthatthebodylanguageandthepersonalityand
yougettoknowtheperson,
andyougettounderstandthemandunderstandtheirlifestyles.
Lesson 5: Context-Transferability Challenges
Therewasincreasingfrustrationamongthedevelopmentteamreprese
ntingtheUKpartner,onthe
logicofbasingtheUKfunctionalityontheSouthAfricanperspective.
OneoftheunhappyBusiness
Analystsmadethefollowingcomment:
Firstofall,youcan’tjustplugandplayitfromonecountrytothenext...
Andalso,whatone
marketingteamwanteddifferedfromtheother.So,itstartedoffsaying
,oh,yes,wearegoingtouse
thisconcept,andthemoreandmoreyoudelveintoit,themoreandmorei
tmovedaway.
Forexample,theconceptionsofanonlinenutritiontoolinscribedwith
aSouthAfricanperspective
requiredmodificationstosuittheUKcontext.Bringingatechnologyt
oanewlocalcontextinvolves
someexplicitandimplicitelementsofculturaltransferandmutuallear
ning.Thefollowingcomment
byourNutritionExperthighlightshow theUK
requirementswereatoddswith the localSouth
Africanrequirements:
TheUKsystemusestheimperialsystemwhileweusethemetricsystem
.Thisaffectedrecipes,
portionsizesandbodymeasurements.ThedieticianintheUKhelpedu
swithtranslatingtherecipe
measurementsandportionsizesfrommetrictotheimperial,whichinv
olvedcalculatingtheequivalent
ounceswheretherecipesstatedgrams,millimetresorlitresandconver
tingkilogramstopounds.
Someofthemeasurementslookedridiculousanddidn’tseemtomakes
ense,sowehadtotryand
converttohouseholdmeasurementswherepossible.Forexample–
1teaspoon,Icupetc.Regarding
thebodymeasurements,oneofthetoolsinthenutritionprogrammeinv
olvescalculatingyourbody
massindex(BMI).Thisrequiresyoutoenteryourheightinmetresandy
ourweightinkilograms.
NaturallywehadtomodifythistooltoallowfortheUKmarkettoenter
metricfriendlydatasuchas
feetandpounds.Thiswasn’tdifficultasitwassimplyacaseofapplying
conversionfactors.
TheUKnutritionistalsorevealedthedifferencesandidiosyncrasiesth
atwereconcealedbeneath
theapparenthomogeneityoftheUKrequirements.Whileonthesurfac
etheUKandSouthAfrican
culturemayappeartobesimilar,thisevidenceiscountertotheglobalh
omogenisationnotionwith
respecttoICTimplementations.TheUKusersappropriatedthetheonl
inenutritioncentre,differently
asaresultoftheirspecificgeographies,histories,standardsandlangu
ages.
At firstwe thought itwouldsimply involve removing
theSouthAfrican foods, forexample
biltong3fromtherecipesandmenusonthemealplansandreplacethem
withfoodsfamiliartopeople
intheUK.Soweneededtofindoutwhatequivalentfoodswouldbeavail
ableintheUKtouseas
substitutes.Thenwerealisedwealsohadtochangethenamesofcertain
foodsthatwerecommonin
bothcountries,butthatwerecalledsomethingdifferentintheUK,like
eggplantinsteadofbrinjal,
whichaffectedrecipesandmenusthatcontainedthesefoods.Wealsoh
adtochangethenamesof
recipes,suchas‘potjie’tosomethingmoreUKfriendlylikecasserole.
Toensurethatallfoodswould
berecognisabletoUKconsumers,weenlistedthehelpofaregistereddi
eticianintheUK.
AmajornutritionalissueintheUKisintoleranceorallergytowheatand
therearemanymore
vegansthaninSouthAfrica.Wehadnotcateredforwheat-
freeandveganmealplansontheSA
NutritionCentreandtheUKofficerequestedthatwedesignsuchoptio
nstosuittheirmarket.This
involvedtheUKdieticiansupplyinguswiththenamesofproductsavai
lableintheUKthatcouldbe
usedassubstitutesforwheatandanimalproteinfoods
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
53
Lesson 6: The Abuse of Incentives by Consumers
ManyoftheusersthatwereenrolledontheNutritionCenterwerelateri
dentifiedas“pointschasers”.
