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Conditions for an app serving unplanned urban communities: integrating cell phones into health promotion messaging
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Conditions for an App Serving Unplanned Urban Communities:
Integrating Cell Phones into Health Promotion Messaging
by
Shirley Feldmann-Jensen
A Professional Dissertation
Presented to the
Faculty of the Sol Price School of Public Policy
University of Southern California
In Partial Fulfillment of the
Requirements for the Degree
Doctor of Policy, Planning, and Development
Committee Members:
Juliet Musso, Ph.D. Chair
Manuel Castells, Ph.D.
Deborah Natoli, Ph.D.
December 17, 2014
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Abstract
Rapid unplanned urbanization is among today’s global challenges and continued
escalation is predicted; further, this growth is most likely to occur in cities of developing
countries. Unplanned growth has widely outpaced the abilities of core services; consequently,
risks to health and wellbeing are amplified in these dynamic environments. As cities have
become more crowded and interconnected, dense populations and degraded environments
facilitate infectious disease transmission, and a mobile society enables rapid diffusion globally.
These complex global public health trends have been largely shaped by advances in
communications technology. Exploring new ways to address these public health issues is needed
in a world undergoing fundamental transformations. A central goal of this project is to advance a
design for a health innovation that can encourage health behavior change among those who have
been excluded from information. Mobile technology converges naturally with community health
education, and has the potential to expand the capacity and reach these informal urban
populations that have been overlooked. The focus of this research inquiry was to determine the
criteria needed for a mobile telephone application development that would present messaging for
infectious disease prevention among urban slums of the world. Described in this report are the
foundational conditions for the development of an app with infectious disease prevention
messaging.
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Acknowledgements
The casual disregard for the smoldering state of infectious diseases in many parts of our
world brought me to this journey. Thus, I must first extend thanks to the many dynamic
communities around the world; which over the years have informed and influenced my
understanding not only of the science of infectious disease transmission and control, but also of
the hardship and suffering that can and does occur because of these diseases.
To the remarkable people who freely gave their time and shared their extraordinary
knowledge to inform this project, I am both grateful and humbled.
The privilege of tutelage under extraordinary scholars has been profound. I am indebted
to Professor Manuel Castells, who has taught me to see the hidden connections in a changing
world. I am deeply appreciative for the invaluable guidance and enthusiasm from Professor
Deborah Natoli. To my advisor, Professor Juliet Musso, who is both inspiring and practical, I
owe much gratitude for urging me toward excellence.
Foremost, to my partner Steven Jensen, who spurred me forward with long illuminating
discussions, encouragement, and support, I am thankful beyond words. Finally, I am obliged to
Barbara Jensen; without her logistical support over the past five years, none of this would have
been possible.
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Table of Contents
Abstract 2
Acknowledgements 3
List of Tables 7
List of Figures 8
Definition of Terms 9
Chapter 1 Introduction 13
1.1 Argument Summary 13
1.2 Context of the Study 15
1.3 Research Purpose 17
1.4 Supporting Literature 18
1.5 Summary 20
Chapter 2 Literature Review 21
2.1 Globalization in the Information Age 22
2.2 Migration 25
2.2.1 Migration trends and governance 26
2.2.2 Migration and health 26
2.3 Rapid Unplanned Urbanization Contributes to Health Inequalities 27
2.4 Infectious Disease 29
2.4.1 Infectious Disease, Urban Inequality, and Poverty 31
2.4.2 Infectious Disease Control 32
2.5 Development in the Global Information Age 33
2.6 Information and Communication Technology (ICT) 36
2.6.1 Mobile Technology for Health 38
2.7 Empowerment 40
2.7.1 Empowerment and ICT 44
2.8 Summary 46
Chapter 3 Methodology 48
3.1 Research Design 49
3.2.1 Ethical Considerations 49
3.2 Processes 50
3.2.1 Participants 52
3.2.2 Data Collection Procedures 53
3.2.3 Data Analysis Procedure 53
3.2.4 Smart Practices 54
3.3 Summary 55
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Chapter 4 Discussion of Results 57
4.1 Infectious Disease Prevention Messaging 58
4.1.1 Infectious Disease Priorities 59
4.1.1.1 Vaccine preventable infectious diseases 60
4.1.1.2 Diarrheal diseases 61
4.1.1.3 Mosquito borne infectious diseases 61
4.1.1.4 Tuberculosis 62
4.1.1.5 Sexually transmitted infections including HIV/AIDS 62
4.1.1.6 Emerging and re-emerging infectious disease 62
4.1.1.7 Non TB respiratory infections 63
4.1.1.8 Neglected tropical diseases and parasites 63
4.1.2 Feasibility of Infectious Disease Priority Sets 64
4.2.1 Feasibility analysis of the disease categories 66
4.1.3 Shaping Health Information for Content Development 69
4.2 Characteristics of Effective App Development 75
4.2.1 Phase 1: Basic Design Considerations 77
4.2.1.1 Mobile devices 78
4.2.1.2 Target audience 79
4.2.1.3 Cost considerations 81
4.2.1.4 Selecting app features 82
4.2.2 Phase 2: Guidelines for Content Development 81
4.2.2.1 Steps 1-3: early stages of content development 84
4.2.2.2 Steps 4- 6: content composition 85
4.2.2.2.1 Step 4: message simplification 86
4.2.2.2.2 Step 5: graphic selection 86
4.2.2.2.3 Step 6: enriching content 87
4.2.2.2.3.1 Decision tree design 87
4.2.2.3 Steps 7-9: testing, adjustments, and software ready 88
4.2.2.3.1 Testing 88
4.2.2.4 Challenges in Content Development 89
4.2.3 Phase 3: Technology Development 90
4.2.3.1 Usability testing 90
4.2.3.2 Technology approach options 91
4.2.3.2.1 Option 1 – scalable SMS platform 92
4.2.3.2.2 Option 2 – mobile web interface 92
4.2.3.2.3 Option 3 – multiple versions from place to place 92
4.2.3.2.4 Option 4 - release to open source forum 93
4.2.4 Phase 4: App Adoption and Diffusion 93
4.2.4.1 Adoption and Diffusion 94
4.2.4.1.1 Marketing considerations 96
4.2.4.1.2 Evaluation metrics 97
4.3 ICT and Public Health Convergence on Community Themes 97
4.4 Summary 98
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Chapter 5 Implementation Considerations 101
5.1 ICT and Implementation Literature 103
5.2.1 Communications Infrastructure 104
5.2.2 Commonly Used Mobile Phone 104
5.2.3 Target Audience: Context and Diffusion 105
5.2.4 Testing and ICT Development 107
5.2 Smart Practices 108
5.2.1 Practice 1: Health care focus 109
5.2.2 Practice 2: SMS samples 110
5.2.3 Practice 3: Optimized text web interface 113
5.2.4 Practice 4: Pilot for illiterate users 114
5.2.5 Practice 5: US Surgeon General 2010 Hosted Health App Challenge 115
5.2.6 Practice 6: The CDC Traveler’s App 116
5.2.7 Practice 7: The ARC First Aid App 117
5.2.8 Practice 8: App Serving Local Food Bank Users 118
5.3.9 Concepts Drawn from Smart Practices 120
5.3 Implementation Logic Model 121
5.4 Summary 127
Chapter 6 Concluding Summary 129
6.1 Characteristics of Effective App Development 130
6.1.1 Basic Design Considerations 130
6.1.2 Foundations for the Content Development 131
6.1.2.1 Topic Narrowing 131
6.1.2.2 Health Messaging 131
6.1.3 Technology Development 132
6.1.4 Adoption and Diffusion 133
6.2 Implementation 133
6.3 Limitations 135
6.4 Further Research 136
Bibliography 137
Appendix A IRB authorization 143
Appendix B IRB application 144
Appendix C Interview protocols 147
Appendix D Construct Analysis Table from PH Field Lessons 150
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
List of Tables
Table 4.1 Feasibility analysis of ID priorities 65
Table 4.2 Conceptually clustered analysis- shaping health information for content 71
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
List of Figures
Figure 1.1 Literature Map 19
Figure 4.1 Infectious Disease Set Priorities 60
Figure 4.2 Vaccine Preventable Disease List 61
Figure 4.3 Methodology for Successful App Development 76
Figure 4.4 Relationship between Infrastructure and Communications Technology
Availability 77
Figure 4.5 Mobile Phone Technology in Developing Countries 78
Figure 4.6 Target Audience Considerations 80
Figure 4.7 Selecting App Features 83
Figure 4.8 Steps of Practice for Content Development 84
Figure 4.9a Testing Stages 89
Figure 4.9b Testing Stages 91
Figure 4.9c Testing Stages 94
Figure 4.10 Implementation Approach options 91
Figure 4.11 Community Theme 98
Figure 5.1 Example: Health Care App Example 110
Figure 5.2 Example: Guide to Using the SMS System for Uploading Patient Data 112
Figure 5.3 Text Web Interface Function 113
Figure 5.4 Example: Bangladesh’s handheld application for semiliterate and
Illiterate Users 115
Figure 5.5 Example: U.S. Surgeon General 2010 Hosted Health App Challenge 116
Figure 5.6 Example: CDC’s Travelers App 117
Figure 5.7 Example: America Red Cross First Aid App 118
Figure 5.8 Example: App Serving Local Food Bank Users 119
Figure 5.9 Logic Model 126
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Definition of Terms
Application (App) - is a software “kernel” that sits on a mobile device and can interact with
internet based services. (World Bank, 2012, p. 4)
Collective action – When people work together on a common goal to produce public goods.
Communications for social change – Use of communication technology to play a role in
strengthening human and social capabilities (Gigler, 2004, p.24).
Development - The “social process by which humans as a collective enhance their
wellbeing while creating the structural conditions for the expanded reproduction of the
process of development itself” (Castells, M. and Himanen, P., 2014/15, p. 1).
Dignity – A fundamental basis of life values where a person’s sense of self-respect and esteem is
essential for individuals to form an integrated citizenship with others (Calderon, 2014-15,
p. 31 & 38).
Disease Outbreak – While it is synonymous with epidemic, it is the preferred phrase as it can be
less sensational. The alternate meaning refers to a localized as opposed to generalized
epidemic (CDC).
e-Health – A centralized electronic health application for a health care provider and/or client.
Epidemic – The occurrence of more cases of disease than expected in a given area or among a
specific group of people over a particular period of time (CDC).
Empowerment – The increase of political, social and economic strength of individuals and
communities, as well as confidence in one’s own capabilities (Grunfeld, 2007, p. 10).
Environmental injustice - certain minority populations are forced through their lack of access
to decision making and policy making processes, to live with a disproportionate share of
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
environmental ‘bads’ and suffer the related public health problems and quality of life
burdens (Agyeman, 2003).
Globalization - “A multidimensional process to which a given system becomes global to
function as a unit in real or chosen time on a planetary scale.” The processes of
globalization today are reliant upon three foundational capacities: technological,
organizational, and institutional (Castells, 2011).
Herd Immunity- The resistance of a group to invasion and spread of an infectious agent, based
on the resistance to infection of a high proportion of individual members of the group.
The resistance is a product of the number susceptible and the probability that those who
are susceptible will come into contact with an infected person (CDC).
Human Development - Refers to a process of enhancement of the living conditions that make
humans human in a given social context (Castells, M. and Himanen, P., 2014/15, p. 8).
Human Wellbeing - The use of the resources generated in the production process to improve
human quality of life according to the cultural values embedded in a given social
organization (Castells, M. and Himanen, P., 2014/15, p. 2).
Incidence Rate- A measure of the frequency with which an event, such as a new case of illness,
occurs in a population over a period of time. The denominator is the population at risk;
the numerator is the number of new cases occurring during a given time period.
Informal settlements- the product of poverty and inequality, social and spatial exclusion, and
inappropriate urban planning that fails to deliver well located serviced land and that
enforces a regulatory framework which requires people to step outside of the law to
survive in urban areas (Watson, 2010).
Information – Facts that can be shared or transmitted through communication
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
(Schilderman, 2002, p. 4).
Information literacy – The ability to know when information is needed, find and evaluate the
information, and then use it effectively to solve a problem (American Library
Association, 1989).
Knowledge - Information which has been internalized by individuals, a community or a society
(Schilderman, 2002, p. 4).
m-Health – Mobile telephone application utilized for health care or public health purposes.
Migration - The movement of a person or a group of persons, either across an international
border, or within a State. It is a population movement, encompassing any kind of
movement of people, whatever its length, composition and causes; it includes migration
of refugees, displaced persons, economic migrants, and persons moving for other
purposes, including family reunification (UN International Organization for Migration).
Morbidity - Any departure from a state of physiological or psychological well-being.
Mortality Rate - A measure of the frequency of occurrence of death in a defined population
during a specified interval of time.
Networks - Complex structures of communication constructed around a set of goals that
simultaneously ensure unity of purpose and flexibility of execution by their adaptability
to the operating environment” (Castells, Communication Power, 2009, p. 21).
Pandemic - An epidemic occurring over a very wide area (several countries or continents) and
usually affecting a large proportion of the population (CDC).
Power - The relational capacity that enables a social actor to asymmetrically influence the
decisions of other social actors in ways that favor the other empowered actor’s will,
interests, and values (Castells, 2010, p.10).
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Prevalence - The number or proportion of cases or events or conditions in a given population.
Rapid Unplanned Urbanization- the case where the speed of urbanization outpaces the ability
of governments to build essential infrastructures that make life in cities safe, rewarding
and healthy (WHO & UN Habitat, 2010).
Slums – a term that describes a wide range of low-income settlements and/or poor human living
conditions. A heavily populated urban area characterized by substandard housing and
squalor (UN HABITAT).
Social determinants of health - The circumstances in which people are born, grow up, live,
work, and age, and the systems put in place to deal with illness. These circumstances are
in turn shaped by a wider set of forces: economics, social policies, and politics (WHO).
Social exclusion - The lack of basic rights and the consequent deterioration of human dignity
(Calderon, 2014-15, p. 58).
Spatial scale of transmission - Refers to the fact that higher urban population densities allow
for increased rates of transmission (Kendall, C., et al, 1991).
Sustainable development – Development that meets the needs of the present without
compromising the ability of future generations to meet their own needs (WCED, 1987).
Urbanization – Dynamic process of economic development, population movement, and growth,
and spatial expansion with issues of sustainability (Vladhov, et al).
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Chapter 1
Introduction
“We cannot really have an adequate understanding of the future without some view about how well the lives of the poor can be expected to go.”
Amartya Sen, “Will There be Any Hope for the Poor?”
Exploring new ways to address global public health issues is of critical importance in a
world undergoing fundamental transformations. As the world steadily becomes more
interconnected and interdependent, the complexity and risk for infectious disease outbreaks
intensifies. Yet, this same interconnection may also be a basis for innovation. The extensive
global penetration of the mobile phone, establishes this technology as a candidate for a new
global public health tactic. Adept use of mobile technology can be a useful tool in what
Buckingham (2001, p. 199) characterizes as the constant yet ever-changing quest to reduce
human suffering and death.
The global burden of disease caused by infectious agents has been reduced to about a
quarter of worldwide deaths. Yet, powerful changes occurring in the social, built and physical
environments of the planet are redistributing the consequences of these microbes. This new and
sobering frontier includes rapid urbanization, competition for water and food, climate change,
environmental degradation, an erosion of global public health infrastructure, and the emergence
of novel and drug resistant pathogens. The relationship between these indicators is they each can
result in public health emergencies.
Argument Summary
Three interrelated phenomena contribute to the daily spread of infectious disease in
developing countries: globalization, population mobility, and rapid unplanned urbanization.
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
With these influences as the broad context of the study, the inquiry focuses on a fresh means to
intervene on these global health concerns and varies from the common public health approach.
For years a knowledge gap has existed between the poor and those more well off. Farmer
confirms, “The viewpoints of the poor are neglected as long as the elites control communication
and information” (Farmer, 2005). Therefore, it is important to advance a design for a health
intervention that can empower health behavior change, particularly among those who have been
excluded from information networks in the past.
Growing penetration of mobile telephone devices around the world has created a new
realm of possibilities for social change. In 2010, 75% of the world’s population had access to a
mobile phone and 90% lived within range of mobile cell signals (World Bank, 2012, p.8). By
2013, 92.6% of the world’s population had mobile cellular subscriptions (World Bank, 2014).
The adoption and use of cell phones in developing countries has exceeded that of the
developed countries, holding 77% of the mobile subscriptions globally (World Bank, 2012, p. 8).
Further growth potential exists among the large younger populations that are present in
developing nations (World Bank, 2012, p. 11). This widespread diffusion positions these
countries to benefit in many ways from mobile technology. Fundamentally, these devices can
play a role both in overcoming information asymmetry and positively affect community health.
The use of mobile telephones for basic health promotion messaging can inform and influence the
end user to take steps toward creating a healthier community.
The use of cell phones in public health applications is in its infancy. Although m-health
is a growing area for health care and health delivery, public health utilization is only beginning
to explore the possibilities. For further utility, the mystery of mobile technology in community
health education needs to be unveiled.
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Overall, the innovation using mobile phones to improve community health in informal
settlements is of high value. The digital technology blueprint can set the groundwork toward a
practical and relevant decision making tool for other applications. Accessibility of basic health
information via mobile telephone is just a beginning point to bridge the chasm.
Context of the Study
Rapid urbanization and the ensuing informal settlements are among the most vexing
challenges in the world today. Over the course of the past three decades, the processes often
referred to as globalization have altered the functioning configuration of humanity. These
changes have been driven by technological developments, economic practices and political
influences, in which the processes have produced a networked and interdependent world
(Castells, 2011). In the midst of this connectedness, a complex trend toward rapid unplanned
urbanization has evolved.
The growth of urban areas has been shaped both by greater population mobility and
population growth. The movement of people not only has increased urbanization, it has widened
the spread of pathogens. Still, the trend of interconnectedness between urbanization and the
spread of infectious disease is not new (Quinn, T., and Bartlett, J., 2010, p. 106). Some of the
oldest public health measures in existence were developed to address migration practices and
manage the spread of infectious disease. However, recent years have brought about changes that
influence both population movements and population health, with increasing exposure to
diseases that were previously unknown to population segments before.
An important aspect of urbanization is the expansion of unplanned, informal settlements.
It is estimated by UN HABITAT that up to one third of the world’s population lives in slums.
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Further, it is projected that by the year 2030 the number of slum dwellers will increase to two
billion people (UN HABITAT, 2003). These dense communities are characterized by deficient to
nonexistent infrastructure, with unreliable water supply, no sewage, poor drainage and ever
increasing solid wastes. The deprived water and sanitation conditions alone are the leading cause
of global child mortality (ONE, 2014). Moreover, the degraded environments support repeated
disease transmission, provide vector habitats, and contribute to emergence of new infectious
diseases.
Creative innovations for constructively influencing change are sought to address the
health deficits in these communities. Local communities are increasingly interacting with the
world community on both social and economic levels (Doarn, C.R., and Merrell, R.C., 2012).
Correspondingly, communications connectivity plays a key role in this interdependent and
interconnected world, and the transformative power of information technology has been widely
observed across societies. For that reason, mobile telephones present an opportunity to explore
its potential as a public health education tool.
The availability of increasingly affordable information technology means that developing
countries are distinctly placed to benefit from mobile communication approaches. In particular,
there is an opportunity to use mobile phones in the diffusion of basic health messages. Even
among the world’s poor, cell phones can now be used as a mechanism to allow greater
participation of the people themselves to promote health efforts in their communities. In the
developed world, dissemination of information for health care delivery via cellular phones is
finding growing success. Broadly speaking, most people are interested in their own well-being
and do want information that may foster improvements.
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Research Purpose
Infectious disease control among informal urban communities is a complex issue and the
solution lies beyond the reach of the public health sector alone. Potential keys can be sought in
the same interconnectedness and interdependency that has also influenced the rise of these
issues. Recognizing the challenges surrounding this real-world need, the idea explored was to
generate an introductory plan that could be applied toward the development of a mobile
telephone application. This research project addressed the question: What criteria are needed
for development of a telephone application that promotes the reduction of the significant
infectious diseases among informal urban settlements of the world?
The purpose of this project was to create the preliminary foundation toward development
of a mobile telephone application with health promotion risk reduction messaging specific to
communicable disease. Existing data and empirical observation will be interpreted and applied
into a decision making pattern toward the development of a mobile phone app with population
health benefits. Intended end users for the mobile app are inhabitants of informal settlements in
developing countries. The overall hope for this blueprint is to promote and guide development
of an app that could diffuse basic communicable disease prevention information to slum
communities of the world.
Beyond the scope of this project, the groundwork may later influence actual development
and implementation of a telephone application, and would provide basic health information for
urban slum dwellers. Upon implementation, a telephone application can be an accessible tool to
provide specific health promotion information to informal communities. Utilizing a nested
hierarchy of choices, or decision tree, users can select a health issue present in their community
that they want to work on solving, and then be guided step by step through achievable prevention
18
CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
measures. Conceptually, using telephone connectivity for basic messages can enable people to
act in their interest and perhaps even their community’s interest.
Supporting Literature
The theoretical bases of the project began broadly with the underlying changes brought
about by globalization then moves inward to its influences on migration, unplanned urbanization,
and the dangerous spread of disease within these informal urban settings. At the same time, the
wide use of mobile phones in these locations links to technology development and mobile
application that could enable broader health information dissemination and encourage
participative action. This structural approach is largely influenced by the ecological and
networked systems views in the selection of supporting literature.
“A key characteristic of systems thinking is the ability to shift attention back and forth
between system levels. At each level we have systems that are integrated wholes, while
at the same time they are parts of larger wholes. Throughout the living world we find
systems nesting within other systems” (Capra, 1994).
The nesting of these multiple classifications forms the categories for the supporting literature,
and is depicted below in Figure 1.1. As illustrated, the relevant literature categories include:
globalization, migration, unplanned urbanization, infectious disease, technology development,
mobile telephony as a public health tool, and participative action. If one imagines this nesting
three dimensionally, it refines the topic to the point of a cone; thus, the topic is not as broad as it
initially appears. Further, the nested categories have subsets which deepen the project’s
foundation.
19
CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
The academic themes can also be viewed as sets. The first set was justificatory and
diagnosing, and comprise the outer themes. The literature themes of the middle set inform the
content and design of the innovation. Finally, the small central segments look to practices for
implementation.
Selected foundational concepts include: systems theory of networks, complex adaptive
systems, risk and vulnerability, social determinants of health, community based participation,
and development theories such as freedoms and capabilities described by Sen, and dignity for
development described by Castells, Calderon, and Himanen. The relevant theories and
principles inform the broader strategy as well as the formation of the design choices. The
overarching goal is to creatively yet practically address a complex public health problem;
specifically, to develop the groundwork toward a mobile telephone application.
Figure 1.1: Literature Map
“In a systems view, we realize that the objects are networks of relationships embedded within larger networks.” (Capra, 1994)
20
CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Summary
Multi-dimensional dynamics shape the challenges existing in global public health today:
migratory movements of people, rapid unplanned urbanization, eroding public health
infrastructures, competition for food and water, environmental degradation, and climate change.
These undercurrents are interrelated, influencing the consequences of pathogens and elevating
the risk for public health emergencies. One way to address the complexity is a grass roots
approach, where information may empower small changes first individually, then within the
family, and finally the community.
