On a global scale, healthcare practitioners are now beginning to move from traditional desktop-based computer technologies towards mobile computing environments[1]. Consequently, such environments have received immense attention from both academia and industry, in order to explore these promising opportunities, apparent limitations, and implications for both theory and practice[2]. The application of mobile IT within a medical context, referred to as mobile health or mHealth, has revolutionised the delivery of healthcare services as mobile technologies offer the potential of retrieving, modifying and entering patient-related data/information at the point-of-care. As a component of the larger health informatics domain mHealth may be referred as all portable computing devices (e.g. mobile phones, mobile clinical assistants and medical sensors) used in a healthcare context to support the delivery of healthcare services

O’ Connor, Y

O’ Donoghue, J

Journal of Mobile Technology in Medicine

English

Yvonne O’ Connor

John O’ Donoghue

Crossref

Contextual Barriers to Mobile Health Technology in African Countries: A Perspective Piece

Spiral - Imperial College Digital Repository

CONTEXTUAL BARRIERS TO MOBILE HEALTHTECHNOLOGY IN AFRICAN COUNTRIES:A PERSPECTIVE PIECEYvonne O’ Connor, PhD1, John O’ Donoghue, PhD21Health Information Systems Research Centre, University College Cork, Cork, Ireland; 2Global eHealth Unit, Imperial CollegeLondon, UKCorresponding Author: y.oconnor@ucc.ieJournal MTM 4:1:3134, 2015doi:10.7309/jmtm.4.1.7On a global scale, healthcare practitioners are nowbeginning to move from traditional desktop-basedcomputer technologies towards mobile computingenvironments1. Consequently, such environmentshave received immense attention from both acade-mia and industry, in order to explore these promis-ing opportunities, apparent limitations, andimplications for both theory and practice2. Theapplication of mobile IT within a medical context,referred to as mobile health or mHealth, hasrevolutionised the delivery of healthcare servicesas mobile technologies offer the potential of retriev-ing, modifying and entering patient-related data/information at the point-of-care. As a component ofthe larger health informatics domain mHealth maybe referred as all portable computing devices (e.g.mobile phones, mobile clinical assistants and med-ical sensors) used in a healthcare context to supportthe delivery of healthcare services.The usefulness of implementing IT in healthcare isreflected in current eHealth initiatives in resource-poor settings (e.g. Baobab Health in Malawi, M-Pedigree in Ghana, Nigeria and Kenya; Cell-Life inSouth Africa). In recent years attempts have beingmade to digitise WHO/UNICEF paper-based clin-ical guidelines when delivering paediatric healthcareservices, namely: Integrated Management of Child-hood Illness (IMCI) and Community Case Manage-ment (CCM). Both IMCI and CCM are stepwiseand structured approaches, employed by Commu-nity Health Workers (CHW), towards reducingdeath, illness and disability while promoting im-proved growth and development among childrenunder five years of age3,4. Digitising the IMCI andCCM guidelines offer profound opportunities toCHW (also referred to as Health SurveillanceAssistants in Malawi, Africa) in terms of improvingadherence to clinical guidelines, offering instantaccess to patient data independent of location andtime and facilitating drug ordering via ShortMessage Service (SMS)5.However, introducing mobile technology in a med-ical context within resource-poor communities isnot without its challenges6. One obstacle faced bymHealth users is lack of user acceptance of thetechnology. Common factors which influence thedecision making process of accepting mobile tech-nology in medicine may include perceived useful-ness, perceived ease-of-use of the technologicaltool7, performance expectancy, effort expectancy,social influence, facilitating conditions8. Arguably,the most imperative barrier faced by mHealth usersin Africa is that of a contextual nature. Theunderlying premise behind this argument is thatmany mHealth solutions for use in developingcountries are often developed in western societies.Such solutions have been criticised for failing torecognise the unique contextual factors associatedwith developing regions9. Contextual factors reflectexternal or driving elements that comprise theenvironment or conditions for decision makingtasks10 and as a result, such factors can vary acrosspopulations and industries. Cultural, economic,political and cognitive dimensions are contextualfactors which could influence how end users interactORIGINAL