Theyusedtheincentivepointsinanunanticipatedway.Ratherthanfoll
owtheassignedwayofusing
theNutritionCenterto“improvetheirhealth”,theanti-
programof“pointschasers”emergedasa
resultoftheincentives.“Dealloyalty”emergedwhereusersweremore
interestedinmovingstatuses
withminimalbehaviouralchangestotheirlifestylestoobtainhigherin
centivesandthereforehigher
discounts.Theonlinefeedbackbelowdemonstratesauser’sinterestin
obtainingpointsasopposed
tothecontentoftheassessment.
Ihavebeentryingtocompletethefourexamsforthenutritionsectionof
thewebsitetogetthe
500Wellnesspoints.Ipassedthelastthreebutcan’tgetthe1st(basic)e
xamtodisplay.Mygirlfriend
logsonandsees(andcompleted)allfoursoitcan’tbemyPCitmustbeso
methingtodowithwhat
happenswhenIlogontothewebsite.PleaseadvisehowIcangetthe500
points.
UponreflectingontheNutritionCenter’sabilitytoplaytheroleofadie
tician,ourNutrition
Expertadmittedthisasamistake.
Tryingtofigureouteverythingadieticianwouldwanttoknowfromape
rsonandtryingtoput
thatinsomekindoftoolwasactuallyamistakebecausewereallydidn’t
intendtobecomeorreplace
theservicesofaregistereddietician,thereisabsolutelynowaythatwe
couldpossiblydothatand
yetweweretryingsohardtogettothatpointofbeinganonlinedietician.
CURReNT APPRoACHeS To PRoMoTING NUTRITIoN
Overmorethanadecadeorsoago,therewouldbeadecliningemphasis
ontheonlinepromotion
ofnutrition.TheonlineNutritionCenterwouldalsoberemovedfrome
-Health.Therewasa
radicalshiftinnutritionfromtheonlinetothe‘physical’world–
inotherwords,towardsthe
organization’s‘realworld’networkofpartners.Today,e-
Health’sroleislimitedtoproviding
genericcontentonhealthyeating,food,nutrition,aswellashealthyrec
ipesandtipsfromthe
organization’s
leadingnutritionexperts.Thenutritionprogramcontinues
toencourageand
rewardmembersforhealthybehaviour.However,cashrewardshaver
eplacedtheredeemable
pointsbasedsystemandisawardedforpurchasinghealthyfoodandma
kinghealthiermeal
choiceswhendining.Customersarerewardedwithcashbackforpurch
asinghealthyfooditems
atselectedretailpartners.Customersarealsorewardedwithcashback
formakinghealthier
mealchoiceswhendiningoutatselectedrestaurantpartners.Thisincl
udesapartnershipwith
UberEats.Meanwhile,thefirmhasalsobegunopeninghealthyfoodst
udiosinmajorurban
centres to
teachbasiccookingskillsandencouragebothadultsandchildren
tocookusing
unprocessedandseasonalingredientstosupporthealthyeatinghabits
.Nutritionassessmentsare
nolongerdoneonline.DieticiansinHIC’swellnessnetworknowdoth
enutritionandweight
assessments.Whileredeemablepointsfornutritionassessmentsaren
olongerofferedonline,
pointscanbeareearnedfordoingtheseassessmentsataccreditedwell
nessnetworks.HIC’s
nutritionexpertusestheYoutubevideo-
sharingcommunitytoprovidedietlessons,eventhough
theviewsareverylow.Thefirmalsooffersincentivesforphysicalacti
vity.Asmartwatchis
offered toqualifying customers.The smartwatchmeasures
thewearer’s activity levels and
setspersonalisedweeklyfitnessgoalsbyconnectingtothefirm’sfitne
ssapp.Thecompany
claimsthattheyhaveobservedincreasedactivitylevelsamongmanyo
ftheparticipantsusing
thesmartwatchrewardprogramme.Today,HICoperatesinmorethan
15countriesandhas
over10millioncustomers.Thecompanyfocusesonusingsmartphone
s,wearabledevicesand
gamingelementstopromotehealthcare.Successinthediffusionofthe
sedigitalhealthcare
promotionprogramscontinuestobemixed.