Community health messaging is needed among populations that characteristically suffer
an asymmetry of information. One possibility is to utilize mobile telephones to bring basic
disease prevention information to people in slums. The exploration of this study is to create a
preliminary foundation for a mobile telephone application. The overall intent is to provide a
guide to the development of an app that could diffuse basic communicable disease prevention
information to slum communities of the world.
The arrangement of this research report follows a customary style. A review of the
literature further defines the dynamics surrounding the problem, builds the theoretical
foundations toward intervention, and informs the proposed innovation in Chapter 2. Research
design and the steps taken in the research process are discussed in Chapter 3. Interview findings
are discussed within Chapter 4, presenting an integration of the infectious disease prevention
messaging and effective characteristics of app development. The applied nature of this project is
discussed in Chapter 5, analyzing existing practices and implementation options. Finally,
Chapter 6 concludes with an overview of the primary findings, project limitations, and further
research recommendations.
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Chapter 2
Literature Review
“If you’ve come to help me you are wasting your time.
But if you’ve come because you believe your liberation is somehow bound up in mine, stay and let us walk together.”
Aborigine proverb
The gravity of the public health issues existing among the urban poor of the world calls
for new strategies to inspire action. These complex global public health trends have been largely
shaped by advances in communications technology. Notably, it is in this same
interconnectedness and interdependency brought about by evolving communications technology
that potential answers can be found.
Technological innovations in communications have fundamentally driven the
transformation of the global economy and with it the way our world is structured. One indicator
among these changes includes overwhelming migration to urban areas. Bleakly, migration is
often accompanied by ineffective policies on urban development, and eroding public health
infrastructure, particularly in developing nations. In addition, the resultant shifts in the social,
built and physical environments not only influence the human and microbial ecologies, but also
their interactions. Population movements widen the spread of microbes, degrade environments,
further disease transmission, increase vector habitat range and give rise to new infectious strains.
Unmistakably, the meager public health services are largely unable to provide infectious disease
control among these weakest elements of society. Approaches to influence this complex array of
issues may lie in the same interconnectedness and interdependency that has also shaped their
advent. This reasoning is confirmed by Calderon, “The new culture of technological sociability
can change both subjectivity and the patterns of knowledge and everyday life of individuals and
communities” (Calderon, 2014-15, p. 45).
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This chapter establishes the interdisciplinary research foundations of the project. It
begins broadly with a consideration of the fundamental changes wrought by globalization, which
influences migration, and in turn affects unplanned urbanization; within these informal urban
settings, infectious disease transmission is an imminent problem. However, technology
development provides a means to creatively utilize mobile telephones for community health
messaging on basic preventive actions. The individual measures taken may have the potential to
become a catalyst for collective action and social change.
Globalization in the Information Age
Globalization provides the broad context within which this project is positioned. The
processes of globalization have altered the social, built and physical environments of the world,
and as a result, affect human suffering and death. Globalization has been described by Castells
as “a multidimensional process to which a given system becomes global to function as a unit in
real or chosen time on a planetary scale” (2011). The processes of present-day globalization are
reliant upon three foundational capacities: technological, organizational, and institutional
(Castells, 1996). Fundamentally, the technological developments of the past fifty years in
computerized communications, internet connectedness and transportation mobility have
facilitated the transformation of interdependent global systems. Although the whole world is not
globalized, it has global processes that are supported by key networks (Castells, 2011). An
important feature is that these processes benefit those inside the network of globalization, but
there are many who remain outside the network. This polarization of inclusion / exclusion
contributes to the fragmentation seen within and between societies (Castells, 2009, p. 20). From
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a public health position, this disparity can be observed in access to and distribution of health
resources and the resulting health outcomes throughout societies.
The relationship of globalization to health has been established historically, and it is
important to emphasize that the degree of globalization and the spread of infectious disease have
followed a parallel course throughout history (Institute of Medicine, 2006). Subsequently, it is
helpful to distinguish that population health is considered affected by globalization when the
spread of transmissible diseases is spatially wider and temporally faster than it may have been
otherwise. To give this historical context, it has been documented that an outbreak of what may
have been smallpox in AD 166 contributed to the decline of the Roman Empire; where
population loss compounded interdependent losses elsewhere (Bray, 2000). Further, the Black
Plague of the mid fourteenth century moved along the lines of human communications (Bray,
2000). Current globalization is viewed as an intensification of historic trends (Quinn, T., and
Bartlett, J., 2010). Today, geographic expansion of infectious diseases can be accelerated by
international commercial trade and increased air travel, and spread worldwide through the
movements of humans, livestock, insects, food, transportation systems or any combination of
these. Additionally, the societal transformation brought about by recent globalized processes is
one that is dualistic and inequitable. As a result, the disproportion of wealth and power add
compounding factors that affect population health.
As social structures have transformed through the globalized network of communication
flows, what is valued has also changed in a way that has become an institutionalized practice
related to the exercise of power (Castells, 2009, p. 10). One way power formation occurs in
today’s society is discourse, where communication technology networks shape the public mind
(Castells, 2009, p. 53). It is through these communications that meaning is constructed, shared
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and legitimized in society (Castells, 2009, p. 12). For that reason, ideas appear to hold the
highest value and communications have the central power in today’s global society (Castells,
2009, p. 29 and 53).
Both threats and opportunities are present in this global interconnectedness and
interdependence. Observing a far-reaching vulnerability, Castells emphasizes the necessity for
attentiveness to these network forms of power, in order to “neutralize the unjust exercise of
power and to challenge their hidden domination” (2009, p. 431). Supporting this position,
Calderon notes that the global network of power exists with no social control or unity of
common belief in value sharing (2014-15, p. 55). Because ideas and communications have the
greatest value and power, it becomes clear that upholding information sharing is integral to
social stability and advancement.
Even in the face of accelerating patterns of global inequality, compelling reasons to
remain optimistic can be found. Power relationships in communications have potential for
change with the introduction and growth of mass self-communication (Castells, 2009, p. 422).
While the global nature of the system remains dominant, opportunity opens up through social
action among smaller, localized communities connecting as a node into global networks
(Castells, 2009). Appreciably, it is this connection to the network that a mobile application with
community health information can potentially stimulate local action, social changes and even
further connectivity.
On the other hand, the global networks also trigger changes in population movement that
can produce further disparity. A recognize occurrence in the milieu of globalization, migration is
rapidly changing the distribution of humanity on the planet. Moreover, the resulting shift of
population has social, environmental, and health complications.
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Migration
The migration or movement of people is an age old occurrence, which is both complex
and influenced by the global economic flows. “Ideas, information & people follow armies and
economic flows and in so doing transform societies” (Nye, J.S., and Donahue, J.D. , 2000). The
global trends of communications networks, liberalized trade policy,environmental degradation
and economic disparities influence migration networks. Despite the fact that capital flows freely
in global financial networks, labor is still highly constrained by institutions, borders, culture,
police and xenophobia (Castells, 1996, 2000).
Migration is considered a defining issue of this century. The International Organization
for Migration (IOM) recognizes migration as: “The movement of a person or group of persons
from one geographical unit to another across an administrative or political border, wishing to
settle definitely or temporarily in a place other than the place of origin” (Migration Policy and
Research Program, 2005). Beyond the definition, the range of migrant populations requires
further delineation. Migratory forms have been described using the distinctive trends in migrant
movement (Migration Policy and Research Program, 2005). Uni-directional refers to the
international migration from one country to another. Circular migration is the form of movement
back and forth between the place of origin and place of current habitation. Multidirectional
indicates a mobile society with livelihood movement between multiple locations. Patterns are
also evident in population movement and can be expressed within broad categories of relocation
rationale. The push pull factors that stimulate migration include movement from unsafe to safe,
poor to rich, or rural to urban movement (Migration Policy and Research Program, 2005).
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Migration trends and governance.
Migration today is not only on the rise, it is increasingly unplanned. According to IOM
data, there is an estimated 1 billion migrants in the world today, comprising 214 million
international migrants and 740 million internal migrants (IOM, 2014). The gender ratio of
migration has also changed in recent years; around 50% of migrants are now women (IOM,
2014). Importantly, the increased ease of movement is tied to the evident disparities between and
within countries (Migration Policy and Research Program, 2005) as well as the influences of
climate change. Contemporary migration is anticipated to continue in relationship to the effects
of climate change, economic imbalance and conflict.
The response to migration is fraught with contradictions. The capacity to acknowledge
the growing scope of, respond to and keep pace with migration has been surpassed in most
countries (Carballos, 2007). The challenge in migration management and policy seems to be
delicately balancing the two worlds: the networked sphere and the institutionally constrained
domain.
Migration and health.
A relationship has been recognized between migration and poor health outcomes.
Vulnerability increases for displaced populations, who are exposed to a wide range of health
hazards moving between environments (WHO Secretariat, 2008). Forces in the health and
migration interaction include “the socio-economic and cultural background of migrants, their
previous health history, and the nature and quality of the health care situation they had access to
prior to moving” (Carballos, M., Mboup, M., 2005). The nature of relocation itself, both the
directionality of movement and the rationale for movement, are other significant influences on
health outcomes. Resource poor and disaster prone areas of cities are often the areas new
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migrants come to; ignored sanitation and prevalent infectious diseases are characteristics of these
zones (Burkle, 2010). Finally, upon entering a different location, migrants can experience ethnic
discrimination, exclusion and poor access to services, irrespective if they are documented or
undocumented, skilled or unskilled. Acknowledgment of the link has recently put migrants in
the midst of a policy focus; still, little has filtered down to a change in practice. Because
countries of the world today are interconnected and interdependent, shared action is critical to
counter the poor health and disease that exists amid migrant populations; not doing so is not only
shortsighted, but can have far reaching effects (Carballos, M., et al., 2005).
Rapid Unplanned Urbanization Contributes to Health Inequalities
Rapid unplanned urbanization is among the most confounding of today’s global
challenges. It has resulted from immigration, and often in-migration seeking economic
opportunities, and has resulted in the proliferation of informal settlements, defined by Watson
(2010) as:
“The product of poverty, inequality, social and spatial exclusion, and inappropriate urban
planning that fails to deliver well-located serviced land, and that enforces a regulatory
framework which requires people to step outside of the law to survive in urban areas”.
Metropolitan regions are magnets because of their concentrated economic activity,
communications, wealth, and access to both transportation and health care. However, instead of
a better life, risks to health and wellbeing are often found in these dynamic environments. Quite
commonly, burdens of morbidity and mortality are seen in cities today due to infectious disease,
chronic disease, injuries and violence. Moreover, the accelerated pace of urbanization amplifies
these health concerns.
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The growth of urban areas are largely influenced by population growth, but are also
affected by rural to urban migration (Montgomery, 2010), with the lack of investment in rural
services being another driver. The number of urban residents is forecasted to grow by 60 million
every year (WHO and UN HABITAT, 2010). Furthermore, most urban growth of the next 30
years will occur in cities of developing countries (WHO and UN HABITAT, 2010).
Fundamentally, rapid unplanned urbanization must be viewed through the complexity of the
globalized forces from which they evolved. As cities have become more crowded and
interconnected, the health consequences also change; dense populations and degraded
environments facilitate infectious transmission, and a mobile society enables rapid diffusion
globally.
Urban growth has outpaced the abilities of governments to build and maintain essential
infrastructures (WHO and UN HABITAT, 2010); and thus, the evolution of informal settlements
or slums. Additionally, United Nations (UN) estimates indicate a massive deficit in provision for
water and sanitation in these urban areas. Consequently, informal settlements can be
characterized by inequality, poverty and environmental degradation. It is the density of
population that drives these deficits in supply of sanitation, shelter, water and food quality
(Burkle, 2010). Moreover, the density of populations exceed the humanitarian requirements for
displaced populations, The Sphere Standards, by100-1000 times in some urban areas. The
significance of an overly dense population is that an infectious disease outbreak transmits far
more rapidly. This landscape highlights the grave vulnerabilities of these slum communities and
they are a weak link in the global network society (Davis, 2006, p. 204).
In developing countries, rapid urbanization has often exceeded labor demands and the
capacity to absorb migrants (Ndiaye, N., Carballo, M., and Ndaye-Coic, R., 2010). A striking
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feature is that over-urbanization takes place without the appropriate infrastructure or systems,
and the process is driven by the “reproduction of poverty” and not the supply of jobs (Davis,
2006, p. 16). Yet, it is critical to discern that “slums and poverty are closely related and mutually
reinforcing, but the relationship is not always direct or simple” (UN HABITAT, 2003).
The relationship between access to basic services and health outcomes has become
paramount. Deficits of core services in informal urban communities reinforce poverty,
concentrate risk and hazards, increase morbidity and disability, and lower life expectancy.
Unreliable and unclean water supply, deficient sewage and drainage, and proliferated solid waste
all contribute to repeated disease transmission and provide vector habitats. Moreover, poverty
limits people’s ability to use proper disease prevention measures, to secure adequate healthcare,
or to act in environmentally responsible ways (Boischio, A., Sanchez, A., Orosz,Z., and Charron,
D. , 2009). As a result, slums are ideal for the spread of infectious disease (Quinn, T., and
Bartlett, J., 2010).
Infectious Disease
Infectious diseases (ID) have been a part of the world for centuries, and were both
commonplace and disastrous before the first antibiotics were developed (Garrett, 2000).
Occurrences of catastrophic epidemics and pandemics in past eras were great regulators of
population and mediated social systems (Bray, 2000). Current trends show that twenty-six
percent of reported global mortality is attributed to infectious diseases today with a similar ratio
for morbidity (W.H.O., 2014). However, this burden is far greater for developing nations
(Quinn, T., and Bartlett, J., 2010), where the higher morbidity and mortality is related to social,
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demographic, and environmental factors such as migration and unplanned urbanization. These
factors ultimately limit access to vaccines, medicines, and care of the environment.
Commonalities exist among infectious diseases, based upon the disease outcomes.
These shared results can be described by three basic characteristics: disability causing, high
mortality causing, and emerging/re-emerging (Migration Policy and Research Program, 2005).
Disability causing infectious diseases are often endemic in Lesser Developed Countries
(LDCs) amid poverty, where people have minimal access to vaccine or medication. Examples of
such diseases include parasitic worms, other vector borne diseases, diarrheal diseases, hepatitis,
cholera, typhoid. In this disease category, the debilitating effects of illness causes loss of
productivity and livelihood, creating even a greater vulnerability to the household. These often
neglected diseases affect approximately 1 billion people, many of whom move into and around
cities transmitting the infections to other susceptible people (Migration Policy and Research
Program, 2005). Nevertheless, basic health messaging for health behavior change could have a
significant influence on reducing this unwanted suffering.
High mortality infectious diseases are endemic through specific populations; which can
be exemplified in malaria or HIV and the populations they affect. Vaccines are generally not
available for these agents. Importantly, these are key targets for health messaging for behavior
change or social action.
Emerging and re-emerging infectious diseases (EID) comprise traits of grave concern.
Contributing factors to the re-emergence of a disease once thought to be under control are
antimicrobial resistance and environmental degradation. Greater than 60% of emerging
pathogens originate from zoonotic origins (Quinn, T., and Bartlett, J., 2010), and can be
associated with development encroachment into bio-diverse zones, environmental degradation
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and increased contact with wildlife. Furthermore, climate change has widened the territory of
vectors, bringing disease to regions it did not exist before. The danger a new pathogen poses is a
greater vulnerability to the infection, because there is no previous human exposure or herd
immunity. In the current globalized context, no location can be secure from the threat of an
emerging infectious disease, even though the outbreak may begin in a seemingly remote part of
the world (Quinn, T., and Bartlett, J., 2010). The potential disruption produced by a serious
emerging infectious disease could be confounding. The emergences of HIV and its spread to
pandemic status, Ebola hemorrhagic fever, SARS and novel influenza viruses all exemplify the
unpredictable nature of a pathogen to which no herd immunity exists in society.
Infectious Disease, Urban Inequality, and Poverty.
Pathogens are not the only influences on health outcomes. The World Health
Organization (WHO) has substantiated the importance of the social determinants of health; the
external forces include economic, political and societal influences. Poverty has been identified
as a primary cause of illness in lower income countries (Clifford, G.D., Blaya, J.A., Hall-
Clifford, R., and Fraser, H., 2008, p. 1). The reasons are clear, the poor are affected
disproportionately because of inequities in basic living conditions, access to health care and
migration patterns (Saker, L., Lee, K., Cannito, B., Gilmore, A., Campbel, D., 2004).
Because more than half of the world’s population now lives in urban settings, the effects
of population density are critical to highlight. Higher urban population densities generate
increased rates of infectious disease transmission, referred to as the ‘spatial scale of
transmission’ (Kendall,C., Huddelson, P., Leontsini, E., Winch, P., Lloyd, L., and Cruz, F. ,
1991). Infant mortality statistics reveal that “infants in poor and more crowded portions of cities
are four times more likely to die” (Quinn, T., and Bartlett, J., 2010). Higher child mortality rates
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are also evidenced among crowded city slums in contrast to other areas of the same cities
(UNHABITAT, 2007).
Pathogens and vectors endemic to rural environments have also been conveyed into urban
areas. Poverty, crowding, lack of services, and frequent migration in and around urban areas
have all created ideal conditions for propagation of disease (Kendall, C., et al., 1991). As a
result, transmission and incidence of infectious disease can also be expected to flourish in these
urban environments. As these pathogens flourish, they also get transported in the mobile global
society. And so, the “multiplication of risks causes world society to contract into one community
of danger” (Beck, 1992, p. 44). A poignant example of this is the 2004 outbreak of SARS. In a
matter of three days, this respiratory infection was breaking out on several continents. While
containment of the disease was achieved within a few days, the cost due to the behavioral effects
from fear of the SARS outbreak is estimated to have cost 40 billion dollars in global GDP loss
(World Bank, 2014). Therefore, the SARS outbreak demonstrates both the interconnectedness
and damage of even a relatively small outbreak.
Infectious Disease Control.
Among the best means of preventing disease outbreaks is coordinated disease detection
with appropriate containment measures to prevent their spread. In the realm of communicable
disease control, hyper-vigilance is necessary. In many regions there is a paucity of
epidemiological information. Poor city migrants are often neglected altogether because public
health authorities do not collect information in informal or illegal settlements, and miss homeless
people completely (WHO and UN HABITAT, 2010). The lack of information on which to base
health interventions is underscored in Davis’ assertion that “rapid urbanization in the developing
world is increasingly unplanned and decreasingly knowable” (Davis, 2006).
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These data deficiencies are an important gap of knowledge that exacerbates inequities
and exclusion, and can affect meaningful interventions. The complexity of infectious disease
control in unplanned urban communities indicates that any solution must extend beyond the
public health sector. Engaging participation of local communities and multiple disciplines is vital
to make inroads in the improvement of public health in this context. Civil society still has the
ability to create pressure from the bottom up, to make protecting environments and promoting
health a topic of concern (Chan, 2010).
Development in the Global Information Age
As the transformation driven by technological communications has moved the world
from the industrial age to the information age, the growing consequences of the inherent dualistic
nature, inclusion /exclusion, are evident throughout global society. The world is simultaneously
“prosperous and miserable” (Calderon, 2014-15). There is a dire need to pair these inclusions
and exclusions to a more holistic development approach. A new approach to development is
needed. One with an “informational human development” focus, “linked to the new
technological intercommunication on which societies and individuals can address the new forms
of power and domination associated with changes in globalization” (Calderon, 2014-15, p. 46).
The models of global human development have largely been shaped by measuring
economic growth, using gross domestic product (GDP) as an indicator. In a pivotal report,
Stiglitz, et al. (2009) argue that the measurements for development are flawed, and the inferences
and decisions that flow from them, unfair. The report’s central message was that the emphasis
of measuring economic production needs to change to measuring people’s well-being and
generating sustainability in development (Stiglitz, J., Sen, A., and Fitoussi, J., 2009). Described
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as multidimensional, well-being is shaped by eight principle components: “material living
standards, health, education, personal activities, political voice and governance, social
connections and relationships, environment, insecurity” (Stiglitz, J., Sen, A., and Fitoussi, J.,
2009).
The idea of capability deprivation is put forth by Sen (1999) to better understand the
poverty of human lives, with freedoms as a social product. Conceptually, development is
approached in the broader terms of substantive freedoms: 1) political, 2) economic facilities, 3)
social opportunities, 4) transparency guarantees, and 5) protective security (Sen, 1999). “Each of
these types of rights and opportunities help advance the general capability of a person” (Sen,
1999, p. 10). This theoretical foundation enables us to recognize “poverty and deprivation in
terms of lives people can actually lead and the freedoms they do have” (Sen, 1999, p. 92) In this
theoretical context, exclusion must be understood within the broader context of social relations,
and poverty understood in terms of deprivation of capabilities (Calderon, 2014-15, p. 60).
Implicitly, the construct Sen frames form a beginning basis for setting criteria of the health
messaging approach.
In a critique of Sen’s concepts, Himanen (2014/15) concurs that capabilities are freedom,
but also recognizes that “notions of capability become the object of particular moral scrutiny”.
“Sen sets out from the concept of freedom, but he does not provide a reason for why people
should be free. The foundation is the idea of dignity, that all people are worthy of freedom.”
(Himanen, 2014/15, p. 84). Importantly, dignity lies at the heart of both human rights and ethics
(Himanen, 2014/15, p. 87). Likewise, the bias of the inclusion/exclusion selection can be
reformed when connected to dignity and equal rights (Calderon, 2014-15, p. 66). Promoting the
conditions for a dignified life is the underlying objective of sustainable development (Himanen,
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2014/15, p. 78). From this new perspective, development is “creating the access necessary to
empower actor’s capabilities” (Calderon, 2014-15, p. 34). Thus, it is vital to incorporate
strategies that further human dignity as an underpinning goal in human development for the
information age (Castells, M. and Himanen, P., 2014/15). While overall health may not qualify
as a right for every human being, the essentials of public health certainly do (Garrett, 2000, p.
500).
A new pattern of sustainable development is endorsed by Calderon. A refocus of effort
is urged, where the subjects of development are people and their communities (Calderon, 2014-
15, p. 76). Further, the endeavor should be to “expand and renew their capabilities of agency,
through linking human development with informational progress and multiculturalism”
(Calderon, 2014-15, p. 76). To change the existing path of development, Calderon (2014-15, p.
45) recommends that “human development policies need to reduce informational gaps and
promote information capabilities and education that handles informational systems.” Building
further on this strategy, ensuring a more “equitable access to global networks of information and
communication technology” is also key (Calderon, 2014-15, p. 45). These recommendations are
substantiated by the development tenets of the informational economy, which can be seen as a
progression that begins with the “value making” activity of information converting to knowledge
(Castells, M. and Himanen, P., 2014/15, p. 6). This concept for development helps provide a key
supporting theory and guiding direction for this project, setting criteria for a mobile health
messaging application. Of specific influence is the aspect of developing people through
information sharing. When the information converts to knowledge, capabilities can evolve to
influence their localized community to begin small public health changes within their
environment.