ARTICLE#JOURNAL OF MOBILE TECHNOLOGY IN MEDICINE VOL. 4 | ISSUE 1 | JANUARY 2015 31with mobile technology in medicine (referenced 14,Figure 1).Cultural factors (1, Figure 1) denote a set of beliefsand norms that are both consciously and subcon-sciously held by any individual in the givensociety11. In the context of this paper, this refersto the principles/customs held by CHW in ruralregions of Africa. Culture diversity between devel-oping and developed countries can be observedbased on ‘‘Individualism versus Collectivism’’,‘‘Power distance’’, and ‘‘Masculinity versus Femi-ninity’’12. That is, developed countries such asEurope and U.S.A. are driven by individualistapproaches whereas developing countries are con-cerned with collectivist strategies. Power distancereflects the way society distributes, shares, andenforces the power among its members13. Powerholders in high power distance cultures such asAfrica are much more comfortable with a largerstatus differential than low power distance cultures.Additionally, research in African countries showspreferential treatment towards males over females.It is worth noting, however, that cultural valuescannot be easily adjusted to conform to any changesintroduced by mHealth. This conformity, therefore,may have an impact on individual users’ intentionsto adopt mHealth technologies in Africa. Theauthors suggest that ethnographic studies shouldbe performed to capture local cultural dimensionssimilar to the work of Kitson (2011)14. In her workKitson identified a number of cultural factorsimpacting the implementation of the Care2x hospi-tal information system in Tanzania.Economic factors (2, Figure 1) refer to the direct andindirect financial opportunities attributable toCHW in rural areas of developing regions. Withoutthe necessary economic support for sufficient toolsand resources, technology transfer from developedregions to Africa becomes very complicated, giventhe existing technological infrastructures at manyAfrican locations15. To help ensure that mHealthsolutions are a viable option for African countries acost analysis should be performed as advocated bySchweitzer and Synowiec (2012)16. Increased mobilecoverage in rural areas, including faster networkconnectivity, is essential to realising the potentialand scope of mHealth in developing countries.However, western societies should develop solutionsthat operate on commonly used mobile devices indeveloping regions. Many mHealth initiatives inAfrica utilise the SMS functionality of mobilecommunication systems as a core connectivitymethod. The underlying rationale for using thislow-cost functionality is that high-performancedevices are not required to transmit data. Forexample, the effects of mobile phone SMS onantiretroviral treatment adherence in Kenya wasexamined17,18. These studies provide empirical evi-dence that mobile health initiatives can improveHIV treatment outcomes.Political factors (3, Figure 1) refer to the govern-mental agenda of central administrations withindeveloping regions. The planning and budgetingprocess in resource-poor areas are often constrainedby expenditures in previous years. As a result,developing regions often face difficulty to mobilisefunds for full-scale mHealth implementation asthere may be no reliable or guaranteed governmen-tal financial support for sustaining mHealth initia-tives. If mobile technologies are to be successfullyintroduced across healthcare within developingregions, it is an essential that government agenciesprovide the necessary support, such as local Min-istries of Health and local software industries tomanage and maintain the software artefact.EHealth Nigeria is an example whereby an organi-sation collaborates closely with appropriate politicalpowers to ensure the sustainability of HealthManagement Information Systems.Cognitive factors (4, Figure 1) refer to users’personal self-beliefs and opinions ability to interactwith mobile technologies in a medical domain. Thatis, the degree to which a CHW perceives his or herability to use mHealth technologies in the accom-plishment of a task19. Cognitive dimensions do playan integral role in the use of mHealth technologiesin developing countries as it is reported that suchregions face education limitations (computer illiter-acy) and a lack of English language skills. ResearchFigure 1: Contextual factors which should be incorpo-rated into mHealth solutionsORIGINAL ARTICLE#JOURNAL OF MOBILE TECHNOLOGY IN MEDICINE VOL. 4 | ISSUE 1 | JANUARY 2015 32conducted in the health domain of Mozambiquerevealed that a limited amount of participants werecomputer literate, with only a minority of healthworkers