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
54
yoUR CHALLeNGe AND TASKS
TheHICexecutiveisreassessingtheirdigitalstrategyfornutrition.Th
eyhavereachedouttoyouand
yourteamofconsultantstoadvisethefirm.Theoverarchingobjectivei
stwofold:
1. Toassesshowwelldigital technologieshaveprogressed
todateand towhatextent they
canaddresssomeofthesocialchallengesexperiencedinthepastiterati
onsofthenutrition
center(assessment);
2.
Toproposewhethertomoveforwardandhowtomoveforwardwiththei
rdigitalstrategyregarding
nutrition(recommendations).
NoTeS
Sincetheorganizationpreferredanonymity,allnameshavebeenficti
onalised.
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
55
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Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
57
APPeNDIX
Table 1. Exhibit 1: Summary of key global health statistics
Subject Measures
Underweightchildren(developingcountries)
Overweight(worldwide)
Deathsfromobesity-relateddiseases
Lungcancerfromsmoking
Men
Women
Globaldeathsfromtobacco-relatedcauses
Globaldeathsrelatedtoalcohol
Physicalinactivity
(causesabout15%ofsomecancers,diabetesandheart
disease)
HIV/Aidsinfections
Globalburdenofinfectiousdiseases
Chronicnon-communicablediseaseburden
(Fiveriskfactors:unsafesexualpractices,alcoholuse,indoorair
pollution,occupationalexposures,andtobaccouse)
Lifeexpectancy(globalaverage)
1950
1998
Europe
Low-andmiddle-incomecountries
170million
1billion
0.5millionperannum
90%
70%
8.8%(4.9millionperannum)
4%(1.8millionperannum)
1.9milliondeathsperannum
40millionpeople
30%
20%
46years
66years
73years
68years
Source:WHO(2002)
Anumberofdeathsordiseasesarerelatedtocausesthatareviewedtobe
withinthecontrolofindividuals.Forexample,
chronicnon-
communicablediseaseswhicharelinkedtofactorssuchassmoking,o
besityandasedentarylifestylecause
20%ofthesociety’sdiseaseburden.
Figure 6. Exhibit 2: HIC’s rapid health membership growth
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
58
Figure 7. Exhibit 3: WSC’s rapid wellness program membership
growth
Figure 8. Exhibit 4: e-Health’s user registration growth. Source:
eHIC’s Management Reports (totals are as at financial year-end
(June) and not calendar year). 2005 shows almost 430,000
registered users.
Journal of Cases on Information Technology
Volume 22 • Issue 4 • October-December 2020
59
Rennie Naidoo is an associate professor at the School of IT,
Department of Informatics, University of Pretoria. He has
served a number of clients on a number of IT projects in both
the public and private sectors over a 20-year period.
Naidoo is also an NRF-rated researcher. His research interests
are broadly about information systems and organisations
with a particular focus on IT value, IT human resources
development and end-user issues. He has published articles in
leading international outlets such as the Journal of Strategic
Information Systems and the Information Society Journal.
He lectures topics on IT investment and enterprise systems to
postgraduates at the university.
Table 2. Exhibit 5: Summary of key user characteristics
Subject Measures
Registration based on gender
Male
Female
Active use based on gender
Male
Female
Registered User Age Group
20-25
26-30
31-35
36-40
40-45
Greaterthan45
Preferred Language of Registered Users
English
Afrikaans
Wellness
Schememembersonwellnessprogram
Wellnessmembersaspartofonlineregistereduserbase
53.37%
46.63%
48%
52%
21.91%
32.02%
23.60%
6.74%
8.43%
7.30%
56%
44%
70%
92%
Source:InternalManagementReport(2004)
ThemajorityoftheusersappeartobeyoungerandaffiliatedtotheWell
nessprogram.
Themeasureofactiveuseisbasedonloginspermonth

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DOI 10.4018JCIT.2020100103Journal of Cases on Informatio