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Information and Communication Technology (ICT)
Amid the influences brought about by information and communication technologies,
mobile telephony may have the furthest reach. “The pace at which mobile phones spread
globally is unmatched in the history of technology” (World Bank, 2012). In 2010, 90% of the
world’s population lived in range of mobile cell signals, with 75% having access to a mobile
phone (World Bank, 2012, p. 8). Of equal importance, the mobile growth has become a
significant force in the developing world, with 77% of all the mobile subscriptions coming from
developing countries (World Bank, 2012, p. 8). The rising level of access is evidenced in the
subscriptions, which increased in the developing world by more than 1,500 percent between
2000 and 2010 (World Bank, 2012, p. 11). 2013 World Bank data now show that 92.6 out of
every 100 persons have a mobile cellular subscription.
Further growth potential exists in the age profile of developing nations, which is younger
than developing countries (World Bank, 2012, p. 11). Cell phones can also be accessed by broad
population segments as only basic literacy is needed for use (Rashid, A., and Elder, L., 2009, p.
10). Additionally, to reduce cost the poor utilize a variety of strategies to maintain mobile phone
access (Rashid, A., and Elder, L., 2009, p. 3)These statistics all give substance to the projection
that “the developing world is well positioned to benefit from mobile communications” (World
Bank, 2012, p. 4). Moreover, fresh opportunities and potential can emanate from wireless
communications now being widespread.
Other elements of communications technology shape mobile diffusion and have
implications for the state of access to communications and information. The need for physical
infrastructure such as roads and telephone lines can be bypassed using mobile devices, which
present possible solutions in Africa (Mars, 2012, p. 3). As a result, developing countries tend to
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rely mainly on mobile networks, and phones already outnumber personal computers (World
Bank, 2012, p. 13). While networks are expanding bandwidth and beginning to go into rural
areas, mobile data traffic is also on the rise and projected to double between 2014-2016 (World
Bank, 2012, p. 9). Still, the coverage of broadband continues to be restricted to urban regions for
the most part and smart phones are not yet reasonably priced (World Bank, 2012, p. 12). Thus,
while mobile technology is continually moving ahead, there remains a segment of the world’s
population with no functional access to these mobile technologies. Even though price has been a
barrier, it is important to note that devices are now becoming cheaper and more powerful with
that trend continuing toward a growing accessibility (World Bank, 2012, p. 4).
The introduction of smart phones has brought further functionality and changes. “Smart
phones typically feature graphical interfaces and touch screen capability, built in WiFi and GPS.
Those with “memory and internet capability are able to download applications for use on the
devise with or without a fee” (World Bank, 2012, p. 14). Older applications based on SMS
remain in wide use because they do not require downloads or data services, particularly for those
who do not have internet access (World Bank, 2012, p. 14). Thus, for a development situation,
text messaging remains prominent (World Bank, 2012, p. 16). Still, downloadable apps can
extend function and so, the past decade has seen a significant rise in the access to a range of app
technology. The most popular apps are games. It is noteworthy that mobile health applications
are also becoming more common. “Although the private sector is driving the market in apps,
social intermediaries, such as nongovernmental organizations (NGOs) play an important role in
customizing applications to meet the needs of local communities” (World Bank, 2012, p. 4).
Much anticipated are the next technology advances, where the next generation of apps may be
cloud based and not require the download of software (World Bank, 2012, p. 15). The idea
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behind these is to be “independent of the network or device, and free users from being locked to
a proprietary system” (World Bank, 2012, p. 21).
It is evident that access and information are important for subsistence among the poor.
Lower poverty levels and economic improvement have been linked with mobile phone diffusion
(Castells, M. and Himanen, P., 2014/15). The improvements have been observed and the benefits
are credited to “better access to information brought through mobile and are related to lower
transaction costs, travel costs, time spent traveling, better market information, and opportunities
to improve one’s livelihood.” (Jensen, 2007, Salahudin et al., 2003, as cited in World Bank,
2012, p.22). Significantly, the indication of this practice is that “there is potentially a synergistic
feedback loop between informational development and human development” (Castells, M. and
Himanen, P., 2014/15, p. 13)
Mobile Technology for Health.
The priority of health care delivery is the treatment and follow-up on the individual who
is unwell. In the context of health care delivery settings, use of mobile phones is often referred to
as m-health. The usage of m-health for this purpose can involve applications such as health
professional tasks, medical information gathering, and treatment monitoring. The practicality,
feasibility, and acceptability of utilizing mobile devices have been demonstrated for giving
health messages for these purposes (Doarn, C.R., and Merrell, R.C., 2012). A number of m-
Health applications are beginning to be seen in many countries on every continent (World Bank,
2012).
Beyond viability, other benefits can also be realized. Settings that are more remote or
hard to reach can benefit from mobile technology and further extend function of their electronic
or e-health systems (Mechael, 2009, p. 106). Most countries in Africa have some form of e-
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health activity occurring, with further investment made to develop a telemedicine program
spanning the African continent (Lester, R., Gelmon, L., and Plummer, F., 2006). Importantly,
transference from e-Health to m-Health can generate a systems opportunity; creating movement
away from top down approaches toward bottom up, away from government process toward
consumer initiatives, and away from centralized to decentralized spending (World Bank, 2012, p.
50). Health information on demand is another new area evidenced. Still, these trends are
primarily occurring in health care to expand their capacity, sending information from the field to
data servers for health professional use.
To make an important distinction, the public health emphasis is population health as a
whole, with a focus on disease surveillance, prevention and containment across populations.
The mobile phone is not a predominant tool in public health yet, but the number of examples is
growing. Applications for public health purposes have largely been utilized for publishing data
for health care professionals or epidemiological data gathering for disease surveillance. For
example, in Peru a HIV health surveillance system was designed utilizing cell phones (Curioso,
W., and Kurth, A. , 2007). In effect, existing public health apps principally acquire data and
send out data to professionals. Messaging apps pertaining to health promotion risk reduction are
still uncommon and in short supply. Encouragingly, one area of success with messaging apps
has been seen with identified HIV populations (Curioso, W., and Kurth, A. , 2007). Being a later
adopter in utilizing mobile technology, abundant opportunity remains for public health
applications with health promotion disease reduction messaging.
Mobile phones have been recognized to be effective in health messaging for specific
groups and goals. This attainment inspires a further goal to put forward similar efforts to reach
the densely populated slums of the developing world. Utilization of mobile phones has also been
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shown to be a means of overcoming problems of poor infrastructure in developing countries.
Also an important characteristic of mobile technology for marginalized populations is the
capacity to communicate and transfer information for low level to no literacy (Mechael, 2009, p.
107). Moreover, “the poorest of the poor do not have access to even the most basic health
information” (Grameen Foundation, 2011, p. 43). A Grameen Foundation pilot project on
maternal child health reported that when people began to hear free information about the health
topic was presented in their language; people were attracted and wanted it (Grameen Foundation,
2011, p. 43). The pilot showed that people can be interested in information that benefits them
directly; though maternal child information can be more motivating than ordinary infectious
illnesses might be.
While the outlook appears promising, the adoption and use of mobile phones in
development confronts several barriers. Age, gender, and education are dominant external
factors in the diffusion of mobile telephony; nevertheless, overlaps of mobile phone use exposure
exist, which can lead to familiarity and adoptions of phone use over time (Lefebvre, 2009).
Specific to m-health, prominent challenges found involve: cost, literacy level, lack of trust,
cultural factors hierarchical access to technology, and appropriateness of the infrastructure
supporting technology (Mechael, 2009, p. 109); (World Bank, 2012, p. 55). Accordingly, thought
should be given to address these known complexities.
Empowerment
A meaningful relationship is known to exist between “economic development and
empowerment of humans to act on their social organization” (Castells & Himanen, p.4).
Empowerment can be defined as an increase of political, social and economic strength of
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individuals and communities, including confidence in one’s own capabilities as well (Grunfeld,
2007, p. 10). Accordingly, it is an important ingredient for strengthening human ability to make
life choices (Gigler, 2004, p. 13). In the paradigm where information is power, the capability to
act on information for self-interest is empowerment. Conversely, exclusion from information
constitutes a deprivation (Calderon, 2014-15). This exclusion is described in a sociopolitical
context by the UNDP (2004), as “the limits to choosing a way of life.” To uphold the interest of
those excluded, a strategic attention is needed to bring about inclusiveness in the space of
information flows and movement toward grassroots action (Castells, Communication Power,
2009, p. 54).
The desired grassroots action alludes to the bottom up process of emergent self-
organization seen in complex adaptive systems; where the feedback of local individual behaviors
contributes to a more global behavior which comes back to the local (Rogers, E., Medina, U.,
Rivera, M., and Wiley, C., 2005). The adjustments to the changing day to day landscape of
information are an important part of this feedback. Defined in Rogers, et al. (2005), Complex
adaptive systems “comprise multiple agents dynamically interacting in fluctuating and
combinatory ways, following local rules to maximize their own utility while also maximizing
individual consistency with influences from network neighbors.” In other words, to maintain
stability the parts of a complex adaptive system adjust in relationship to each other to create
stability for the system as a whole. Wildavsky underscores this point saying, “no system can
remain stable unless the parts are able to vary in order to protect the whole” (Wildavsky, 1988, p.
77). Thus, the stability of components of the sysem is linked to the steadiness of the whole, with
risk shared throughout the system (Comfort, 2001). The idea of system stability/instability can
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be important when addressing the distortion within the global network resultant from exclusions
and the vulnerabilities created by the exclusion.
A key characteristic of complex adaptive systems is the network (Rogers, E., Medina, U.,
Rivera, M., and Wiley, C., 2005, p. 10). As discussed throughout this review, the complex issues
of this interconnected and interdependent world are beyond the capability of any individual
entity to solve. At the same time, complex adaptive systems enable the interactions of nodes
within and between networks facilitate the system to adapt toward surmounting problems
(Rogers, E., Medina, U., Rivera, M., and Wiley, C., 2005, p. 10). Comfort (1994) (Comfort,
1994)goes on to discuss four operational conditions that are essential to adaptation and system
stability: 1) The capacity for creative innovation toward a common goal, 2) Relationship
flexibility between the parts and whole of the system, 3) Interactive exchange between the
system and its environment, and 4) Information is critical for finding the right balance between
order and chaos. The central significance is balancing the relationship of the parts with the whole
system; this ongoing process of adapting can generate greater resilience in communities.
Furthermore, Rogers, et al. (2005) draw attention to the fact that “a social system needs time to
absorb new information and integrate change so as to maintain a reasonable internal stability.”
Adaptable networks are clearly evidenced among the urban poor. Social networks are the
dominant source of information and livelihood for the urban poor; consequentially, they are
highly reliant on these relationships (Schilderman, 2002).The ability to form groups and
organizations at the community level, and collectively pursue the goals of a shared vision is an
important strength among poor populations (Gigler, 2004, p. 16). This social capital may well
be their most valuable resource. Emphasizing the critical nature of these social networks, Gigler
(2004, p. 16) cautions to not underestimate the role of existing customs and organizations within
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communities; past development projects that have not considered these norms have reinforced
the marginalization and exclusion of specific groups and given rise to power struggles within
communities.
New behavior adoption in people is strongly influenced by close personal networks and
peer behavior, as evidenced in behavior change and diffusion studies (Valente, 2010). Further,
information diffusion is influenced by the strength of the ties within and between social
networks; where strong ties produce local cohesion and weak ties bring opportunity and
integration (Granovetter, 1973). Rogers, et al (2005) verify that heterophily provides
information processing and indirect interaction, while homophily enables information
transmission with less energy. Thus, as a system adapts, there is higher likelihood of emergent
self-organization for collective action when heterogeneity exists (Musso, J. and Weare, C.,
2014/2015).
Connecting specific network forms to civic activities, collective action concepts were
explored by Musso and Weare (2014/2015). Specific types of network ties were found
necessary for collective actions to occur: bonding types with dense internal relations, and
bridging types for diffusion (Musso, J. and Weare, C., 2014/2015). Relevant factors to
empowerment of community action for health include were found by Musso and Weare (2015):
1) Promote creation of diverse bridging type bonds, 2) Not all actors are equally capable of
converting network capacities into actionable resources, 3) Contextual factors challenge the
ability of participatory institutions to leverage network-based assets, and 4) Pay close attention to
building organizational capacity to leverage social capital assets. Germane to public health
application, these factors of empowerment inform community and organizational relationships,
along with strategies for behavioral and social change.
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Information and relationships are elements that promote community resilience and
adaptive capacity among marginalized communities. The capabilities in the process follow key
activities: adapting to change and learning by doing is empowering and develops the capability
to innovate, the ability to form and join groups, and collective action at a wider community level
(Grunfeld, 2007). Predictors of resilience are found in the course of people’s everyday life
experience, where accessible information builds knowledge about the small things they can do to
make a difference (Becker, J., et al., 2011). Interdependency is a key feature of the
empowerment processes at both the individual and collective levels (Gigler, 2004, p. 17). At the
community level, participation and empowerment give rise to risk identification and
determination of solutions (Becker, J., et al., 2011). At the institutional level resilience indicators
have been shown to be community empowerment with mutual trust and respect (Becker, J., et al.,
2011). Confirming these features, the formation of trust requires a sense of community must
exist first, and that community must have a collective belief in its own future (Garrett, 2000).
Empowerment and ICT.
The hope is that information and communications technologies (ICT) can assist in the
quest to change the asymmetric information that has long been a stumbling block for the poor in
developing countries. With the growing accessibility of mobile telephony, access to information
and knowledge can now begin to penetrate marginalized groups. Mobile technologies can play a
role in the strengthening of human and social capabilities (Gigler, 2004, p. 24). Further, ICT can
serve as a catalyst to initiate community dialogue and collective action. Further prominence is
given by Castells, who argues: “technology of communication that shapes a given
communicative environment has important consequences for the process of social change”
(Castells, 2009, p. 412).
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The use of communication technology for social change has been compared to analogous
practices, such as collective action and literacy. The processes of dialogue are both iterative
(Figueroa, M.E., Kincaid, D.L., Rani, M., and Lewis, G., 2002) and capability building (Gigler,
2004). Further, evidence has shown that a clear benefit is “psychological empowerment”
(Gigler, 2004, p. 32). The information acquisition can also enhance control over individual lives
and extend to the community (Gigler, 2004, p. 31). The “dynamic, multidimensional
interrelationship between technology and the social context” is the feature that contributes to
empowerment (Gigler, 2004, p. 1). The fundamental empowerment that occurs through
individual communication activity is pivotal; consistently, it has also been correlated with the
development of social and political autonomy (Castells, 2009, p. 414).
Technology design is an essential component in effective communication for social
change. Above all, the project ought to be centered on the purpose, human development, not the
technology (Gigler, 2004, p. 32). In other words, the technical knowledge needs to be linked to
the particular social action (Walker, 2008). Four key components bridge communications and
social change, as identified by Figeroa, et al. (2002, p.ii): “1) Sustainability of social change
occurs if individuals and communities affected own the process and content of communication;
2) Communication for social change should be empowering, horizontal, give a voice to unheard
members of community, and biased toward local ownership; 3) Emphasis should shift from
persuasion and transmission of information from outside experts to dialogue, debate, and
negotiation on issues that resonate with the community members; and 4) Emphasis on outcomes
should go beyond individual behavior to social norms and supporting environment.”
Still other strategic elements to incorporate in a social action venture include: participation,
learning, critique, and entrepreneurship (Walker, 2008, p. 1). Finally, the key attributes of a
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social change design should be “cyclical, relational and lead to an outcome of mutual change”
(Figueroa, M.E., Kincaid, D.L., Rani, M., and Lewis, G., 2002) Overall, operationalizing
technologies as sociotechnical arrangements should be thought of as networks that link people,
practices and relationships (Walker, 2008, p. 3).
The future relationship of communications technology and social change holds abundant
possibilities. People are no longer bystanders, because the social nature of cellular phones
imparts the ability to actively participate in communications and practices (Castells, 2009). A
new space exists for people to freely engage in civic action and human rights, resulting from
wide penetration of mobile devices, social networking, and a means to produce their own
messages (World Bank, 2012). Early examples have already been seen among networked
cultural transformations in grass roots movements. The introduction of mass self-
communications is an important dynamic in related social movements (Castells, M. and
Himanen, P., 2014/15, p. 12). Moreover, the rise of mass self-communication along with the
culture of autonomy confirms the potential for significant social change in relationship to
communicative practices (Castells, 2009, p. 129).
Summary
The gravity of the public health issues existing among the urban poor of the world calls
for new strategies to inspire action. These complex global public health trends have been largely
shaped by advances in communications technology. The paradox suggested is that potential
solutions can be sought in the same interconnectedness and interdependency that has also
influenced the rise of these issues. The supporting development approach promotes providing
access necessary to empower an actor’s capability. Moving away from top down toward a
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bottom up mode, the hope is to inspire collective action toward basic community health
improvements. An innovative public health strategy which includes communications technology
may be able to bring to the world to what Garret (2000, p. 501) terms “a sense of singular
community in which the health of each community member rises or falls with the health of all
others”.
The adoption and use of cell phones in developing countries is an important trend.
Fundamentally, these devices can play a role in disseminating basic health information, which
can be a beginning in surmounting information asymmetry in marginalized communities.
However, it should be noted that perseverance is needed as diffusion studies have observed
disease prevention interventions can diffuse slowly because they offer less noticeable feedback
(Rogers, E., Medina, U., Rivera, M., and Wiley, C., 2005). All the same, the opportunity to
engage this technology in meaningful ways to influence population health can bring salubrious
adaptation in many communities across the globe.
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Chapter 3
Methodology
“The researcher’s role is preeminently discovering, collating, interpreting, criticizing, and synthesizing ideas and data that others have
developed already.”
Eugene Bardach “A Practical Guide for Policy Analysis”
Urban slums present numerous challenges for global public health, and give emphasis to
the need for an innovative approach of reaching these marginalized populations with community
health education. Research into a practical means for bringing community health education
among these disregarded masses may be one step toward that vision. The notion that a mobile
phone app could contribute to this end, came to light during an early review of the literature.
The goal of this inquiry is to describe the foundational conditions for public health messaging in
mobile technology. Applied in nature, the target of this study is projected to be a pragmatic
conception for public health practice.
Embodying improvements to current practices is the domain of translational research.
This approach is typically broader than that of classical research. The National Institutes of
Health (NIH) definition of translational research includes two areas of translation. The most
relevant area of translation concerns “research aimed at enhancing the adoption of best practices
in the community” (NIH, 2011). At the same time, Bardach (2009, pp. 95-96) points out that the
phrase ‘best practices’ can be misleading and can be better characterized as ‘smart practices’.
Such practices are working to solve a difficulty or accomplishing a goal through an idea that
came from effort in employment (Bardach E. , 2009, p. 96). Similarly, an epidemiological
framework furthering translational research was developed to meet the challenge of translating
health discoveries into population health; the process entails knowledge synthesis, comprising a
systematic approach of reviewing evidence on what is known, identifying what is not known,
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and considering how to convert effective practices into day to day use (Khoury, M., Gwinn, M.,
and Iannidis, J.P. , 2010). Both the smart practices and translational concepts were influential
on the processes of this project.
Research Design
The study design of this project has been shaped by a qualitative strategy of inquiry and
the composite of advocacy and pragmatic philosophical outlooks brought to the study. Creswell
identifies three primary world views that a researcher can bring to a study. The advocacy world
view is one that “contains an action agenda focused on the needs of groups in society that may be
marginalized” (Creswell, 2009, p. 9). The pragmatic approach arises out of “concern for
application with what works” (Creswell, 2009, p. 10). Thus, these perspectives will inevitably
be reflected in both the research foundations and analytical outcomes.
The concrete approach of this inquiry entails semi-structured interviews identifying and
informing smart practices, cross-validated by a review of practices in the literature. A qualitative
strategy in analyzing the interview data included comparisons of emerging categories with
information similarities and differences (Creswell, 2009, p. 13). Included in the approach of
looking at smart practices is considering the source context and the context of this project
(Bardach, 2009, p. 107).
Ethical Considerations.
The interviewees contributed specialized information toward prioritizing policy actions in
the establishment of the application criteria. No personal information was taken. Because the
interviews were not soliciting information about human subjects, but rather seeking expert
opinions regarding policy and practices, the study was categorized as “not human subject”
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(NHS) research under the current policy of the University of Southern California (USC)
Institutional Review Board (IRB). An application was submitted to the IRB to substantiate that
the project was indeed designated NHS research, and a confirmation was given by the USC IRB.
A copy of both the IRB application and the authorization letter from the USC IRB can be
reviewed in Appendices A and B, respectively.
Fundamentals of informed consent were infused into the introductory contacts with the
interviewees. Letters of request were sent via email to present the purpose of the research, the
length of time participation was anticipated, acquire written agreement to participate, and to
establish appointments. Upon the onset of each interview, the purpose of the study was
reviewed, a statement was made that participation was voluntary, and participation could be
withdrawn from the interview or any question during the interview without concern. A further
statement was made about the participant’s right to confidentiality, and that the data would be
reported in aggregate. Finally, a verbal consent to audio recording and archiving was obtained
before proceeding with the interview.
Processes
The overall idea for the project was to translate existing knowledge into criteria for
creating a telephone application that would enable diffusion of health information specific to
communicable diseases and informal settlement communities. The research question driving this
project was: What criteria are needed for development of a telephone application that promotes
the reduction of the significant infectious diseases among informal urban settlements of the
world?
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As the initial step, supporting literature was gathered to gain a fuller understanding of the
complex processes that influence not only the global public health problem, but also the
innovation considered. It was determined that experts from two distinctly different fields would
be engaged in semi-structured interviews: Global Public Health Infectious Disease experts and
Technology Development experts. The rational was to match the technical development
processes with the subject matter messaging portion. Subsequently, the instrument of this study,
the interview protocol and two specific sets of questions were scripted to guide the interviews.
The protocol and questions can be referred to in Appendix C.
The interviews with global public health experts were intended to standardize and
prioritize infectious disease prevention topics, and to narrow health messaging concepts and
actions to be communicated within the application. A sampling of the key questions for dialogue
with the global public health experts include: 1) Discuss the three most pressing infectious
disease priorities for action on the global health stage and the criterion that informs your
prioritization.; 2) Discuss the infectious diseases seen among the urban poor that have the
greatest likelihood of control.; 3) Describe basic actions that individuals can take to reduce their
risk of these infections.; and 4) Discuss basic health information would you consider most useful
in a social milieu of scarce resources and low levels of education.
The conversations with technology development experts were aimed at identifying
priorities and themes of best practice in an application development processes. An example of
the primary prompts for dialogue with this set of technology development experts comprises: 1)
Describe successful characteristics of an app development; 2) Discuss the considerations to be
given in establishing content criteria for an app development; 3) Describe smart practices for
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developing application criteria; and 4)Explain how impact evaluation can be factored into the
criteria development.
Participants.
Semi-structured interviews were conducted with two sets of subject matter experts to gain
strategic counsel toward the delineation of mobile technology criteria. A total of sixteen subject
matter experts were interviewed, eight within each specialty: global public health infectious
disease and technology development. Accordingly, n=8 for each domain.
Sampling of the technology development subject matter experts began with one expert
identified at the outset. All the other participants were derived through a snowball approach of
recommendations. Serendipitously, some of the experts were further specialized, which
augmented the breadth of information into areas such as broadband, app coding, process
evaluation, notable health usages, and international experience.