at health facilities having the cognitiveability to interpret health data20. MHealth initia-tives promoted by developed countries are oftendeveloped using the English language. This canhinder the use of mobile technology in medicine dueto the lack of language translation abilities imple-mented within the software solution. It is thereforeimperative that developers facilitate multi-languagesupport to enhance the usability of mHealthtechnologies. Furthermore, training workshopsshould be provided to end users of mHealthsolutions to enhance proficiency with the technol-ogy21. The importance of providing training work-shops is reflected in the work performed by Baobabhealth in Malawi. They offer initial and refreshertraining courses to end users of their eHealthsystems arguing that training is essential.ConclusionThe status quo of the healthcare sector in Africais plagued with uncertainty surrounding lack ofresources (financial, technical and human), inade-quate training to support health care providers, lackof technical infrastructure, limited participation inthe development of medical/clinical standards, andlack of understanding of standards at nationallevel)9. As a result, extant research on IT in theless-developed world has been severely limited. Toadd to this complexity IT solutions designed indeveloped countries have often failed to transfereffectively to African regions. To ensure thatmHealth is a viable option for the health servicessector in African countries many eHealth initiativesare attempting to address contextual factors as partof their development. This perspective piece arguesthat it is imperative for developers to encompasslocal cultural, economic, political and cognitivefactors to ensure intentions, use and diffusion ofmHealth initiatives.Acknowledgements‘‘The Supporting LIFE project (305292) is fundedby the Seventh Framework Programme forResearch and Technological Development of theEuropean Commission www.supportinglife.eu’’References1. Wu J-H, Shu-Ching W, Li-Min L. Mobile computingacceptance factors in the healthcare industry: Astructural equation model. International Journal ofMedical Informatics 2007;76:6677.2. Kjeldskov J, Skov M. Exploring context-awarenessfor ubiquitous computing in the healthcare domain.Personal and Ubiquitous Computing 2007;11:54962.3. Handbook: IMCI management of childhood illness.2005 edition. Geneva and New York, WHO andUNICEF, 2005. Available: http://whqlibdoc.who.int/publications/2005/9241546441.pdf4. CORE Group, Save the Children, BASICS andMCHIP, 2nd Edition 2012. Community Case Man-agement Essentials: Treating Common ChildhoodIllnesses in the Community. A Guide for ProgramManagers. Washington, D.C. Available: http://www.coregroup.org/storage/documents/CCM/CCMEssentialsGuide/ccmbook2012-online.pdf5. Mitchell M, Getchell M, Nkaka M, Msellemu D,Van Esch J, Hedt-Gauthier B. Perceived improve-ment in integrated management of childhood illnessimplementation through use of mobile Technology:qualitative evidence from a pilot study in Tanzania.Journal of Health Communication 2012;17:11827.6. Mechael PN. The case for mHealth in developingcountries. Innovations 2009;4:10318.7. Davis FD Perceived usefulness, perceived ease of use,and user acceptance of information technology. MISQuarterly 1989;13:31940.8. Venkatesh V, Morris MG, Davis GB, Davis FD. Useracceptance of information technology: toward aunified view. MIS Quarterly 2003;27:42578.9. Avgerou C. Information systems in developingcountries: a critical research review. J Inf technol2008;23:13346.10. Fjerrnestad, J, Hiltz, SR. Experimental Studies OfGroup Decision Support Systems: An AssessmentOf Variables Studied And Methodology. In: Proceed-ings of the Thirtieth Hawaii International Confer-ence on System Sciences, IEEE 1997: 4565.11. Adler NJ. International Dimensions of OrganizationalBehavior. Cincinnati: South-Western College Pub-lishing 2002.12. Hofstede G. Culture’s Consequences: InternationalDifferences in Work-Related Values. Beverly HillsCA: Sage 1980.13. Al-Abdul-Gader, AH. Managing Computer BasedInformation Systems In Developing Countries: Acultural perspective, IGI Global 1999.ORIGINAL ARTICLE#JOURNAL OF MOBILE TECHNOLOGY IN MEDICINE VOL. 4 | ISSUE 1 | JANUARY 2015 3314. Kitson N. 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Contextual barriers to mobile health technology in African countries: a perspective piece

O\u27Connor, Yvonne

O\u27Donoghue, John

Irish Universities

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Contextual barriers to mobile health technology in African countries: a perspective piece

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