In order to gain authoritative recommendations, selection of the global public health
experts was more purposive in approach. The inclusive endeavor was to ensure representation of
experience from each continent, with the exception of Australia. Another defined criterion was to
achieve a balance between current practitioners and academics. Each of the experts met the
following criteria for inclusion: 1) held expertise both in global public health and infectious
disease control, 2) considerable field experience with underprivileged communities
internationally, and 3) publication on some aspect of their work. A tip for interviews from
Wildavsky (1993, p. 63) was to request retired people with long experience and stature to
participate. Following this guidance, three elders of prominence were invited; regrettably, ill
health prevented participation from one of these respondents. The other two interviews provided
rich and insightful information.
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Data Collection Procedures.
To gain a composite trend with contextualized factors from subject matter experts, the
data collection means involved the semi-structured interview. The interview process was
established and repeated for each interview. The practice consisted of several steps: 1) Contact
the person via email to introduce the study and the invitation to participate, 2) Schedule a time
for the interview and whether the interview would be face to face or via Skype, 3) Review the
consent to participate information, 4) Obtain permission to record the interview, 5) Conduct the
interview, and 6) Query about other experts that should be contacted for an interview. Once
underway, the conversations were audio recorded and hand written notes were taken. Each
interview ranged from a half hour to one hour in length.
Data Analysis Procedures.
In preparation for analysis, the interview recordings were organized and then transcribed
into narrative format with line numbers. Reviews of the transcriptions were performed first to
ensure accuracy and second to detect the broader themes found in the readings.
An iterative organization and thematic coding of the data was done. Initial level of codes
included perspectives held by experts, strategy, and descriptive codes. The coding process
generated themes for a pattern analysis for each set of interviews: public health messaging and
technology development. A feasibility matrix was done to ascertain the practicability of
infectious disease category options, and it is illustrated in Table 4.1 of Chapter 4. The eight
identified categories of infectious disease were considered in light of the control measures
available in public health, the external influences, and the number of priority votes it received.
A conceptually clustered matrix was also utilized with the public health interview data, which
further narrowed the health of information for application content development. The ten
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prevention strategies for education messaging and the critical health information for each of
these strategies were itemized. These were considered for what the most useful emphasis was,
which the least useful messages were, and what barriers may exist for those actions related to the
message. This table is shown in Chapter 4 Table 4.2.
Smart Practices.
The interview results were then considered in light of the existing literature as a means of
confirming the interpretation. A relational process was employed between information gathered
in semi-structured interviews, the thematic data derived from the interviews, the literature and
smart practices found in the literature. This step confirms the information gained in the
interviews conducted, and that this approach is consistent across various projects (Gibbs as cited
in Creswell, 2009, p. 190).
Insufficient public health messaging and ICT publications are available to draw upon for
this scrutiny, and so, the ICT for social change literature was drawn from and utilized as a
supplemental source for smart practices and actions to avoid. The ICT for social change
literature was comprised of works from the past five years, along with a couple formative
publications. Further, the sources comprised credible case studies that did have a public health
application. This base provided comparative data of smart practices and failure causation. A few
key examples of this ICT for social change include: 1) Gigler’s “Including the Excluded: Can
ICTs Empower Poor Communities?”, 2) Grunfeld’s “Framework for Evaluating Contributions of
ICT to Capabilities, Empowerment, and Sustainability in Disadvantaged Communities”, 3)
Heek’s “Information Systems and Developing Countries: Failure, Success, and Local
Improvisations”, and 4) Walkers’ “What do We Mean by Technology and Social Action?”. The
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review derived was then used in a triangulation with the interview findings, confirming or
refuting the interview results.
Further evidence of smart practices or practices with failures was examined from a range
of literature presenting projects that were parallel to the proposed app. These practices came
from a variety of sources and have few similarities. The scrutiny of the examples gave a
construction of what works, why it works, and if ideas from those practices can be projected into
the considered context.
Finally, a logic model for implementation was constructed. In it the implementation paths
were considered in relation to the technology paths that could be chosen. The logic model can be
reviewed in Chapter 5 Figure 5.9.
Summary
The translational public health research conducted was to establish conditions for a health
messaging mobile phone application design. The processes discussed in this chapter have shaped
the research design and methodology of the project. Two groups of specialists were conferred
with: global public health infectious disease experts and health technology development experts.
A snowball sampling approach was utilized in securing technology development experts
interviews. A purposive sampling with some referrals was utilized in recruiting global public
health infectious disease experts. Finally, an iterative thematic analysis was employed to
identify the main priorities and strategies from the interviews. The priorities, messages, and
processes were then cross-referenced with existing literature for added confirmation. Connecting
the practices derived from the technology development and global public health interview
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findings was a uniting step toward shaping the conditions for the effective technology
development of a health messaging application.
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CHAPTER 4
DISCUSSION OF ANALYSIS
“Tell me and I forget. Teach me and I remember. Involve me and I learn.” Benjamin Franklin
A thorny global health challenge surrounds the human suffering, disability, and death
occurring in informal urban settlements. The complexity surrounding infectious disease control
among these marginalized populations spurred this examination. Amid these global health
burdens, one ongoing emphasis is community health education to nurture healthier behaviors
among individuals, families, and communities. Yet, rapidly growing settlements and the eroding
public health capacity have yielded a widening information gap in populations chronically
afflicted by information asymmetry. Mobile telephony is explored as a way to bring basic
community health education to these disregarded people.
Although the use of mobile phones in health care delivery has been shown effective, the
role of this tool is not widespread within public health. To be clear, the discipline of public
health is concerned with comprehensive population health and disease containment within
populations. The primary usage of mobile phone apps within public health at present is to gather
disease surveillance data and to disseminate updated disease control information to healthcare
professionals. Utilizing mobile phones to give out information to the general public is in its
early stages, with health promotion risk reduction endeavors mostly around calculators for
smoking cessation and weight loss. As a result, little integration between the messaging content
and the technology development is seen.
Discussed previously, the goal is to inform the development of a mobile phone
application that can disseminate health promotion risk reduction information to the residents of
informal settlements in developing countries. Several critical questions are raised to this end: 1)
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what diseases and prevention strategies should be the focus of the app; 2) what are the design
characteristics of an effective app; and 3) what design processes should be followed in app
development?
Dialogues with both global public health infectious disease control experts and
technology development experts informed the discussion of this chapter. The interview findings
from the public health messaging priorities are placed in relationship with the technology
development practices as a unifying step. This integration shapes the foundational criteria
for an application that can serve to strengthen the health literacy of people dwelling in the slums
of the world.
Because the centerpiece of an application is its subject matter, this chapter begins with an
analysis of the infectious disease emphasis coming together with the messaging. Following that,
the discussion turns to app development processes and design possibilities. The promise for the
app is in the convergence of these two components.
Infectious Disease Prevention Messaging
To gain substantive guidance for the subject and broader early steps of content
composition, eight recognized global public health specialists were consulted. The primary focus
was to outline topic selections and blend health strategies and information as initial content
shaping. The range of perspectives observed within the data may be reflective of specializations
within global public health and infectious diseases. These variations have added
multidimensional relationships which further enhance project premise and enriched the shaping
of the content. Attaining content that communicates the objective is pivotal for effectiveness
with or without the technology.
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Infectious Disease Priorities.
In order to begin delineating content choices for the app initial selection screen, experts
were queried about which three infectious diseases (ID) they would prioritize for action in global
health. To be clear, it is impractical to generate a universal priority list because a tremendous
variation exists from continent to continent, country to country, and even from area to area
within a country. Each place has multi-dimensional factors influencing ID, such as: climate,
density of population, environmental degradation, and scarcities of food, water and energy. And
so, it must be borne in mind that each disease entity is location dependent. At the same time, the
responses provide a starting point for the primary problem identification for app content.
Unfailingly, respondents based their ID choices on epidemiological measures: prevalence
and incidence rates, morbidity and mortality rates, disability adjusted life years and productivity.
Also significant were overall life expectancies, and cost effectiveness of the disease control.
Raw data yielded a mixture of specific disease entities, broader groupings and specific
groupings of ID. Coding and thematic analysis distilled the range to eight defined sets of ID:
Vaccine Preventable ID, Diarrheal Diseases, Mosquito Borne ID, Tuberculosis, Sexually
Transmitted Infections including HIV, Emerging Infectious Diseases, Other Respiratory ID, and
Parasites and other Neglected ID. These infection categories are visually delineated in Figure
4.1 below.
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Figure 4.1: Prioritizing Infectious Disease Sets
1. Vaccine preventable infectious diseases.
The vaccine preventable category of infectious diseases encompasses specific diseases
completely preventable with vaccine. This form of technology, when available, is the best means
in which to control a particular infectious disease. Vaccine is an agent that can be delivered
through a medicinal route and cause the human immune response to develop immunity to the
given ID. Notably, the target populations for a large portion of the vaccines are young children
and school age children. Currently, many of these vaccines are being subsidized and available for
low or no cost throughout the developing world. Great strides in reducing the incidence of these
diseases could be attained with customized promotion and messaging. Figure 4.2 below provides
the Centers for Disease Control and Prevention (CDC) list of pertinent vaccine preventable
diseases.
App Content Priorities:
Global Infectious Disease
1. Vaccine Preventable ID
2. Diarrheal Diseases
3. Mosquito borne ID
(Eg.Malaria, Dengue fever, Chickungya)
4. TB / MDR TB
5. Sexually Transmitted
Infections including HIV
6. Emerging Infectious Disease
(Eg. MERS, new influenza form)
7. Other respiratory infectious
diseases
8. Parasite Diseases & Neglected ID
(Eg. worms, protozoa)
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Figure 4.2: Vaccine Preventable Disease List
Vaccine Preventable Infectious Diseases (CDC, 2014)
1. Anthrax 13. Mumps
2. Cholera 14. Pertussis
3. Diptheria 15. Pneumococcal
4. Hepatitis A 16. Polio
5. Hepatitis B 17. Rabies
6. Haemohpilus Influenza type b
(Hib)
18. Rotavirus
7. Human Papilloma virus (HPV) 19. Rubella
8. Influenza 20. Tetanus
9. Japanese encephalitis 21. Typhoid
10. Lyme disease 22. Tuberculosis
11. Measles 23. Varicella (chickenpox)
12. Meningococcal 24. Yellow Fever
2. Diarrheal diseases.
A deceptively innocuous category is diarrheal diseases, which describes the primary
symptom from a range of microbial agents. These microbes are largely transmitted through non-
potable water and poor hygiene. In degraded urban environments such as slums, diarrhea
becomes an everyday normal state of being, which can become debilitating for adults and deadly
for young children. In fact, it is the largest cause of infant mortality globally. In a similar vein,
chronic diarrhea has also been shown to flatten out the cognitive development of children. More
dramatic still, the introduction of cholera to a community can quickly become a disaster.
Therefore, messaging about microbial causation and practices that could prevent many exposures
could bring improvements to families from these disabling microbes.
3. Mosquito borne infectious disease.
The mosquito borne infectious disease category includes illnesses such as Malaria,
Dengue Fever, Chickungya, Filariasis, and Yellow Fever. As the category implies, the infectious
agents are transmitted through the bite of mosquitoes. The prevalence of mosquitoes makes these
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
diseases a significant, widespread, and growing problem, particularly among informal
communities. In fact, Dengue fever rates are used as a sensitive indicator of urban decay.
4. Tuberculosis.
Tuberculosis (TB) is a difficult to treat respiratory infection that is transmitted by droplet
through the air. The poor nutrition and density of population among informal urban settlements
can amplify the transmission as well. The further threat with TB lies in the growing multi-drug
resistance of infections, which have been largely fueled by misuse of antibiotics. A common
problem among the world’s poor is access and affordability of the lengthy treatment. As a result,
their treatment is often intermittent at best, and this practice is one that advances antibiotic
resistance.
5. Sexually transmitted infections including HIV/AIDS.
The Sexually Transmitted Infections (STI) category including HIV/ AIDs comprises a
range of bacterial and viral infections transmitted through sexual contact. HIV is a virus that
newly emerged in the 1980s and has since spread to become a serious pandemic. While
international attention has been given to make inroads with HIV, few resources to stem these
infections trickle down to the poor of the world. Another challenge with STIs among poor
women in the developing world is that often the only option for earning enough money for food
is being a sex worker. The larger roadblocks to STI improvements among the poorest of the
world are the prevailing forces of power inequity, hunger, and culture.
6. Emerging and re-emerging infectious disease.
Emerging Infectious Disease (EID) entities are serious in their threat to all human life
because with new pathogens no herd immunity exists. This means a new infection can rapidly
affect large populations. At the same time, much depends on the transmissibility, infectivity, and
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virulence of the new organism and its effects on humans. Primary causal factors for emergence
include growing resistance to antibiotics among infectious agents, and encroachment of human
development into wild and bio-diverse areas. An example of a virus which emerged in the late
1970s as a result of the encroachment into bio-diverse areas is Ebola. While Ebola had remained
contained in minor outbreaks for many years, we are now seeing its evolution to several distinct
strains, a multiplicity of outbreaks, and few resources to contain the spreading contagion. Also of
significant concern is that drug resistant pathogens are multiplying and spreading at a time when
few new antibiotics are being developed.
7. Non-TB respiratory infections.
The Other Respiratory ID category is exclusive of TB and can include illnesses such as
pneumonia and bronchitis caused by a variety of pathogens. These infections are also a leading
cause of both infant mortality and under 5 year child mortality globally. Basic hand washing and
cough hygiene could yield inroads, which could lead to improvements of overall life expectancy.
8. Neglected tropical diseases and parasites.
The final category includes Parasites and other Neglected ID, which includes infections
from worms, protozoa, and so forth. These are diseases that typically affect only the poorest of
the world, they are completely preventable and treatable, but have been largely neglected. They
are spread by too many people sharing space with too little hygiene. All of these diseases are
dependent upon the density of population; density that exceeds the ability of public health
infrastructure and social protection like good water, sanitation, food safety, shelter, and health
care access. Providing basic microbial causation concepts, coupled with ways to minimize
transmission would bring about many improvements in day to day health among the very poor.
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Feasibility of Infectious Disease Priority Sets.
To examine the above priorities from another perspective, the experts were asked to
weigh in on which ID entities had the greatest likelihood of control among the urban poor of
developing countries. The analysis derived from the expert responses sets the initial direction for
the content development. Distinctively, the goal for these resulting priorities is to determine the
content choices for the initial screen selection. However, these results must be reexamined in
relationship to the local user context.
The category of vaccine preventable diseases was clearly the most recognized ID
category for ability to be controlled. Hepatitis A and B were identified separately as good
candidates for control, but as these diseases fall into the vaccine preventable category and they
were placed with this grouping. Further evidence for this category prioritization was supported
with a World Bank study from 1983, which looked at many practices and concluded
unequivocally that the most effective intervention is vaccination.
Equally incontrovertible, a high priority area is diarrheal infections. Currently, diarrheal
infections are responsible for the largest under 5 year old mortality rate globally. Notably,
vaccines are available for three of these microbial agents. Basic education on microbial
causation, improved hygiene practices, and differentiating the means to purify water and when it
should be done could make also great strides toward reversing the trend.
Attention was given to the disease control characteristics and external influences for each
of the infectious disease categories to determine their practicality for application content. The
priority column documents the number of experts naming of the category. Shown below in
Table 4.1 is the multi-attribute analysis of infectious disease categories, control measures
available, and external factors of influence.
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Table 4.1: Feasibility Analysis of Infectious Disease Priorities
Infectious Disease (ID)
Category
Priority Control Measures Available External Influences
Vaccine preventable ID –
including Hepatitis A & B
- 7 submits Vaccine preventable
Educational approaches for behavior
change:
o Basic vaccine concepts
o H2O purification
o Safe food handling
o Safe sex practices
o Safe sharps use
o Hygiene practices
WHO vaccine outreach campaigns
free or low cost
Hep A vaccine is subsidized for
developing countries
Access may still be difficult
Mistrust of organizations
dispensing vaccine
ID transmits easily in dense
populations
Diarrheal ID
-6 submits
Vaccines exist for 3 pathogens
Education approaches for behavior
change:
o H2O purification
o Hygiene practices
Particularly affects children under 5
Transmits easily in dense
populations
Mosquito born ID:
Malaria
Dengue Fever
Chickungya
Yellow Fever
Rift Valley Fever
Malaria:
– 5 submits
Other:
- 2 submits
Vaccine only available for Yellow
fever
Poor mosquito control available
Education approaches for behavior
change can help:
o Addressing pooling water
o Use of bed nets
Transmits easily in
o dense populations
o degraded environments
Particularly affects children under 5
& pregnant women
Pesticides & repellants are
expensive
Climate dependent
TB / MDR TB
-5 submits Vaccine available
o effectiveness is poor
Treatment available
Spread via respiratory route
Transmits easily in
o dense populations
o HIV population
Treatment is lengthy & expensive
o Multi drug resistance
STIs including HIV
HIV:
-4 submits
Other STIs:
-1 submit
No vaccine available
HIV Antiretroviral treatment
available
HPV vaccine available but is
expensive
Educational approaches for behavior
change:
o Use of condoms
o Safe sex practices
Access & cost of treatment can be
difficult for the poor
Transmission related to behaviors
influenced by:
o power
o culture
o hunger
Emerging & re-emerging
infectious diseases (EIDs)
-2 submits
A new pathogen will have no
research on it.
o Limited to basic PH tools
o No treatment or vaccine
No existing herd immunity to a new
pathogen
Depends on the new microbe
o Transmissibility
o Virulence
Influenced by
o Intrusion in bio-diverse
areas
o Environmental conditions
o Population density
Other respiratory ID
- 2 submits Vaccines exist for 4 causal pathogens
Difficult to control transmission:
o Respiratory route
o Close contact
Education approaches for behavior
Preferentially affects children under
5
Transmits easily in dense
populations
Antibiotics are costly in poor
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change:
o Wash hands
o Cough hygiene
o Distancing
communities
Neglected tropical ID/
parasites
Worms & Protozoa
Vector borne diseases
Chagas, Leprosy, Rabies,
+12 others
- 2 submits Educational approaches for behavior
change:
o H2O purification
o Hygiene practices
o Safe food handling
Eradication efforts for the Guinea
Worm underway
Transmitted easily in
o degraded environments
o areas of poor sanitation
o dense populations
Only affects the poorest of the
world
Feasibility analysis of the disease categories.
To determine the most practical category selections for an app selection, and to bring
greater precision to the narrowing process, the disease sets analyzed in the feasibility analysis
were considered in light of the control measures and external influences endorsed in expert
discussions:
The priority is heavily dependent on the public health technology available.
Prioritize the ones that preferentially affect children under 5.
Place the priority where it can have widest impact.
When each disease category was examined in relationship to the available public health
technology, the widest influence, and early childhood preference, the most practical ID
categories for a disease prevention messaging app became evident. The four disease categories
concluded to be essential for the initial app screen options include: 1) Vaccine preventable
diseases, 2) Diarrheal diseases, 3) other respiratory diseases, and 4) Neglected tropical diseases
and Parasites. Discussion of the analysis yielding these four priority sets follows below.
Vaccine preventable diseases have been highly prioritized. The likelihood of control is
strong because the technology of vaccines do exist for these entities, and organized outreach
campaigns are ongoing from the international community to provide these vaccines free or at low
cost. The high priority and the feasibility of achieving control over infectious diseases make this
category promising content choice for either an app specific to this category or an app with the
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category as one of the initial options to choose from. As stated earlier, young children are the
primary emphasis for receiving vaccines; therefore, a primary target audience for the prevention
messaging would be mothers of young children. Overall, an application promoting the benefits
of vaccine and identifying the nearest location for low cost vaccine dispensing could reduce the
under 5 year old mortality rate and improve overall life expectancy in most countries. This is a
category that could have significant value in reduction of many infectious diseases through
provision of information that may break down barriers of misinformation and mistrust.
Similarly, diarrheal disease is a foremost category for prevention messaging. Not only is
diarrhea the number one killer of infants globally, chronic diarrhea in childhood is known to
flatten out cognitive development. Basic information for prevention and intervention can
greatly influence the reduction of transmission of some of these pathogens, as well as the
availability of both typhoid and cholera vaccines. Once again, young mothers would be the
primary target audience for this category of prevention messaging.
Emerging infectious diseases designates an important category because they hold a
serious threat to human survival. Nevertheless, the absence of knowledge and control
mechanisms for a yet unknown pathogen, render this category impractical for an informational
application as it is currently conceptualized. An exception may occur in the event of a new
outbreak. Prevention information available to the affected regions would be desired by the
people of the affected areas, and supportive to health workers. As we have seen in the 2014
Ebola outbreak, health education teams have been murdered because of the fear and mistrust. In
this case, a mobile phone application with prevention messaging from a trusted source, such as a
NGO held in high regard, may be far more ideal and sought out.
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The multi-attribute analysis also suggests that some tradeoffs exist between the priorities
based on epidemiological measures (prevalence, incidence, disability, morbidity and mortality),
the control measures available, and the external influences. As an illustration, sexually
transmitted infections inclusive of HIV were cited as a priority category for control because there
are simple educational things that can support preventing transmission. Yet, in the case of
HIV/AIDS, there is no vaccine available; treatment is ongoing with cost and access problems for
the poor. While some inroads can be made with education on basic safe sex practices, these
expected behavioral changes are also linked to the powerful forces of power, inequity, hunger,
culture, and pleasure. Thus, this nominee is not a suitable app topic for messaging.
Similarly, Malaria and other mosquito borne disease are a high priority disease set to
address. However, transmission control is expensive and the current technology available for
control is insufficient. Beyond use of nets at night and staying indoors during mosquito biting
hours, the educational components indicate a high level of community involvement needed to
achieve enough behavior change to reduce mosquito breeding. As a result, it is not an ideal topic
for an app option, other than to promote nets and mosquito avoidance.
In contrast, Neglected ID and Parasites, as well as other respiratory ID categories were
ranked lower among the disease sets. Yet, the technology exists to treat and cure these; further,
vaccine exists for four of the respiratory causal pathogens and even an eradication effort is
underway for the Guinea worm. Moreover, these disease sets also preferentially affect children
under five, giving them higher priority. Educational approaches around environmental/home
hygiene to reduce transmission could influence much improvement in health outcomes. It
follows that these two sets would be good candidates for a disease prevention health promotion
messaging app.
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Furthermore, the case can be made that the current Ebola outbreak is a result of the
disease being a neglected one for the past forty years since its emergence. People’s fears may
increase their willingness to learn even more about how to prevent getting the illness and reduce
fears with a mobile app tool from a more trusted source. The poignant reason for addressing
these neglected diseases is that they no longer affect only small pockets of the world’s
population, as populations increase in mobility.
In conclusion, the feasibility analysis yielded four practicable ID categories for the health
promotion disease reduction messaging app: 1) Vaccine preventable diseases, 2) Diarrheal
diseases, 3) other respiratory diseases, and 4) Neglected tropical diseases and parasites. These
categories have been identified to be the app’s problem selection options on the first screen.
Within the social environment of these categories, children under the age of 5 are a focus of
morbidity and mortality prevention. Accordingly, young mothers of children living in urban
slums would be the broader target audience for the application.
A possible variation may be that the disease set selections are the second screen of the
app, with the first screen being a selection of related questions as an attention deriving hook.
When a question such as ‘How can I avoid missing work because my child is ill?’ is selected, the
next screen may have a choice of respiratory illness and diarrheal disease to choose from, with
the 3
rd
screen holding the educational information for action. However, this is an option that
could be determined within the community focus group stage when ascertaining the best
approach for that location.
Shaping Health Information for Content Development.
In the discussions with the public health consultants, basic prevention strategies were
identified and then discussed. Following on were critical health messaging action items that
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were associated with the strategies. These were further characterized by the experts, with the
most useful prevention tactics emphasized, ensued by the least useful tactics and potential
barriers to actions. A conceptually clustered matrix was constructed to scrutinize the basic
health information for content development, which can be examined in Table 4.2 below.
In all, ten prevention strategies were emphasized in these dialogues. Two cross-cutting
message themes were found to be essential no matter which disease category being addressed:
1) present the basic microbial concepts of disease causation, and 2) present information on how
to keep germs from spreading within a household. Also pivotal for each category that vaccine is
available, is presenting the basic idea of how vaccine works to protect people from illness and
why it is important. Key behavioral messages identified were around two basic practices: 1)
practices of personal and indoor hygiene, and 2) When and how to make water potable. The
discussion about these central messages follows the table below.
Excluded from the concept matrix was the recognized strategy of epidemiological disease
surveillance. While a vital part of public health infectious disease control is gathering data for
early awareness of any outbreak and initiation of containment measures, this prevention strategy
is a structural one; and it has negligible use for the health promotion disease prevention
messaging app of this investigation. Moreover, a number of successful public health apps exist to
gather epidemiological data for surveillance purposes. But it should be highlighted that the
directionality of a surveillance function is toward the health professional and not the general
public.
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Table 4.2: Conceptually Clustered Analysis: Shaping Health Information for Content
Shaping Health Information for Content Development
Prevention
Strategy
Critical Health information Most Useful Emphasis Least Useful Approaches Barriers to Action
Basic education
about the role
of microbes in
human health
- Basic microbial concepts of
disease causation
- How specific disease is contracted,
so they can control personal
exposure
- Culturally tailored
- Keep it simple
- Behavior focus
- Make the common problems interesting
- Building a sense of community – sharing
- Create a continuum to show how the
problem is affecting people as a whole
---no data --- - Needs to want to know
Basic practices
of personal &
indoor hygiene
How to keep germs spreading in
own household:
Hand washing & why it is
important
Cleaning clothes
Keeping cooking utensils clean
Sweeping
Keeping vectors such as rats &
cockroaches out
Keep animals separate
How to keep a baby with
diarrhea clean
Address barriers to these actions
Culturally tailored
Keep it simple
Behavior focus
Make the common problems interesting
Doable actions to improve diarrheal illness
Building a sense of community - sharing
Create a continuum to show how the
problem is affecting people as a whole
---no data--- The common problem may
be uninteresting –too
familiar with it even
though key information is
missing.
Competition with other
priorities
Immunization
Basic concept of how vaccine
protects from illness
Emphasize children under 5
- Culturally tailored
- Keep it simple
- Personal action focus
- Doable actions to improve diarrheal illness
- Create a continuum to show how the
problem is affecting people as a whole
- Identify free local vaccine centers
- Any message involving
costly medicines
- Directing to medical
structure; it may not be
available for them, the
action is useless & trust is
lost.
- Competition with other
priorities
- Access
- Cost
- No long term thinking –
survival mode
When & how to
make water
potable
Water purification actions: boil,
treat, filter
Distinguish use purpose & level of
purification needed for each
Culturally tailored
- Keep it simple
- Behavior focus
Make the common problems interesting
Doable actions to improve diarrheal illness
Building a sense of community – sharing
Create a continuum to show how the
problem is affecting people as a whole
Any action that requires
technology beyond the
mobile communication
device
- Competition with other
priorities
- The common problem is
uninteresting –too familiar
with it even though key
information is missing.
- Cost
- No long term thinking
Safe sex
practices
- Use of condoms
- Identify risky practices with
options to protect self
- Culturally tailored
- Keep it simple
- Behavior focus
- Create a continuum to show how the
- Any message involving
costly medicines
- Advice that may conflict
with religious practice
- Competition with other
priorities
- No long term thinking –
survival mode
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
problem is affecting people as a whole
Vector
management
Use of mosquito netting
Stay indoors during biting hours
because the mosquito load is much
smaller
Sweeping daily to keep rats &
cockroaches away
Keep animals separate
Measures to reduce mosquito
breeding – pooling water
Culturally tailored
Keep it simple
Behavior focus
Make the common problems interesting
How to handle this illness if you have it. If
you don’t want to get it again take these
steps…
Building a sense of community – sharing
Create a continuum to show how the
problem is affecting people as a whole
Any action that requires
technology beyond the
mobile communication
device
- The common problem is
uninteresting –too familiar
with it even though key
information is missing.
- Competition with other
priorities
- No long term thinking –
survival mode
Sanitation
Location dependent
Human waste solutions
Pooling water in refuse containers
Culturally tailored
Keep it simple
Behavior focus
Keep inexpensive
Doable actions to improve diarrheal illness
Building a sense of community – sharing
Create a continuum to show how the
problem is affecting people as a whole
Any action that requires
technology beyond the
mobile communication
device
- The common problem is
uninteresting –too familiar
with it even though key
information is missing.
- Competition with other
priorities
- Cost
- No long term thinking –
survival mode
Safe food
handling
- Hand washing
- Clean utensils
- Storage of food
- Culturally tailored
- Keep it simple
- Behavior focus
- Make the common problems interesting
- Doable actions to improve diarrheal illness
- Create a continuum to show how the
problem is affecting people as a whole
- Advice that may conflict
with religious practice
- Any action that requires
technology beyond the
mobile communication
device
- The common problem is
uninteresting –too familiar
with it even though key
information is missing.
First aid for the
home
Basic 1
st
aid
Treating dehydration at home:
fluids & salts
Include symptoms processing:
how to recognize when to get
someone who is sick more help &
not to wait
- Culturally tailored
- Keep it simple
- Personal action focus
- Building a sense of community – sharing
- Create a continuum to show how the
problem is affecting people as a whole
- Advice that may conflict
with religious practice
- Any action that requires
technology beyond the
mobile communication
device
- Directing to any medical
structure; it may not be
available, the action is
useless & trust is lost.
---no data---
Prevent getting
an infection
someone else
has
- Use of distancing
- Hand washing
- Not touching own face
- Culturally tailored
- Keep it simple
- Personal action focus
- If you don’t want to get it take these
steps…
- Create a continuum to show how the
problem is affecting people as a whole
- Any message involving
costly medicines
- No long term thinking –
survival mode
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The analysis indicates that a holistic approach and culturally tailoring the action steps is
of central importance. It is unmistakable that people need to know how and why the problem
affects them in order to make a meaningful behavior change. This construct is further supported
by the example of a recent study where young mothers showed interest in mobile applications for
child health related information, such as first aid and symptom recognition (IBRD, 2012).
The decision about the health information will be dependent upon the diseases in which
the app focuses. Of the ten educational strategies, four are cross-cutting among the disease
categories: 1) the role of microbes in human health, 2) basic practices of personal and indoor
hygiene, 3) first aid for the home, and 4) prevent getting an infection someone else has. The
basic idea of how vaccine works to protect people from illness is clearly related to the vaccine
preventable disease set, but some of these exist in other disease sets as well. Additional
strategies are related directly to diarrheal diseases and neglected tropical diseases: 1) when and
how to make water potable, 2) safe food handling, 3) sanitation, and 4) vector management
referring to rodents, cockroaches, and animals kept in the home. The remaining two can be self-
evident, where strategies for safe sex practices would be in relationship to STIs, and strategies
for vector management would be largely related to mosquito borne diseases.
Among these ten strategies, two educational messages are pivotal for health
improvements for each disease set nominated and should be priority for inclusion: 1) basic
microbial concepts of disease causation, and 2) how to keep germs from spreading within a
household. Closely related is the basic concept of how vaccine works to protect from illness.
Key behavioral messages identified were around two basic practices that widely affect diarrheal
and neglected tropical diseases, along with some vector borne diseases: 1) practices of personal
and indoor hygiene, and 2) When and how to make water potable.
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It is important to bear in mind that the distinct localities will influence the content path.
The location dependency of each infectious set will need to be considered, incorporating the
whole situation of the community and not just the disease process, so that the widest influence
possible is achieved. It is also a good idea to build information upon existing policies of the
target country (Grameen Foundation, 2011); and more specifically, the country specific health
policies, conditions, and disease priorities (Mechael, 2009). Content that agrees with local
interpretation can be achieved with field inquiries (Grameen Foundation, 2011); further,
collaboration with local NGOs is another constructive path (Gigler, 2004). An optimal approach
is to engage the local focus groups to determine which messages best match the ID category or
categories selected for that locale.
The ten informational strategies can be options in early content development, where local
focus groups can select those most suited to that community’s needs and interest. Developers
should harmonize the optimal numbers for selections on a screen (3-9 options) with the number
of strategies selected. The strategies can then lead to easy health information and actions as
designed.
Both simplicity and indigenous creativity need to be infused to generate interest and
engagement with a problem that is common and overly familiar. Several ways to engage
attention have been offered in the interviews. One of these is to begin with a selection of
questions that may be ones the people would ask and are derived from a focus group. These
questions create a hook of interest to find the answer to something they want to know.
Integrating gaming concepts has been highlighted and can include engaging another person who
has no phone in a question and answer, giving reward icons, and so forth. Yet another way is to
address the day to day thinking and survivalist aspect of this population, by appealing to their
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need to work, feed their families, and try to gain more than just survive. The message needs to
reveal how a small common problem, such as diarrhea, may be affecting them as a whole over
the long term in terms of: missed work and income, missed school for the children, lost
opportunities, and increasing disability. Relevance and a glimmer of hope that there may be a
way to improve day to day existence can be attractive.
In sum, for essential messaging, it is vital for people to know how and why they get
infections in order to make any meaningful behavior change. Secondly, individuals need to
know how to prevent getting an infection someone else may have. Also strategic, is to demystify
how vaccines work to protect humans. Proceeding from these facts, should be basic achievable
actions that can be taken, such as getting the children vaccinated, and home hygiene basics. The
nuance of the basic action to take should match not only the disease set intended, but also
integrate the context of the region the app will serve.
With the basic subject matter for the message in place to the point where it must be
tailored to a local context, it is helpful now to turn the focus to the process of an effective app
development. It is important to understand the vehicle of technology, what is possible, and how
it fits with the message. The goal in exploring prevention messaging with mobile technology is
to establish a process for communicating the message correctly, faster, easier, and to more
people than otherwise may have been possible to reach.
Characteristics of Effective App Development
The guidance derived from the eight subject matter experts in technology development
brought together pieces of the larger picture in technology development for a public health
disease prevention application. The amalgamated data aligned to reveal a process of application
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
development could be identified. The method can be structured further into four distinct phases:
1) Basic design consideration, 2) Content development, 3) Technology software development,
and 4) Application adoption and diffusion. The data have also shown distinct guiding principles
recommended in each of these phases. The resulting methodology is both a valuable and
practical finding of the analysis, and establishes a pattern for the app development process with
the essential specifications for each phase. These guidelines are subsequently discussed in
greater detail within the context of each of the four phases. The approach presented below in
Figure 4.3 contains the four phases and their validated criteria, which have been identified as
facilitating a successful app development.
Figure 4.3: Methodology for a Successful App Development
Basic Design
Consideration
•Understand the mobile infrastructure specific to the target population location.
•Understand the problem.
•Understand the target audience
•Understand the ouput wanted.
•Understand the costs.
Content
Development
•User focused content/ User context (Eg. culture, language, numeracy, situation, need, & benefit)
•Visually pleasing content / rich content
•Testing details of wording and graphics
•Identify gaps and problems
Software
Development
•Usability/ Ease of use / Utility/Navigation
•Feature variety / Fun / Engagement of user
•Testing every dimension
•Identify details in function that need greater transparency
App
Adoption &
Diffusion
•Discoverability of the app - marketing considerationsa
•Technology Support provided for users
•Assess application usage and evaluate impact
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Phase 1: Basic Design Considerations
The beginning step toward technology development needs to take into account the
existing communications infrastructure of the country and region for which the app will be
developed; this beginning direction is confirmed by Mechael (2009) and Clifford, et al. (2008).
Infrastructure in this context includes the availability, scope, and reliability of the internet
network modes, the bandwidth properties for transmission, and the locally common phone. The
relationships between these elements of communications technology infrastructure are illustrated
in Figure 4.4 below.
Conduits for internet transmissions include local telephone networks, cable, fiber optics,
or mobile wireless. Decidedly, this type of infrastructure constitutes an expense barrier for many
countries. The mobile web configuration is a more economical model; as a result, it is more
commonly relied upon, data also confirmed by a World Bank report (World Bank, 2012).
Figure 4.4: Relationship between infrastructure and communications technology availability
Transmission of information through the internet medium is affected by the conduction
size or width, often referred to as bandwidth or broadband. Network reliability needs to be
planned for (Grameen Foundation, 2011). While generally available in most countries, the extent
Communications Technology Infrastructure
in
Developing Countries
Data is
Expensive
Internet Conduit & Broadband
Differs between Countries
Different
investment
decisions
Infrastructure
Expense
Barriers
Wired /
Wireless ratio
differences
Internet Conduit
& Broadband
Differs within Countries
Clustering in
urban areas
Region to
Region
Investment
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of broadband access differs both between and within countries. Further, access tends to be
clustered within urban areas, and varies in quality from region to region, contingent on local
investment. This availability is also validated by the World Bank report (World Bank, 2012, p.
12). Relevantly, this clustering in urban areas is a vital factor for utilizing mobile technology in
reaching the broader target audience of urban squatters.
A barrier for poor people in lower income countries can be the high cost of data
transmission. Because the data transmission continues to be expensive, informal markets have
also emerged. Looking to the future, changes can be anticipated to reshape this environment, as
investment decisions get reprioritized for this all important and critical infrastructure.
Mobile devices.
The commonly used phone in specific locales is a vital factor in determining the approach
for both content and technology development of an application. Figure 4.5 below illustrates the
mobile device options and the traction they have within developing countries.
Figure 4.5: Mobile Phone Technology in Developing Countries
When targeting the bottom billion of the world, the i-Phone is not a competitor for the
reason that its cost is well beyond the reach of this audience. While prices continue going down
on Android models and low-cost models are in production, the data infrastructure costs most
likely will remain unattainable for many of the urban poor in developing countries. There is
likelihood that Windows based phones may gain significant influence in the not too distant
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future, provisional on the infrastructure decisions underway. The prospect is also substantiated
in the World Bank report, describing an agreement to offer Windows operating system on the
Nokia smart phone (World Bank, 2012, p. 21); the relevance is that Nokia is a large developing
world provider and could become the affordable system of the future.
Currently, the most commonly used mobile devices among deprived populations are SMS
models; this has also been validated in a World Bank report (World Bank, 2012, p.16).
Consequently, the most relevant candidate at the time of this writing is an SMS application; this
is particularly true for Africa. Strikingly, these are populations also invest a large portion of their
resources in updating their phone technology because information is critical to them (Rashid, A.,
and Elder, L., 2009, p. 4). Also, these communities engage in phone sharing schemes and other
strategies (Rashid, A., and Elder, L., 2009) in order to have the more advanced capabilities. The
mobile technology utilized can also be location dependent. Regardless, when tailoring a new app
development for the broader urban slum population, it will be most comprehensive in its reach,
created in the SMS platform.
Target audience.
Understanding the selected target audience may well be one of the most critical aspects to
a successful application that is promoting behavior change. The technology designer needs to be
in touch with the reality of the end user (Heeks, 2002, p. 134). The creation of an app is reliant
on understanding the full situation of the user: including their context, local situation, language,
and levels of literacy and numeracy (Clark, P., Evans, S., and Hovy, E., 2011). Approaching the
development process with a user focus brings greater benefit to the user and tailors the
information and content to the audience. The potential users’ familiarity and comfort with the
mobile devices is influential to the tailoring piece as well. Worth highlighting is the fact that
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youth place a high value on technology and apps in most locales, and are adept at using and
learning from the mobile technology. The tailoring will determine the approaches to both
content and software development. Content tailoring of the health information to be diffused is
adapted to the user context and then matched with the technology common to that user.
More specific to the case for health messaging among informal settlements, young
children have been identified as being the most affected by the four priority ID categories.
Consequently, the mothers of young children living in an urban slum would be the target
audience for this app. These young mothers will have little education, if any, and will require
low level literacy content. As motherhood begins at a young age in most developing countries,
these young mothers will most likely have been exposed to mobile technology and have working
familiarity with it. Even though no gender differences are seen in mobile activities, according to
a World Bank report (2012), disparity of phone ownership persists; and this smaller ownership
may have implications for this proposed app. The relationship of end user and the app
development considerations are shown in Figure 4.6 below.
Figure 4.6: Target Audience Considerations
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Cost considerations.
A recognizable component of an application development is cost. Several strategic
approaches can be selected to best match the task. The for-profit tactic pays for development to
place the product out there to make more money. The non-profit approach may take on a project
for the greater good or humanitarian purposes. An effective information system for development
purposes includes the private sector in the establishment of a low revenue yet robust mobile
application (World Bank, 2012, p. 54). Grants are yet another way for obtaining funding for
implementation. Finally, it is also possible to develop the criteria framework and then release
that to an open source online forum. This action allows local code developers to freely use the
concept and infuse the localization during code development.
Processes of development are resource intensive. In view of that, it is imperative to
understand the problem and goal of the project, the output desired, and then identify matching
metrics to achieve the product at a realistic value. There is a cost attached to how each aspect is
accomplished. Additionally, each feature or functionality selected to be included in the app will
have a cost. One technology expert stated, “If the functionality helps achieve the mission then it
should be pursued. If it does not help the mission, then by not doing it will reduce the cost and
time, and will probably increase usage because it’s simpler.” For example, linguistic and cultural
tailoring increases costs, but at the same time, will make the app more effective. In the situation
of informal slums around the world, the cultural and linguistic tailoring for each locale is
essential for success, and is worth the extra budgetary allowance. Moreover, if the app begins to
affect health outcomes, its value is even greater.
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Selecting app features.
While the wide array of application features can be tantalizing, it is important to
remember the hallmark of an effective app is its simplicity. Foremost, the app should be easy to
use and user focused. Narrowing this field to a few relevant choices can be done by aligning the
project mission and the intended user benefit with the selection of function features and content.
As an example, if the application mission requires development in SMS, the choices of features
would more basic and need to align with the technological function. A useful feature to consider
with the SMS system may include the scalability with updates available as the user adapts or the
technology changes.
The overall appearance of the app should be visually pleasing, attracting the user.
Notably, an SMS application can contain graphics, but it is unfortunately of limited visual
attractiveness. The visuals should enrich the message and not distract from it. Simple
illustrations are essential in a low level literacy style, which is central to the focal populations of
this project.
The ability to share the information or forward it to a friend is engaging. People want to
be able to share the app and open it as many times as they like, which is confirmed by the
Grameen pilot project report (Grameen Foundation, 2011, p. 4). Sharing does not necessarily
mean the app must have the ability to be forwarded, as people often like to share the content face
to face. Likewise, audiences like being able to give direct feedback within the app.
A variety of features keep people involved. Content rich elements take this concept
further and are even more engaging, but can also use significantly more data. A location aware
feature offers an advanced functionality which can serve content based on where the user is; but
the complexity of this feature and the data required to support it does not make it a good choice
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for the target audience. Integrating gaming concepts can more deeply engage a user as well.
Importantly, some basic game concepts can be applied into the design and have minimal to no
data use. For example, a game technique may include list of action items for the user and as the
user performs it, then selects the item as done, a star or other reward icon can appear. Game
approaches can also include another person less adept at the technology, such as engaging a child
and parent in a ‘Q & A’ quiz. The game concepts in this function can be thought of as an
engagement approach and not complex gaming. Some of these elements can even be used in
SMS, such as receiving icon awards for specific selections or responses. Bear in mind that each
feature or functionality selected will add to the overall cost of development. Depicted below in
Figure 4.7 are features that could be considered for the proposed app.
Figure 4.7: Selecting app features
Considering the general characteristics of the broader target population and the mission
of this proposed app, a few key features are identified as indispensable. Because the common
phone among the world’s poor is a basic phone requiring a SMS based application, a feature
making the app scalable with updates would be important. As technology continues to advance,
this feature would allow it to keep pace with the changes. Another essential feature for the end
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user is accessibility for low level literacy. Selecting meaningful visual representations for the
low literacy is also an important piece of the feature. As stated earlier, aligning the project
mission and the intended user benefit helps with the selection of other content features. Given
this app will be on a SMS base, the visuals will be restricted to the icons for non-readers. A
game-like engagement aspect could be employed but is not essential; this aspect could be used as
a point of decision making during the localization process.
Phase 2: Guidelines for Content Development
Content development is the crucial second phase toward application development. The
combined and coded data indicated that a practical process could be identified for influential
content development. The practical steps derived for this phase of app development is a
beneficial and concrete finding from the analysis. The discussions regarding criteria for
establishing content revealed nine primary considerations. Certain key practicalities for this stage
are identified in the earlier phase, other criteria may hold more emphasis; nevertheless, a
pathway to follow is evident. The nine steps of practice are discussed in the proceeding portion
of this phase. Depicted below in Figure 4.8 is the Pathway guide for content development.
Figure 4.8: Steps of practice for Content Development
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Steps 1-3: early stages of content development.
The content development process begins with budgeting for the cost of its creation. The
cost of content development can be potentially large for reaching low income groups. The
situation of target audience is clearly pivotal to determining the content approach and infusion.
Meeting local context needs of the target audience in the content design is a concept that is
validated throughout the literature (Evans, S., and Clark, P., 2011); (World Bank, 2012, p. 54);
(Heeks, 2002). It is worthwhile that representatives of the end user identify the focus of the
subject matter from the four practicable ID priority categories for messaging: 1) Vaccine
preventable diseases, 2) Diarrheal diseases, 3) other respiratory diseases, and 4) Neglected
infectious diseases and Parasites. Within the social environment of these categories, children
under the age of 5 are a focus of morbidity and mortality prevention. Accordingly, young
mothers of children living in urban slums would be the broader target audience for the
application. If the information needed by this population is connected to the communications
they seek, there will be greater success in gaining access to the available information.
The contextual setting of the user is another vital determination. Determining the cultural
and linguistic needs for tailoring the content to the audience’s situation is an important piece of
this. Vital factors in ICT effectiveness in strengthening the capabilities of the poor is localizing
content for different cultures (Gigler, 2004) and translation to the common language (Grameen
Foundation, 2011).
Steps 4-6: content composition.
Content composition is based on the problem, the message that needs to be
communicated, the target audience and the cultural and linguistic context in which the audience
is positioned. It comprises the simplification of the message to simple words in the language of
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the end user and can include simple images. The four infectious disease categories identified
earlier form the identification of the composition problem in the beginning stages of content
composition. Potential initial screen options, the categories include: 1) Vaccine preventable
diseases, 2) Diarrheal diseases, 3) other respiratory diseases, and 4) Neglected tropical diseases
and parasites. Subsequent messaging around microbial causation of disease and how to
minimize the spread of illness within a household is pivotal. Closely related would be
information about how vaccine works to protect children from disease and death. Key
information about basic actions that can be taken as the final screen include: 1) practices of
personal and indoor hygiene, and 2) When and how to make water potable.
Step 4: message simplification.
The content should be understood by the target audience with or without the technology.
As previously emphasized, the intended user is key to meaningful content development. The
subject matter and key information to be communicated are first customized and then must be
condensed to simple phone text. Field testing the simplified message with a focus group is
needed to ascertain any difficulties with assumptions or lack of clarity (Clark, P., Evans, S., and
Hovy, E., 2011). The process is to think through the audience, and then test with a representative
focus group from the target population, as this action informs the content.
Step 5: graphic selection.
Graphics and illustrations are part of the content composition, their role is to enhance the
message and not detract from it. An SMS application most often does not use graphics.
However, basic visuals can be used with SMS, and are useful in a low level literacy context or as
prizes. The selection and testing of these icons is an important next step in this process.
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If the app is being developed for a phone that can display images, the next step is to
include simple illustrations of the content to be communicated. An assortment of artwork should
also be tested with the target population, to determine which style is most visually pleasing to
that population and communicates what it was intended to.
Step 6: enriching content.
The subsequent stage is to enrich the content by infusing variety into the overall
messaging and visuals. The variation is vital to holding user attention. The enrichment decisions
for the identified audience will need to be well-suited to low level literacy. An SMS application
would benefit greatly with a scalability feature that has updates, so that the app could grow in
capabilities with new SMS capacity.
Decision Tree Design.
The design of the decision tree within an app was considered, with two different phone
screen patterns discussed. The first sought the optimal number of infectious disease topic
choices that can be given on the initial screen. The numerical range pairs the software coding
and content development, even though optimal criteria are based on the information that the
population needs. Answers by most respondents were given in numerical ranges, with one reply
as less is better. Overall, the favored range was 3-9 topic options. Realistically, the lower
number of options would be best in a SMS app.
The second feature considered was the optimal layering of screens, which narrows the
user choices to get to the core information they are seeking. This layering can occur in both
SMS based applications and smart phone applications; less choice in SMS would be practical.
Generally, there was agreement that the core information should be arrived at by the third screen,
a fourth layer could be used for related or additional information sources; more than five layers
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would lose people’s interest. Nevertheless, the layering is ultimately based on the topic, problem,
audience and audience technology comfort.
Steps 7-9: testing, adjustments, and software ready.
Pilot testing the full content with a representative focus group is sensible before having it
placed into the software. The representative test group will be looking at the comprehensive set
of simple text, graphic, and variety. Based on the test response, make the necessary adjustments
to the content elements. After fine tuning the content composition, it should be ready to interface
with the technology for the beginning phases of programming design and coding into mobile
device software.
Testing.
Testing is the central element in bringing the content composition and technology design
to an understandable, usable, and user focused point. The recommendation is that testing be
done early, often, and on each key element in Phases 2 and 3. Early focus groups representative
of the target group can help formulate and guide content and graphic development. Clarity of
message and usability of the technology design are important dimensions to work out any
difficulties that may exist. Once the design is ready, the full design benefits by undergoing a
usability trial or a pilot test. When the application is released other metrics can become
important measures of goal achievement. An essential component in app development, testing is
repeated throughout the process. These stages in testing are depicted below in Figure 4.9a.
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Figure 4.9a: Testing Stages
Challenges in content development.
Awareness of occurring challenges can be useful for effective content development.
Maintaining simplicity seems to pose the trickiest aspect of content development. Four
foundational parts of content development are important to keep simple: 1) the content outline,
2) writing in uncomplicated language, 3) limiting the key message, and 4) clean visual
representation for each step, if appropriate to the common phone.
External challenges can also interact with these content elements. Notably, the agile
environment of software development itself can be a continual stimulus for adaptation. While it
is strongly advisable to not test with populations different than the target audience (Evans, S.,
and Clark, P., 2011); the engagement of target users in focus groups could pose challenges in the
international context. This difficulty requires strategies to enable a message development that is
desired and sought. One possible strategy may be to engage a local NGO as a local partner in this
information presentation and gathering. Of course, the end user interest in the topic and comfort
level with the technology is predominant in the utilization of an app.
Beyond generic challenges, recognizing the everyday pitfalls in the processes of content
and technology development is useful in order to avoid them. A primary problem that can occur
is ‘scope creep’, meaning that the mission and functionality are allowed to grow excessively
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complex. The project should remain focused on the purpose, human development, not the
technology (Gigler, 2004, p. 32). Equally unmanageable is endeavoring to include too much
content. Attending to the accuracy of the assumptions for the central messages and having a
willingness to revise according to what the testing reveals is expedient. Maintaining a mission
and goal focus will enable the testing metrics to stay in alignment.
Phase 3: Technology Development
Usability and simplicity are the strategic attributes to uphold as the technology
development integrates the content to software for the mobile device application. The overall
mission at the time of implementation will determine the technology the app is being
programmed for as well as the features to be included. As in earlier phases, keeping the design
user focused is foremost. The technology designer needs to be in touch with the reality of the
end user (Heeks, 2002, p. 134). The technology design concept must be easy to navigate and use,
variety and features that engage the user are secondary.
Usability testing.
Similar to the content development phase, testing is an essential aspect of the process.
Each dimension of the tool needs to be assessed for usability by a focus group that is
representative of the targeted audience, as seen below in Figure 4.9b. Testing is important to
achieve quality feedback for final system design (Grameen Foundation, 2011). The testing
process reveals details in function that are unclear to the user. Adjustments can then be made for
greater transparency in functionality.
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Figure 4.9b: Testing Stages
Technology approach options.
Because wide penetration is the goal, a range of approaches were put forward as
technology choices in this phase of development. The adoption of a specific option or
combination of options will hinge upon the mission at the time of implementation. A brief
discussion follows below, and a more in depth applications of these will be discussed in Chapter
5. These selections are illustrated in Figure 4.10 below and subsequently summarized.
Figure 4.10: Implementation Approach Options
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Option 1- scalable SMS platform.
The leading option identified in the interviews and literature is to develop the app in an
SMS text based system (World Bank, 2012, p. 14), because at the time of writing, the most
common mobile phone in the target populations is an SMS based device, Important to this
selection is that the programming can include a scalable function with an update process as a
systems upgrade and capacity grows.
Option 2 – mobile text web interface.
A second tactic is the use of a web version interface going to a URL. This type of system
utilizes SMS text and a mobile optimized site with no data use, instead the user types in a URL
and the information from the web is retrieved from the web, and then signs off. In an
environment where data access and affordability is limited, this option seems promising.
However, in the survey of practice discussed in chapter 5, this approach requires a
technologically savvy user and it tends to cater to professional usage rather than general public.
Option 3 – multiple versions from place to place.
The third choice is to create multiple versions of applications for different regions, using
different technological platforms. This option could use the same framework, but have both a
tailored cultural and linguistic context, and a customized selection of the mobile phone system in
each location it is implemented. Conceivable participants could include a large international
NGO, a variety of local NGOs, or a combination in partnership, developing it in areas they are
already functioning, recognized, and trusted. The downside is that a separate app for every locale
can engender inefficiencies and multiplicities of outcomes, which is not very practical (World
Bank, 2012, p. 55). On the other hand, the customization required for each region indicates that
the strength of this option is in its bottom up approach. All the same, this option is one that
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could work for a large NGO, such as the Red Cross, which has operational relationships in most
countries.
Option 4 – Release to open source forum.
The robust fourth possibility is to relinquish the design criteria to an open source online
forum that software coders use. The online submission freely allows the code developers from
target communities to handle the localization, using and adapting the design to the local needs,
and then develop the software coding. A unique forum identified is a consortium known as
Innovative Support to Emergencies, Diseases, and Disasters (InSTEDD). Importantly, this open
mobile consortium has global partners from technology, international organizations, NGOs and
broad financial foundation support. Their mission goal is to encourage the sharing of code or
design for mobile apps with a focus on humanitarian and health needs. This vision not only
aligns well with ideas of this project, but also the main office is located in California. The option
may be a practical one enabling the widest diffusion, and has been demonstrated in other
situations. Whereas this alternative is not seen in commercial contexts, it does provide a course
of action for the software development with a humanitarian focus.
Phase 4: App Adoption, and Diffusion
Ensuring the discoverability of an application is a primary consideration upon its release
for general use. A well designed app will be of little use if it is not discovered and used by the
target audience. People in the urban slum population do not have time to search for the
information or an app; they are busy trying to survive day to day. Still, if testing has been done
with focus groups of the target population, beginning nodes are already in place. These early
adopters can be role models and bring it to their social network (Rogers, E., Medina, U., Rivera,
M., and Wiley, C., 2005). Select metrics for following the trends of diffusion include the
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number of downloads, time people spend in an app, and direct feedback sent. However, in
communities that phone sharing occurs, the people may be sharing the information from the
phone face to face instead, and this information diffusion will not necessarily be measurable.
After an interval, correlation with health outcome data can gage the influence of the intervention.
The testing for Phase 4 can be seen in Figure 4.9c below.
Figure 4.9c: Testing Stages
Adoption and Diffusion.
To ensure applications will be adopted by the intended users, effort must be invested in
the discovery of what is appropriate for the target audience (Lefebvre, 2009). This result will
enable connecting the information people already seek out with the information they need in the
app. An effective approach for the establishment of a low revenue yet robust mobile application
is one that includes the private sector in the investment (World Bank, 2012, p. 54).
Network widening options can be built into app functionality; one such possibility is to
be able to share the app electronically with a friend. Resourceful ways to connect the target
audience with something they are already connected to need to be sought and identified during
the customization process. One example given was a health app in South Africa that was able to
be promoted within a popular soap opera. Another hint to expand exposure is by linking into
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social media, particularly Face Book, and promoting it there. Face Book is an important
phenomena globally, and many in urban slum dwellers utilize internet cafes or accessible smart
phones to communicate in this social media. In a developing country, it is also advisable to make
it clear that the app will use little to no data, or there will be a reluctance to try it. Also critical
for continued user engagement is to have some type of technical support provided to the user.
It is important to recognize that the diffusion path may be measured and uncertain with
this innovation. The slow information spread from place to place can also be due to the nuanced
customization required for each social setting (Evans, S., and Clark, P., 2011). The customizing
process is differentiated from replication by Evans and Clark (2011, pp.46-47), and they outline
the following guidelines for practice:
1. Become recognized for practical knowledge by being informed about the innovation
details.
2. Learn about the specific local conditions for flexible local solutions.
3. Regularly monitor progress with patience.
4. Identify barriers to adoption that may impede the new ideas.
5. Have solid evidence about the innovation benefits.
6. Find an advocate to lead in each locale.
7. Give the credit to others to foster continued engagement.
Innovation efforts in disease prevention are known to be poorly observable and diffuse
more slowly (Rogers, E., Medina, U., Rivera, M., and Wiley, C., 2005). In implementation
terms, this is a situation of low conflict with some ambiguity, which implies that the
implementation will be driven by contextual factors and the diffusion will not readily transmit
from place to place. The steps above enhance the complex adaptive system feedback loop,
which is critical when diffusion processes are irregular (Rogers, E., Medina, U., Rivera, M., and
Wiley, C., 2005). The investment in adapting and localizing this particular innovation is
undoubtedly necessary for it to overcome adoption barriers and become viable in different
locations.
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Looking at diffusion to a poor urban community from another angle, the notion is that it
is not necessarily the number of phones reached where the app is downloaded. In developing
country slums, mobile phones may not utilized in the same way traditional to developed
countries, and often a single phone has multiple users. It may be enough that access is available
through a community engaged in some sort of sharing program, and a single shared phone with
mobile broadband within a community can be as effective as multiple people or the entire
community having access to smart phones.
The intent is to provide communities information they can act on as individuals or as a
community. In this context, it may be important to structure the content so they can show each
other the messages and interact with the information face to face. This interaction of information
with others reinforces the potential they will do something that may lead to and enduring
behavior change. Realistically, the idea is reliant upon the social structure of the community,
how interdependent people are, the position of the telephone owner, and how the community is
linked in to the wider network through the app.
Marketing considerations.
When contemplating either the traditional commercial path or the humanitarian route, the
associated cost and a marketing budget could be a pragmatic starting point. A point of mission
planning is for the promotion to be built into the overall development budget. A potential
opportunity might be through a larger NGO or philanthropic organization. In that situation, the
marketing would be built upon that entity’s reputation and networking. A more creative approach
encountered was to embed a promotion in a television soap opera.
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Evaluation metrics.
Upon release of the app, metrics beyond the focus group testing can become important
measures of goal achievement. The application usage and impact are the relevant focus for
assessment. Referring back to Figure 4.8c, these metrics can include population penetration,
time people spend in the app, and direct feedback received. A featured functionality that can be
included in the app is to allow direct feedback about the apps usability and issues, as these can be
critical for updates and technical support. Importantly, a health focus app needs to correlate with
health outcome data over time.
ICT and Public Health Convergence on Community Themes
Themes of community, respect and dignity were themes woven throughout the interviews
with both sets of experts. Expert lessons from the field were a concluding point of discussion; a
construct chart was used to examine these reflections. The analysis largely presents a promotion
of community based approaches. This construct analysis can be viewed in Table 4.3 of
Appendix D. The recurrent premise surrounding community recognition is well supported in
public health, public policy, and emergency management literature: community leadership,
community engagement and whole of community approaches. On the whole, these lessons also
have congruence with the processes recommended in the communications technology
development interviews and literature. Returning to the common data themes, the passages from
Table 3 were placed together for common word searches for illustrative purposes. Shown below
in Figure 4.11, the world cloud depiction highlights the emergent theme.
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Figure 4.11: Community theme
As noted in both domains of expert interviews, the target population and their context is
the pivotal point of the entire innovation. To gain specific information for content
appropriateness and technology usability, field testing with the target population is indispensable
for providing the necessary insights. Likewise, involving recognized target community leaders
can be a key to success, a concept echoed in the literature (World Bank, 2012); (Evans, S., and
Clark, P., 2011). The important directive is to get the people of the target areas involved with the
development process, interacting with the app and information, and ultimately acting on the
information in their lives and community.
Summary
This chapter was informed by semi-structured interviews with both global public health
infectious disease control experts and technology development experts. The findings for public
health messaging in combination with the practices of technology development coalesced to
inform the criteria toward an application that could make available basic health information to
people inhabiting slums.
The centerpiece of an application is its subject matter and target audience. The process of
narrowing priority infectious disease categories for the app subject matter also revealed the
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prospective end user. The key public health infectious disease priorities identified for the mobile
app are: 1) Vaccine preventable diseases, 2) Diarrheal diseases, 3) non-TB respiratory diseases,
and 4) Neglected tropical diseases and parasites. The most affected population by these disease
groups is children under the age of 5 years; it follows that the mothers of the young children
living in urban slums should be the target audience for the application. The primary messaging
information should unveil the mystery of why and how people get sick from infections and then
basic measures that can be taken to prevent getting an infection someone else may have.
Secondly, to inform people how vaccines work to keep people safe from certain diseases. These
facts need to be followed with simple actions that people can take to reduce the risk of illness
and improve the quality of day to day life. Tailoring the message content to the context and
situation of the end user is vital for an app of this nature.
For the poor of the world, the most accessible and common phone is the basic one with
an SMS app platform. Simplicity and usability of the software creating the education tool is
central. Making the app scalable with an update process is an important feature to include, as it
will allow the app to keep pace with technology changes. Also essential for the target population
is a low level literacy feature in order to serve the undereducated young women.
A four stage methodology was identified through the combined technology development
information. Within each stage there are specific tasks for development, testing and adjusting to
the target population. The first phase establishes the basic design and budget for the project, the
second phase is the development and refinement of both simple wording and visual content, the
third phase integrates the content and the software, with refinement for greater usability, and the
final phase consists of the app release, adoption and diffusion. To further guide the distinct
actions of content development, a nine step pathway was derived from the data.
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Disease prevention innovations are known to diffuse slowly, which may require planning
for additional network building efforts. Moreover, uptake from place to place may require
nuanced customization to integrate subtle contextual differences between social settings. The
implementation approach is humanitarian in nature and not for profit. Four implementation
options have been identified by the experts and briefly discussed; and these options and
processes for putting the app into practice will be further scrutinized in the subsequent chapter.
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Chapter 5
Implementation Considerations
“Specimens of a smart practice in the real world look rather different from one another and require careful interpretation.”
Eugene Bardach “A Practical Guide for Policy Analysis”
Communications technology can be viewed a tool that helps people do something already
being done, but to do it with greater efficiency. In the case of community health education, the
ongoing focus is on messaging that fosters healthy behavior change at the individual, family and
community levels. That emphasis is constant amid the global public health burdens. However,
information asymmetry has been a barrier among the poor populations of the world. Rapid
growth of unplanned urbanization has rendered these mobile and dense populations hidden from
public health efforts. Mobile telephone technology is explored as a means to bring basic
community health education to these overlooked populations.
Mobile phone use is not predominant in the public health field yet. While mobile use in
health care has been proven effective, as discussed earlier, its function is quite different from that
of public health. The focus of health care delivery is on the treatment of the individual, and
utilizes m-health for health professional tasks, medical data gathering, and treatment follow-up
and monitoring. In contrast, the emphasis of public health is the broader population health and
disease containment in populations. The use of mobile technologies in public health is evolving
out of formative stages. Employment of apps for public health purposes is beginning to catch on
and the number of examples is growing. These public health apps tend to fall into three
categories: 1) epidemiological data gathering, 2) publishing disease control information and data
for health professionals, and 3) disseminating information for the general population. The latter
category is still a newer trend, and tends to be calculator tools for matters such as body mass
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index (BMI), smoking cost, smoking cessation counts, exercise measures, calories, vaccine
schedules, and so forth. Educational messaging apps pertaining to health promotion risk
reduction remain insufficient. So, there is ample possibility for considering how best to
communicate health promotion disease prevention messages that will be accepted and sought in
mobile technology by the general public or specific target populations.
The key public health priorities for a mobile messaging app as identified in the data
discussion of chapter 4 comprise: 1) vaccine preventable diseases, 2) diarrheal diseases, 3)
neglected tropical diseases and parasites, and 4) non-tuberculosis respiratory infections. The
primary group affected by of each of these disease sets is children under the age of 5 years; thus,
mothers of young children living amid urban slums would be the strategic target audience for
this application. In the basic messaging, people need to know how and why these infections
affect them. Secondly, the mystery of how vaccines work needs to be related. These facts need to
follow with the basic achievable actions that can be taken to improve the day to day quality of
life, and reduce the undermining effects of these infections.
This chapter emphasizes practice considerations for interfacing the communications
technology requirements for implementation with the community health messaging previously
discussed. Linking the population context, the promoted health behavior action, and the
technological knowledge is indispensable for practice (Walker, 2008). In order to inform and
advance current practices, it is helpful first to look more closely at the germane literature
surrounding the practice of ICT development and then examples of ‘smart practices’ of relevant
health promotion apps already piloted or implemented.
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ICT Implementation Literature
Implementation planning for use of mobile technology in public health needs to build on
existing strengths and forestall threats. As the beginning point of the process, basic workings
that should be taken into consideration include: “information technology, processes, objectives
and values, skills, management systems and structures” (Heeks, 2002, p. 132). Essential thought
must be given to the country’s communications infrastructure sustaining mobile devices, which
mobile phone technology is most widely used, the target audience, the local context for that
population, and the content being developed. It is advisable to understand and build information
upon the existing policies of the target country (Grameen Foundation, 2011). More distinctively
to health policies, the current state of e-Health & m-Health should be considered, along with the
country specific health conditions and disease priorities (Mechael, 2009).
The project being explored presents opportunities of setting fresh goals, applying
innovative methods, and learning in the overall implementation process (Matland, 1995). Basic
to implementation planning is establishing targets and measures of success (Mechael, 2009, p.
115). Planning targets require thought as to how information flow can build capacity, how
community inclusiveness can be fostered, how adaptability can be encouraged, and what
information can become a predictor of resilience. Thinking through the existing disparities of
access, together with an estimation of how the technology intervention may improve or worsen
those inequalities is a prerequisite (Clifford, G.D., Blaya, J.A., Hall-Clifford, R., and Fraser, H.,
2008, p. 4). Broader tactics such as creating both short and long term strategic plans are also
valuable (Mechael, 2009). Strategies for behavioral and social change, adaptation, capacity
building, and resilience are also relevant influences for outcome measures.
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Communications Infrastructure.
As highlighted in the chapter 4 discussion, a critical first step for a project’s viability is
an assessment of the existing communications infrastructure and systems supporting mobile
devices. Technology can be affected by a country’s level of reliable power, public infrastructure,
or an availability of technical expertise (Clifford, G.D., Blaya, J.A., Hall-Clifford, R., and Fraser,
H., 2008, p. 4). Planning must incorporate the technological capacity of the nation
implementation is directed (Mechael, 2009); (Clifford, G.D., Blaya, J.A., Hall-Clifford, R., and
Fraser, H., 2008). While technology can appear to be fairly straightforward, differences in
capacity do exist from country to country and underscore the findings from the expert interviews.
Network reliability needs to be planned for (Grameen Foundation, 2011). Mobile
broadband coverage is often limited to urban areas (World Bank, 2012, p. 12), which is an
advantage in for planning the development of apps to reach urban slum populations. Planning for
other possible external factors which can affect technology implementation and maintenance is
pragmatic. These external factors can include corruption, inequalities within the country,
imposition of sub-optimal policies or technologies by authorities, incorrect information or the
lack of information can affect a project (Clifford, G.D., Blaya, J.A., Hall-Clifford, R., and Fraser,
H., 2008). As a brief guideline to assess where the project falls into the contextual reality, it is
recommended to assign a 1-10 scale ranking for each of these elements (Heeks, 2002, p. 132).
Commonly Used Mobile Phone.
The type of mobile devices that are commonly used by the target population is an
important determinant for content and software development. Older and more economical
applications based on SMS are the most widespread in use at this time (World Bank, 2012, p.
14), which substantiates earlier findings. Accordingly, SMS based text messaging is the most
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viable candidate for applications targeting the world’s poor at this time (World Bank, 2012, p.
16). It is also worth mentioning that Java enabled phones provided stronger foundation for
applications in poor network areas (Grameen Foundation, 2011).
While smart phones are becoming more widely available and economical, the data
services can lag and remain expensive in many places. At the same time, substantial growth in
the smart phone diffusion globally is anticipated over the next few years (World Bank, 2012, p.
20). Another consideration is that this target population can devote much of their income to have
updated technology because the information is vital to them (Rashid, A., and Elder, L., 2009, p.
4). Additionally, the mobile phones are used differently than in developed countries, and phone
sharing or other strategies can frequently be the norm (Rashid, A., and Elder, L., 2009). And so,
the commonly used phone of specific target communities must be addressed on by each case.
Looking forward to evolving changes, Nokia, with its large mobile device market in the
developing world, has made an agreement with Microsoft in 2011 to offer Window operating
system on its smart phones (World Bank, 2012, p. 21). The import of this agreement is that this
could become the future accessible and affordable system; and thus, could influence app
development in the future.
Target Audience: Context and Diffusion.
As has been emphasized in the data discussion, the primary target audience in the context
of the proposed app is mothers of young children who live in urban slums. The mother’s
situation is a vital consideration for the app content, utility, and features. An important critique in
the past surrounds the compatibility of the message with the local situation of the target
population (Heeks, 2002). Implementation designers need to be in touch with the reality of the
target audience (Heeks, 2002, p. 134), and the disease prevention material should be tailored to
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them (World Bank, 2012, p. 55). Simultaneously, it is also important to understand the country’s
health sector priorities and ensure the information to be communicated is in alignment with them
(Grameen Foundation, 2011) ; (World Bank, 2012).
To further ensure applications will be adopted by the target audience, effort must be
invested in the discovery of what is best suited for this end user (Lefebvre, 2009). In considering
the target audience, several elements are known to be prized features of an application: it needs
to be easy to use, engaging, have choices embedded, and is sharable. People want to be able to
share the app and open it as many times as they like (Grameen Foundation, 2011, p. 4). It’s key
that people get to select which knowledge and behaviors are important to them, since their well-
being is primarily their concern (Grunfeld, 2007, p. 5). Giving the end user choices and
opportunity to convey preferences has been found to have significant merit as well (Clark, P.,
Evans, S., and Hovy, E., 2011). What is more, the opportunity of choice and the user’s need,
appears to influence the spread of information (Clark, P., Evans, S., and Hovy, E., 2011).
A practical dynamic in ICT is to recognize what already exists in a community’s
interactions, and then strengthen traditional information arrangements, build on existing local
understanding, and enhance existing information networks (Gigler, 2004, p. 33). New
technologies can sometimes be viewed as a threat and a challenge to the “knowledge brokerage”
or “gatekeeping” role in some communities, as a result impact diffusion and use of the ICT
(Robinson, 1998 as cited in Gigler, 2004, p.11); (Schilderman, 2002). Correspondingly,
engaging recognized leadership from the target communities in the customizing process can be a
force multiplier for diffusion (World Bank, 2012).
While the implementation of an app venture may need to adapt to the situation of each
target region, it is also important to find a balance between the context and the inefficiencies
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created by a separate and incompatible app for every local (World Bank, 2012, p. 55).
Additionally, the international setting can also present difficulties in engagement of users in
testing, and tactics to overcome this barrier would be beneficial. Achieving content that matches
local interpretation can be done with field inquiries (Grameen Foundation, 2011) and engaging
partnerships with local NGOs (Gigler, 2004). Vital factors in ICT effectiveness in strengthening
the capabilities of the poor is localizing content for different cultures (Gigler, 2004) and
translation to the common language (Grameen Foundation, 2011).
Testing in ICT Development.
Assessing every aspect of content composition and technology utility is one of the most
valuable practices in predicting application success. When implementation of the design is
underway, testing should be integrated into the process, testing early and repeatedly in the
development of both content and technology usability. The period of implementation is where
assumptions, principles, and ideas are tested as well as the technology (Matland, 1995, pp. 158-
9). Early assumptions that went into the design can be verified or revised by these tests;
moreover, the new information should update project planning for the remainder of the final
stages of implementation (Shirky, 2014, p. 56). This insitu testing is important to achieve quality
feedback for the final system design (Grameen Foundation, 2011).
An essential element of a project is to asses both the diffusion and outcomes related to the
intervention. The aspect sought after is the interrelationship between context and action (Heeks,
2002, p. 131). Project objectives and outcome information can be used as metrics to gage this
relationship (Gigler, 2004. p.15). Building effective monitoring tools into the software is worth
consideration in the planning process. On the whole, factors influencing outcomes are “social,
political or cultural in nature, while technical issues have been observed to have a minor role”
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(Gigler, 2004, p. 33). At this time, “little evidence exists yet on how the use of mobile devices
leads to improved health outcomes” (Kaplan, 2006 as cited in Mechael, 2009, p. 111). As a
result, evaluation data becomes even more critical to infuse into a design plan and then correlate
with local health statistic data.
The practices summarized in the ICT development literature set preconditions for an
effective application development. Essentially, a successful app plan should build on the
existing local context, strengthen day to day knowledge, and link to existing information sources
(Gigler, 2004, p. 33). As we turn from the literature, further insights for implementation and
practice can be gleaned through reviewing a few selected cases of applications already in
practice.
Smart Practices
Interesting health apps and good ideas within apps abound, yet some diffuse well and
others do not. As a part of the process, it is worth examining a selection of a few good ideas
among apps to understand further how and why they work or not work. Moreover, the review
can present supplementary ideas to build on and put into practice.
The shortcoming of parallel projects is that appropriate evidence about the influence on
outcomes is often limited. Hence, prudence should dictate a closer inspection of the example
ideas. In order to gain a realistic view on how a practice may be utilized in a new setting,
Bardach (2009, p.95) recommends carefully assessing the situations and considering the
projections within the new context.
A smart practice is defined by Bardach (2009, p.96) as “an expression of some
underlying idea – an idea about how the actions entailed by the practice work to solve a problem
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or achieve a goal”. Featured within smart practices are the hidden potential for value and a way
to connect that potential to a way for it to be reapplied (Bardach, 2009, p. 101).
Examples of health care apps or m-health are plentiful. Further, apps purposed for public
health have a dedicated presence in domains of epidemiological data gathering and professional
information distribution. And even though the use of cell phones for health promotion risk
reduction is still evolving, a number of relevant and good examples exist to draw upon. In
reviewing smart practices, Bardach (2009, p. 105) suggests careful interpretation, because these
samplings will appear dissimilar from one another. Several important considerations must be
made when utilizing good ideas from somewhere else. The review of the following elements
outlined by Bardach (2009) will prove useful in testing each practice for a new condition: 1)
Observe and analyze the smart practice (p.96), 2) Characterize the features and distinguish the
functions, 3) Allow for variation (p.103), 4) Identify generic vulnerabilities (p.105), and 5)
Determine if it will work in the new situation (p.107). As the discussion turns to smart practice
examples, the presentations will include a discussion reflecting these recommended factors.
Practice 1: Health Care Focus.
To demonstrate the difference of focus between health care delivery and public health, a
health care app has been selected as an initial example. The use of apps has been demonstrated to
be quite useful for management of chronic health problems and further research into these long
term diseases, particularly with HIV/AIDS. The use of applications has been applied to aspects
of disease management, treatment monitoring, and research data gathering; and one system
showed it was feasible to deliver peer health messages.
The app example for consideration assists asthmatics in tracking and improving their
symptom status. Some of its features can be worth looking at more carefully. The app has been
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developed for an android smart phone. The content for information gathering is in 4 levels of
screens, within the optimal 3-5 level range. The first screen gathers allergy history which can be
then selected to display in graphic version. The screen has only 4 response options, but the
question is quite wordy. The second screen allows entry of additional symptoms with a
qualitative rating. The third and fourth screens record medical interventions, the timing and
severity of the incident. Interestingly, the app features a two way approach for information:
health data being sent out to the health center and asthma diary being recorded. Overall, the app
is dry, not engaging unless user is motivated to control symptoms, and requires tech savvy,
literate users. It appears to have been developed for those retrieving and studying the data and
not the user who is unwell. Refer to Figure 5.1 below to view the example screens.
Figure 5.1: Example of Health Care App (Burnay, E., Cruz-Correia, R., Jacinto, T., Sousa, S., Fonseca,
J., 2013, p. 15) A. Questionairre tool, B) Symptoms form, C) Healthcare Form, and D) Attack Form.
Practice 2: SMS samples.
As noted throughout this study, SMS is the most widespread and commonly available
mobile technology globally, especially among resource constrained locales. Therefore it could be
the most viable app for development in the near term. It follows that while SMS text messaging
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is not visually rich, a brief sampling of some practices with SMS may be useful to inform new
practices.
UNICEF utilized an SMS phone messaging in two applications. The first project was in
Malawi for data gathering on child nutrition status. Relevantly, the second application was a
vaccine follow up data for children in South Africa. Both designs enabled health workers in the
field to text specific data directly to a server for collection at a health center.
In Peru, a study to design a system utilizing cell phones for HIV support was conducted.
The reception was positive and implementation began shortly thereafter. The infrastructure and
cell phone use in place were considered in the process. The app was constructed to promote
medication adherence, and transmission risk reduction with SMS behavior support messaging
(Curioso, W., and Kurth, A. , 2007). The pilot was found to be successful in managing existing
HIV cases and reducing the transmission of the virus. It is also worth noting that the piloted
system was funded by NIH and developed by the University of Washington for the Lima
community.
The Grameen Foundation hosted a pilot project in Ghana that integrated an SMS data
gathering with an SMS messaging app to send messages to pregnant women in the health system.
The recipients were enrolled in a program for the follow-up and the messaging was
unidirectional. The messages were tailored to the individual, the pregnancy stage, care history,
and location (Grameen Foundation, 2011, p. 5). The messages included alerts, reminders,
actionable information, and educational information about the pregnancy week by week. The
second aspect of the system was for the field nurses following up on the pregnant women to
upload the patient assessment data to the server at the health center. Shown below in Figure 5.2
is a page from the nurse’s guide for utilizing the phone to input the data.
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HIV and TB medication adherence messaging is an example found in a number of
countries. A few other relevant examples from South Africa are worth mentioning. One is
around empowering self-diagnosis and serves as a guide when to seek medical attention. A
health provider localization app is a useful one for those with limited resources, as it helps locate
providers that are close, as well as low in cost.
The significant pattern for each of the SMS health apps presented is the unidirectional
messaging. Either a reminder messages is going out only, or data is being sent in to a central
server only. Additionally, each population set for receiving messages were already pre-identified
and signed into the system. In the end, a model that better informs an interactive SMS design
may be found among the abundant mobile banking and finance app examples. Considering how
to reach and diffuse through a more general population with messaging in this format will be a
central implementation task.
Figure 5.2 Example of SMS System for Uploading Patient Data (Grameen Foundation, 2011)
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Practice 3: Optimized Text Web Interface.
An optimized text web interface is also a widely available, economical, and SMS based
option with low data usage. In its basic function, the user sends a text to the server with a URL
requesting that information, the server sends the page back and the information should be
displayed, and then the connection is closed. This system has the capacity to take the user to any
URL on the web; however, the URL must be known beforehand. The observation is that the text
web interface requires a technologically savvy user, and the examples are most often catering to
skilled professionals. One such professional example is the CDC’s WISQARS mobile web based
injury statistics query and reporting system. This application focuses on four public health
problems that are preventable: motor vehicle injuries, drug poisonings, traumatic brain injury,
and violence against children. The mobile user can go to the URL to retrieve the data, maps,
graphs and charts from the interactive database. The data set is designed for a range of
professional purposes and information awareness about injury disability and mortality. Drafted
below in Figure 5.3 is the basic process of this functionality.
Figure 5.3 Text Web Interface function
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Practice 4: Pilot for Illiterate Users.
A frequent barrier to grass root users is the language of the internet, which affects
information flow in communities (Gigler, 2004, p. 11), and so a much stronger match is the low
level literacy aspects of mobile application technology. It is also recognized that most people
give more weight to visual cues (Muraya, J., Miller, A., Mjomba, L., 2011). The context of
communication can have preference to words or visuals depending on the technology selected.
A pilot project in Bangladesh demonstrated an effective tailoring of content to illiterate
populations. The Amadeyr Cloud Ltd. is a young communications delivery system dedicated to
solving the literacy and digital divide in Bangladesh. Moreover, their technology is reported to
be scalable and locally implemented with sustainable practices (Amadeyr Cloud Ltd., 2014).
Planning to incorporate the technological capabilities and existing policies of the nation the
implementation is directed is advantageous (Grameen Foundation, 2011). The pilot project is
seeing engagement and learning among the test population, and provides a strong model for
efforts to reach disadvantaged populations elsewhere.
One of their projects features an android handheld device, which has been piloted among
poor and illiterate Bangladeshi families. Depicted in Figure 5.4 are the first 2 screen selection
levels showing larger icons with easy accessibility. The first screen gives four topical choices,
when one is selected the second screen reveals twelve more specific choices. Once the selection
is made on the second screen the user is taken to the information to be gained. The screens
profile simplicity, ease of use, and yet are visually pleasing and engaging for basic information.
Significantly, the ease also boosts technology familiarity for the user, which achieves one of the
project’s goals. Variety of content and function engages the user for greater amount of time in
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the application, so that more learning can take place. The uncomplicated and interesting screen
displays for low level literacy provide a robust model for similar endeavors.
Figure 5.4: Example: Bangladesh’s Application for Semiliterate and Illiterate Users
Source: Amadeyer Cloud Ltd. http://amadeyr.org/en/content/amadeyr-tablets
Practice 5: U.S. Surgeon General 2010 Hosted Health App Challenge.
In 2010, the U.S. Surgeon General hosted a Healthy Apps Challenge to stimulate
innovative provision of health information in this new platform. Four categories for subject
matter were promoted with a winner in each category: Healthy Eating, Physical Fitness,
Integrative Health, and Children’s Health. The winners included a barcode scanner for food
shopping, a weight loss calorie budget and food intake recorder. One of the apps presented
promoted a healthy lifestyle and was called Livifi: an app to build a healthy lifestyle. The
content has relevance, albeit for a western lifestyle, and the execution is worth inspecting further.
Shown below in Figure 5.5 is the Livifi App screen image.
The subject matter is interesting but the presentation is complex and wordy, in fact overly
dense at times. The initial screen begins with goal options, of which there are 40 options to
select from, when the optimal range for options should be around 3-9. Once the goals are chosen,
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the next screens set your targets and these can be adjusted. The progress is recorded and tracked.
Overall, the user needs to be comfortable with technology, be a strong reader with good eyesight,
and be motivated to make these changes.
Figure 5.5 Example: U.S. Surgeon General hosted Health App Challenge 2010
Source: http://challengepost.com/software/livifi-an-app-for-building-healthy-lifestyle
Practice 6: The CDC Traveler’s App.
In contrast to the previous app, the CDC’s app for international travelers is designed for
low levels of literacy. The hallmark of simplicity is a basic practice, yet it is tricky to attain.
Clear and easy content is essential for small screens and low level literacy. The minimalist
approach can also be important when the target population has many cost barriers. Simplicity in
the four elements of content development is key: 1) content outline, 2) writing in uncomplicated
language, 3) limiting the key message, and as appropriate 4) clean visual representations.
The CDC app is designed to help international travelers determine what is safe to eat in
order to avoid acquiring a gastro-intestinal infection. It is a strong example of content being
tailored to the user situation. Further, it is a design that is easy to navigate which is known to
improve app usage, and may in turn prevent a number of gastro-intestinal infections among
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travelers. Because the user is most likely American, the app is available for the i-phone and
android smart phones.
Figure 5.6 Example: CDC’s Travelers App
Source: CDC http://www.cdc.gov/mobile/generalconsumerapps.html
Practice 7: The American Red Cross First Aid App.
One shortcoming to beware of is many health oriented apps on the market have not been
based on science and can be misleading. It is important to ensure a health information app is
coming from a reliable and trusted source, such as the CDC or the Red Cross. The Red Cross
First Aid App is one that is scientifically based. Their scientific advisory council ensures it is
based on the latest and best in emergency science utilizing the iterative PRISMA method for
meta-analysis. Currently the American Red Cross has a range of emergency apps available: First
Aid, Tornado, Earthquake, Hurricane, Shelter Finder, Swim, Flood, Wildfire, and Team RC
Volunteer.
The Red Cross First Aid app is the example considered for review and is exhibited below
in Figure 5.7. The app supports the average person responding to an injury or acute health
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problem when first aid is needed. The first page (Learn) offers 15 initial options, which is quite a
few, but is appropriate to the content and mission of the app. The choices also have symbols for
low level literacy and the page maintains simplicity. Once a selection is made, the user is taken
directly to the information sought. The words on the information page are complemented by a
clear illustration of the information. It is clear that the app is easy to use and designed for when a
user may be panicked.
Figure 5.7 Example: American Red Cross First Aid App
Source: http://www.redcross.org/mobile-apps/first-aid-app
Importantly, evaluation is ongoing throughout the process of Red Cross app development
and activation. The app uses a Superusers subgroup from the target population and is about 7,000
people in sized. This group gives detailed feedback pre and post development release, which
removes the cost of a survey and analysis for the non-profit. Real time analytics are used to
learn about how users are accessing the apps, how they are moving within an app, and how they
are referring others to the app. This feedback enables adjustments to optimize the app
performance.
Practice 8: App Serving Local Food Bank Users.
The resourceful vegetable recipe app tool for users of local food pantries is an
imaginative example being developed by researchers at the Annenberg Innovation Center. Users
of food pantries often get vegetables that they do not know how to cook. Further, they get a lot of
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one type of vegetable and need serving variation. The target audience is the lower socioeconomic
and semi-literate users of local food banks. They spend a long time waiting in lines for food and
the use of the app during this wait is ideal to match recipes with the vegetables being distributed.
The Veggie Book app is designed for use in the United States, and utilizes and Android
smart phone as its delivery platform. It is currently under development and is in the full pilot
stage. The app begins with an array of eight vegetables that can be selected from, followed by a
second screen of options for specific information wanted. The third screen takes the user to a
grouping of recipes. The recipes desired can then be selected and saved as a booklet, and which
can also be shared. The app also offers a secrets section, giving healthful shopping, cooking and
serving tips. The idea of a secret can be instantly engaging! A few screen selection examples can
be viewed in Figure 4.13 below.
The app designers emphasize that understanding the situation the user is in is the smart
practice. Each aspect of content and software development has been tested with representative
focus groups. The planning for customization and tailoring of an app from place to place is
anticipated for this app and they are working with food banks around the country to do so.
Figure 5.8: Example: App serving local food bank users
Source: (Clark, P., Evans, S., 2014)
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Concepts Drawn from Smart Practices.
Among the practices observed, simplicity and usability remain the essential ingredients.
Easy approaches can be the most engaging, such as choices, sharing, saving, and secrets. As has
been highlighted, a key point is that people need choice and connection to others. Having the
choice to select topics is in itself interesting, add in the ability to share and save information and
it can be attractive. The capacity to save information to the phone for future use and not have to
click through the screens again to retrieve the information desired is an alternate means of
continuing interest.
In considering SMS applications for practice, the global health examples were pilots or
pre-identified or enrolled populations. In the app proposed, a more market based approach will
be needed to engage a more general population in the health messaging, and align connections
with media that young mothers in informal settlements already connect with. The simplicity of
the examples was derived from a pattern of a unidirectional messaging: either data going to
professionals or one way messages being sent to the user. SMS does have the capacity to be
more interactive as has been seen in mobile banking throughout the developing world. Therefore,
practices deriving the interactions with choices for this app may be better modeled in the
financial sector apps than in existing health apps.
In the future, as smart phones of some form become more economical and accessible, the
idea presented of the user creating a book to be saved could translate well to a health messaging
application. The ability to save health information into a health action or a health secrets book
could have both desirability and utility to the user. For example, mothers who want to keep
information on symptom recognition, or first aid, or vaccine information for their children, could
then create booklets with that title and save it for their own use.
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Taking the notion another step further, would be to utilize the findings of the ID priority
analysis as the central options in creating a saved electronic booklet. The central product of an
app could be for mothers to create their own well-child guide. This tactic could then have initial
selections of vaccine benefits, diarrhea mitigation, respiratory infection reduction, and malaria
exposure avoidance as initial screen options for selection. When complete, the mothers could
save the electronic booklet for their own use without using more data with additional downloads.
The emphasis on adapting the message to the user situation and context is fundamental.
While the key subject matter has been prioritized, how it can be best communicated so that it is
received appropriately remains to be refined at the location selected for implementation. Any of
the ideas that may have potential to infuse into the app development will need to be shaped by
the local conditions and feedback.
Implementation Logic Model
A prerequisite for implementation planning is the selection of mobile technology
pathway for proceeding. Four pathways for implementation can be selected from based upon the
mobile technology and software development medium; for a brief review, refer to Figure 4.10 of
chapter 4. The selection of an option can begin the path to address some challenges surrounding
field testing in different regions of the world. The following summary briefly discusses these
technology development pathways for implementation.
Option 1 promotes beginning with an SMS text based application, because SMS is the
most widely available mobile function globally at this time, and specifically among the poorest
of the world. A specific feature recommended to include within the app is a scalable update
process as systems upgrade and grows in capability. This feature can also minimize the leap as
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technology advances, and when the Windows based phone / smart phone become economical
and widely available.
The implementing group or groups will be the actor(s) that select the target location,
establish implementation goals, and identifies focus groups for participation and testing.
Plausible participants for the implementation process can include a larger international NGO,
multiple local NGOs, or a blend of these. Conceivably, a candidate with capacity to take on the
scope of implementation is the Red Cross. This NGO has already produced a number of reliable
high quality apps, and has a recognizable and respected presence around the world with critical
community relationships already established.
The uncertainty of the actors and means exhibit a high ambiguity and low conflict
implementation situation where contextual drivers will dictate the process (Matland, 1995, p.
165). Consequentially, the outcomes of this option are contingent upon the implementing group
and the location selected for implementation.
Option 2 also begins with a SMS text base, but it is optimized to interface with the web
by going to a URL for the information sought. The implementation is similar to the first option,
with the variance in the technology approach. However, upon surveying the samples in practice,
this approach tends to cater to professional usage and requires a technological savvy user. Thus
the option may not be an effective one for a target audience that comprises young low level
literacy mothers who dwell in urban slums.
Option 3 is to create multiple app versions for multiple locations, and potentially
implemented by one or more organizations. These versions could use both SMS and smart phone
apps based on the prevalent mobile technology of different regions. Additionally, they would use
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the same content foundation, but customize it to the common mobile technology, language,
literacy levels and culture for the area.
This route can be more of the policy garbage can approach described by Matland (1995).
The conditions of the option are marked by uncertainty, and employ a range of mobile
technologies with an unpredictable participation of actors (Matland, 1995, pp. 165-6). The
process for policy implementation is influenced by the ratio of ambiguity and conflict in policy
implementation. In his discussion of policy implementation, Matland (1995, p. 160)
differentiates the 4 types of implementation in relationship to this ratio: Symbolic, Political,
Administrative, and Experimental implementations. The combination of undecided means and
goals contribute to ambiguity, a hallmark of the experimental implementation.
The strength of this option lies in the bottom up nature of implementation. On the other
hand, the process can be constrained by the contextual conditions (Matland, 1995, p. 165). Yet,
the customization required to reach marginalized populations can be quite appropriate. The
variances and multiplicity of approaches from place to place can be part of the nuanced
customization required for each social setting to widen the health information diffusion.
The fluidity of participants is marked by a wide range of involvement (Matland, 1995)
across sectors and economic strata. Broadly speaking, potential participants can include a larger
international NGO, multiple local NGOs with local leadership, or a combination thereof. At the
same time, there is a probable candidate with the capacity to take on the scope of
implementation. As noted above, the Red Cross has already produced a number of reliable high
quality apps, and has a respected presence around the world with those community relationships
already established.
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The outcomes of this approach will be reliant upon the resultant actors involved and the
resources available to this implementation environment (Matland, 1995, p. 166). Nevertheless, it
is this type of prospect that presents an opportunity to learn new means to achieving the goal.
The multiplicity of strategies and outcomes can be compared and evaluated to determine which
tactics can be most creative, effective and influential on health behavior changes.
Option 4 is to release the design criteria to an open source online forum. The sharing
allows an assortment of code developers from the potential target communities to handle the
localization of the content and then create the software for the app. This course of action may be
quite a practical one, providing for software development without financial investment, and it
may also enable the widest diffusion.
Open source forums exist with diverse goals, often these are present for software coders
to share code or develop code for new ideas. These open forums can range broadly from a high
stature organizations collaborating for humanitarian purposes to technology nerds wanting to
sharing ideas to rather nefarious collectives. Thus, understanding the purpose and mission of the
open forum would be a primary consideration for selecting an open forum.
Further certainty can be gained in selecting forums that align well with the vision of this
research. An example of a forum that offers this confidence is an open mobile application
consortium based in California titled: Innovative Support to Emergencies, Diseases, and
Disasters (InSTEDD). The affiliation goal is to foster code and design sharing for mobile apps
with a focus on humanitarian and global human health needs. This particular assemblage is a
collaborative effort between numerous global partners from technology, mobile communications,
organizational support, international organizations, NGOs, and financial support. Notably, the
financial support is derived from a dozen foundations, with the Gates and Rockefeller
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foundations prominent; and the Red Cross is among the prominent NGOs associated. Of
further weight, another Red Cross App similar to the First Aid app, was also funded by the
InSTEDD consortium.
The implementation approach will be contingent upon the forum selected for release. In
many cases it may be a bottom up implementation where the means and goals are unclear, along
with diverse implementation actors, strategies, and outcomes (Matland, 1995). Similar to the
discussion in Option 3, this too can become a more experimental implementation. On the other
hand, if the InSTEDD consortium is the optimal forum for release and the project is selected for
implementation, specific goals will be in place and the ambiguity diminishes for the
implementation process. As a result the process can become an administrative implementation,
based upon Matland’s Ambiguity-Conflict model for implementation (Matland, 1995, p. 160).
The logic model in Figure 5.9 below illustrates how these implementation options can
work independently or together to achieve customized health promotion apps that are available
to a wide array of the world’s urban slum communities. Unless there is large buy in by an
influential group such as InSTEDD or The Red Cross, implementing two or three options in
tandem would yield a broader coverage of disenfranchised communities. The comprehensive
outcome desired is a reduction of the under 5 morbidity and mortality rates, improved day to day
health within informal communities, and a reduction of ID transmission among the families of
these communities.
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Figure 5.9 Implementation Logic Model
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Summary
The implementation condition of the project explored in this study not only has several
pathways for achieving technology development, it also includes diverse locales and a fluid
participation of actors. This situation suggests there are many ways the criteria can be
customized and carried out, and that the implementation will differ from community to
community.
The circumstances described are ambiguous for the processes of implementation, and this
ambiguity affects these processes. Several ways this can play out are outlined by Matland (1995,
p159): 1) the ability to observe accomplishments diminishes, 2) differences will occur among
implementation locations, and 3) local contextual factors will dictate the development.
Relevantly, these effects are also reflective of the unreliable diffusion path that requires a
nuanced customization for each social setting in app diffusion.
The key sources of ambiguity in policy implementation were identified as unclear
application goals and vague execution means (Matland, 1995). Germane to this project, Matland
(1995, p158) identifies that ambiguous means can happen “when a complex environment makes
it difficult to know which tools to use, how to use them, and what the effects of their use will
be”.
It has already been noted that outcomes in this implementation environment depend on
the grass root actors and the resources for implementation. In considering evaluation for this
situation, Matland (1995, p.166) recommends describing the process and how outcomes are
achieved in a formative way. Importantly, a comparative analysis of the diverse
implementations can advance the way of knowing which actions and social settings yield the
better health outcomes. In an uncertain implementation condition, it is helpful to view ambiguity
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as opportunity to learn innovative means with fresh goals (Matland, 1995). The assessment
should be about adapting to what you learn, not removing uncertainty in advance (Shirky, 2014,
p. 55). In reality it should be a continuous cycle of evaluating, learning, and adapting.
Despite what may appear to be a nebulous entrance to putting the app into development,
some options appear to offer greater potential than others. The uncertainty then is around the
interest and acceptance of the possible players. In the end, both Options 3and 4 may be the most
resilient for wider diffusion. If a large NGO, such as the Red Cross, selects to adopt the project,
the capacity and relationships are in place to enable the path of multiple app versions in different
locations. The other choice is to engage an open forum such as the InSTEDD consortium with a
proposal. If selected as a project the consortium pursues, the implementation would be robust,
widely diffused, and undoubtedly influence health outcomes in these fragile communities.
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Chapter 6
Concluding Summary
“What we are called upon to provide is a quality service, delivered with respect, so that people using it can receive it with dignity.”
Sister Stan, The Road Home
Global public health is influenced by multi-dimensional factors: rapid urbanization
influenced by migration, expansion into bio-diverse zones, meager public health infrastructures,
limited access to potable water and sanitation, and the neglect of infectious diseases among the
populations living in the slums. The interrelationships of these dynamics influence microbial
effects and amplify likelihood of public health emergencies. The same interconnectivity served
as the basis for exploring mobile technology as an instrument for a health promotion effort
among the most vulnerable communities of the world.
The emphasis of community health education is promoting healthy behavior changes at
the individual, family and community levels. Mobile technology converges naturally with this
communicative effort, and has the potential to expand the capacity and reach to populations that
have been long disregarded. Bringing about a message that is both wanted and believed is a
dynamic process in the coming together of the messaging content, communications technology,
and the communities targeted as the end user for an application. The significance of this
relationship is how it can help the capacity of individuals, as new information can bring
differences, values, and opportunities.
The focus of this research inquiry was to determine the criteria needed for a mobile
telephone application development that would present messaging for infectious disease
prevention among urban slums of the world. Described in this report are the foundational
conditions for the development of an app with infectious disease prevention messaging. The
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further intent of the investigation is to provide direction not only for the development of the
proposed app(s) targeting informal urban communities around the globe, but also to establish a
methodological approach for other health promotion risk reduction messaging applications. The
patterns founded within the data of this research provide a framework to operate within for each
new problem set, target population, and subject matter.
Characteristics of Effective App Development
The methodological process for a public health app development is a fundamental finding
outlined in this exploration. The process of developing a mobile phone application for a public
health messaging can be defined in four phases, each with unique tasks and considerations
associated. Described in chapter four, the phases of the methodology are: 1) Basic Design
Consideration, 2) Content Development, 3) Software Development, and 4) App Release. The
involvement of community focus groups in each phase of application development in both the
localization of content and usability testing of software is central. Refer to Figure 4.3 in Chapter
4 for greater detail of the outlined method.
Basic Design Considerations.
Many key decisions for the application are made in the first phase. The centerpiece of an
application is its subject matter and target audience, and these are pivotal determinations in this
phase. Identifying mobile phone platform that best reaches the desired audience is also vital. In
the case of the proposed infectious disease prevention messaging app, the target population was
identified as the priority problems were narrowed. Children under the age of 5 were those
primarily affected by the priorities, as a result, mothers of these children living in urban slums
would be the target population for the app. Currently, the mobile phone with the widest
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penetration among the targeted slum communities is an SMS based phone, suggesting that a
SMS based app would be the choice that would provide messaging to the widest range of users.
Foundations for the Content Development.
Content development is the second phase of development, and is when the messaging for
preventing infectious diseases is to become infused into the application. Aptly, a nine step
approach for effective content development was outlined, and provides practical guidance for the
process. This pathway guide can be reviewed below in Figure 4.8 in Chapter 4. Amid these
steps, basic aspects are selection of the local disease priorities and related health information
according to the user context, and adaptation of the health information choices to local needs and
context, and simplification and depiction for mobile presentation. Importantly, this is a phase
where much field testing for concepts and contextualizing occur.
Topic narrowing.
The process of narrowing priority infectious disease categories for the app subject matter
also revealed the prospective end user. Four ID categories were prioritized for the app problem
set to be selection options on the first screen: 1) Vaccine preventable diseases, 2) Diarrheal
diseases, 3) other respiratory diseases, and 4) Neglected tropical diseases and parasites.
Localized tailoring can further lessen the options to what is locally appropriate. Children under
the age of 5 are those most affected by these disease sets in the social environment, and are a
focus of morbidity and mortality prevention. In view of that, young mothers living in urban
slums would be the broader target audience for the proposed application.
Health messaging.
The importance of how the message goes out is a guiding theme, and is connected to a
holistic approach and culturally tailoring of the disease prevention messaging. The location
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dependency of each infectious disease set will need to be considered, incorporating the whole
situation of the community and not just the disease process, so that the widest influence possible
is achieved. Ten basic prevention strategies and the associated health information were
identified. Of the ten educational strategies, four are cross-cutting among the disease categories:
1) the role of microbes in human health, 2) basic practices of personal and indoor hygiene, 3)
first aid for the home, and 4) prevent getting an infection someone else has.
Following on from the strategies, are basic health literacy concepts to be communicated.
The provision of the how and why a health problem affects people is critical information to give
when promoting behavior change. Two educational messages are pivotal for health
improvements for each disease set nominated and should be priority for inclusion: 1) basic
microbial concepts of disease causation, and 2) how to keep germs from spreading within a
household. Closely related also is the simple concept of how vaccine can work to protect from
illness. These can be specifically refined and adapted to be culturally appropriate information.
The essential behavioral messages identified to be communicated were around two basic
practices: 1) practices of personal and indoor hygiene, and 2) When and how to make water
potable. Of critical importance is that the messaging following on from these approaches must be
customized to the local context. The localization considerations include the most useful emphasis
and considerations for how to overcome barriers.
Technology Development.
The third phase in the app development method, the technology development integrates
the content with the appropriate software to produce the app. Simplicity and usability are key
attributes to prioritize in this process. This phase includes vital testing processes for usability
and clarity of function. Adjustments for ease of function are encouraged.
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Adoption & Diffusion.
The fourth phase of development includes the release of the app for adoption and
diffusion. Providing localized tailoring for the innovation in different locations may also be
important to surmount irregular diffusion often associated with disease prevention interventions
and possible adoption barriers.
Likewise, respect of local ways of knowing in the beginnings of the customization
process not only engenders trust of the information, but may also foster the diffusion of the app
as well as the coming together of the community for disease control. The whole community can
be viewed as a complex adaptive system, which is primarily a network of communications
between nodes, a fundamental characteristic of complex adaptive systems. To communicate,
relationships must exist; in those relationships there must be trust and dignity or communications
and balance in the system will be limited. The foundational beginnings of dignity and trust in the
connection with the target population will influence dissemination of the information and
augment the linked community. The whole point is connection with the people, which can begin
with those representing the target audience in the development phases of the application. The
vision is for a sense of community to begin within the app communication, which then influences
the community outside the app.
Implementation
The selection of one of the four mobile technology pathways is a precondition for
implementation planning. An overall goal is a wide penetration for the infectious disease
messaging, and so a range of software development implementation approaches have been
presented in chapter 4 and discussed in chapter 5: 1) straightforward development of app in
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SMS platform with a scalable update feature, 2) utilize a web optimized SMS text based app, 3)
create multiple app versions for multiple locations, implemented by one or more organizations,
and 4) release the criteria to an identified open source online forum for development. It should
be recognized that it can be appropriate to select more than one option. While the options for the
outset appear to be an unclear entry into app development, some of the options do present greater
potential than others. Using these options, a logic model was devised to track the
implementation path for each of these inputs, identifying the participants, activities, and
outcomes. This logic model can be reviewed in Chapter 5 in Figure 5.9. The finding is the
uncertainty lies around the interest and agreement from potential participants. Options 3 and 4
each present a wider diffusion potential. If a large NGO selects to adopt the project, the capacity
and international relationships in place can enable the multiple app versions in different
locations. The other strong choice is to present a proposal to the open forum consortium with the
humanitarian mission for development implementation. If selected, the outcome would benefit
the neglected slum communities.
At the end of World War II many jeeps were discarded in countries around the world.
The vestiges of these damaged tools were transformed by the local people who adapted them to
their needs, re-creating a tool that served them in their current context. Today these jeeps are
still seen in many places, but the distinctive revisions of the vehicle is widely different from
place to place. Similar to the jeep, the findings of this study show that the criteria set forth is a
tool that can take on many forms to meet the functional need of different contexts across the
globe. The physical and social context of each selected target audience will determine the
language and cultural elements, which problem the health messaging should be directed to, and
which technological arrangement is best to utilize.
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Limitations
Location dependency of disease entities has been clearly specified, and the health
messaging must be adapted to the user context, language, and situation. These facts point to the
necessity for nuanced customization in each new region the application will be implemented.
The conditions for this app reveal the characteristics of an innovation that will not readily spread
from place to place, and may need locally specific customization. Moreover, innovation efforts
in disease prevention are known to diffuse irregularly or slowly. Thus, a repeated localization
process will undoubtedly be necessary to become viable in different locations. An additional
implementation challenge lies in the international fieldwork with focus groups during
development customization; although, some possibilities to achieve the varied field testing may
be found in the technology approaches options for development.
This trans-disciplinary exploration sought to identify the foundational criteria toward the
development of an application with infectious disease prevention messaging. Principles,
guidelines and pathways for the processes have been described, and prioritization for disease
categories and health messaging was distilled. Yet, the wide penetration goal for messaging, and
diverse implementation avenues, project missions and regions can make putting these into
practice appear confusing and uncertain. The ambiguity exists because options exist; a fluid
participation of actors and diverse locales influence further complicate it. There are myriad ways
the criteria can be customized and executed. The circumstances describe a lack of clarity in
means for the processes of implementation, which contribute to what Matland identifies (1995)
as local contextual factors dictating the process. A subsequent phase of research can investigate
each of these variables further for a more delineated pathway to a specific target population.
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Further Research
The use of mobile telephony in public health messaging application is evolving out of
formative stages. While examples exist for healthcare and health delivery usage, and obtaining
epidemiological data, public health applications messaging the general population lag. Interest is
now growing and cases have been made to explore the use of mobile telephony for public health
outreach. It is an opportune time for innovative ways to communicate a disease prevention
messages through this ubiquitous medium.
A need for further research exploring mobile phone’s role in public health is clear. No
literature on using mobile phones for infectious disease prevention in developing countries
exists; the nearest example is an HIV treatment management and peer messaging application.
Further, only a few public health project examples are evident in the literature, most often around
maternal child health or epidemiological data gathering.
Beyond the immediate scope of this research, future applied possibilities exist to connect
with a recognized organization to develop the template into an actual telephone application. The
strength of such a digital tool is that it can be available anywhere people have access to mobile
telephones. Most importantly, the great potential lies in using telephone connectivity to empower
people to act in the interest of their own community’s health.
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CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Appendix A: USC IRB Authorization
UNIVERSITY OF SOUTHERN CALIFORNIA
UNIVERSITY PARK INSTITUTIONAL REVIEW BOARD
FWA 00007099
Determination of NOT Human Subjects Research
Date: Fri Jan 24 10:34:35 2014
To: Shirley Feldmann-Jensen
From: Dalar Shahnazarian
Project
Title:
Empowering Community Health in Developing World Slums: A foundation to
support the development of a mobile telephone application_IRB Information
Request - Wed Dec 11 15:34:46 PST 2013 ( IIR00001556 )
The University Park Institutional Review Board (UPIRB) designee reviewed the information you
submitted pertaining to your study and concluded that the project does not qualify as Human Subjects
Research.*
This project focuses on interviewing Global Health Infectious Disease and Technology Development
experts. This project is not collecting information about subjects, but rather creating the preliminary
foundation toward developing a telephone application that could further empower communities to act
together to improve their community health. The research activities as described do not meet the Federal
definition of a human subject and are not subject to the requirements of 45 CFR 46 or continuing review.
This review and opinion is based on the information provided and is not valid if the proposed project is
not exactly as described, or if information has been withheld. If your project design changes in ways that
may affect this determination, please contact the IRB for guidance.
Sincerely,
Dalar Shahnazarian
*From 45 CFR 46.102, The Federal Regulations on Human Subjects Research
Human Subject: A living individual about whom an investigator (whether professional or student) conducting
research obtains data through intervention or interaction with the individual, or identifiable private information.
Research : A systematic investigation, including research development, testing, and evaluation, designed to develop
or contribute to generalizable knowledge.
144
CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Appendix B: USC Non-Human Subjects Research Application
Date: Thursday, December 12, 2013 12:48:46 AM
NOT HUMAN SUBJECTS RESEARCH(NHSR) APPLICATION (USC ONLY)
This application is used to determine if a project meets the regulatory definition
of human subjects and/or research. When the IRB determines a project does
NOT meet the regulatory definitions, a determination letter will be generated
which states IRB approval is not required. If the IRB determines the project
DOES meet the regulatory definitions, a "New Study" application must be
submitted for IRB approval.
Guidance
DO NOT use this application for:
Projects involving FDA regulated products
Projects that meet the regulatory definition of human subjects research
Projects that involve only Coded Data/Specimens
These projects will not be reviewed through this application, and need to be
submitted as a “New Study” application in iStar.
To proceed, click the Continue button. Otherwise, click the Back button.
I. Project Information:
* Specify a title for this project: Empowering Community Health in Developing World
Slums: A foundation to support the development of a mobile telephone application_IRB
Information Request - Wed Dec 11 15:34:46 PST 2013
Guidance
* Please indicate which IRB you are requesting review from:
University Park IRB (UPC)
Guidance
* Is the Principal Investigator a student, resident, fellow, other trainee, or visiting
scholar?
Yes No
Guidance
Please designate a Faculty Advisor:
Juliet Musso HS Certification: Current ( 6/5/2016)
Guidance
II. Does Project Meet Regulatory Definitions
"Human Subjects"
145
CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
1. * Does the study involve interaction or intervention with live human
subjects?
Yes
(Though interaction or intervention may have occurred previously,
specimen(s)/data/information were collected from live subjects. Cadavers, autopsy
specimens or specimens/information from subjects now deceased is not human
subjects).
Guidance
2. * Is the information/data/specimen(s) obtained about the subjects?
No
(i.e. does the research data sought pertain to the individual subject, or is the data sought merely
provided by the subject. For example, a quality improvement project for an education program may
ask teachers to provide information on how to improve the program. This information is not “about”
the teacher but information provided by the teacher about the education program.).
Guidance
3. * Is the collected information/data/specimen(s) private information?
No
(Private information is that which allows identity of individual to be associated with the
information/specimen/data)
Guidance
"Research"
1. * Is your study designed to produce generalizable knowledge?
Yes
(Generalizeable knowledge is when the intended use of the research findings can be applied to
populations or situations beyond the studied unit.)
Guidance
2. * Is the study systematic?
Yes
(Follows step by step procedures organized according to interrelated ideas or
principles evidenced by a research plan and objectives.)
Guidance
III. Study Description
Additional information (to determine whether or not your project qualifies as human
subjects research:
1. * Provide a brief (1 to 2 paragraph) description of the study in LAY
LANGUAGE. This should not be a scientific abstract.
Infectious disease control among informal urban communities is a complex issue
and the solution lies beyond the reach of the public health sector alone.
Recognizing the challenges surrounding this real-world need, the idea is to generate
an introductory plan that can be applied toward the development of a mobile
telephone application. This project addresses the question: What framework is
needed to develop a telephone application that could further empower communities
to act together to improve their community health?
Guidance
146
CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
The purpose of this project is to create the preliminary foundation or decision tree
schematic toward a mobile telephone application. The decision tree will include
identified best practices and a whole community approach. The goal is to translate
existing data into a blueprint for a feasible tool that could diffuse health
information specific to communicable diseases in informal settlement communities.
The desired outcome is to foster action for healthier communities.
2. * Describe the subject population being studied.
The interview purpose is to learn greater detail about best practices from subject
matter experts. These experts will be from the two distinct fields which intersect
this project.
1. Global Health and Infectious Disease
Four to seven Global Health Infectious Disease subject matter experts will be
interviewed to gather greater detail about best practices and prioritization of actions
for infectious disease control in a scarce resource environment.
Potential interviewees include:
-Dr. R. Bissel – University of Maryland
-Dr. F.M. Burkle – Harvard University and University of Hawaii, Emeritus
-Dr. D.A. Henderson – John’s Hopkins University, Emeritus
2. Technology development
Four-six technology development experts will be interviewed to ascertain best
practices and optimal information parameters for an application development.
Potential interviewee includes:
- Melissa Loudon - USC Annenberg School of Communication PhD candidate
Guidance
3. * Provide a brief description of the design and methodology of the study.
The semi-structured interviews will be with subject matter experts utilizing a
snowball approach to sampling. The interview will be voluntary and confidential.
The estimate is to conduct 10-14 such interviews.
The objective is to ascertain expert prioritization and best practices that will inform
the foundations for the health messaging application. The interview data derived
will be triangulated with the published data. The triangulation process will inform
the creation of the decision tree for the telephone application.
Guidance
4. Submit the survey or questions that the subjects will be asked (if applicable).
name Version Modified
A foundation to support the development of a mobile
telephone application
0.01
12/12/2013 12:44
AM
147
CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Appendix C: Interview Protocols
Empowering Community Health in Developing World Slums:
A foundation to support the development of a mobile telephone application
Interview Protocol
The Purpose of the Interview
Thank you for agreeing to discuss best practices in your area of expertise:
Global public health infectious disease control or
Mobile telephone application development.
Shirley Feldmann-Jensen, a doctoral student at the University of Southern California, Sol Price School of
Public Policy, is conducting a research project to establish messaging criteria toward the development of a
mobile telephone application. The objective is to ascertain expert prioritization and best practices that
will inform the foundations for the health messaging application.
The purpose of this interview is to learn greater detail about best practices from the two distinct fields
which intersect this project:
1. Preventive medicine: to gather greater detail about best practices and prioritization of actions for
infectious disease control in a scarce resource environment.
2. Technology development: to ascertain best practices and optimal information parameters for an
application development.
The interview is voluntary and confidential. The information gathered will be stored in a separate and
password protected place. You will not be quoted by name without your advance written permission. If
you have any questions about the project please feel free to contact Shirley Feldmann-Jensen
(feldmann@usc.edu).
148
CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Questions for Public Health Infectious Disease Experts
1. From your research, what are the three most pressing infectious disease priorities for
action on the global health stage?
a. Discuss the criterion that informs your prioritization.
b. Describe the best prevention approaches for these.
i. In particular, I am interested in basic actions that ordinary people can take.
ii. Explain how these approaches may change in a scarce or deprived
resource environment.
2. Discuss the infectious diseases seen among the urban poor that have the greatest
likelihood to be controlled?
a. Describe the best practices that would achieve control of these infections.
b. What changes would need to occur in these practices to accommodate a scarce
resource environment?
c. Describe basic actions that individuals can take to reduce their risk of these
infections.
3. How would you prioritize the following: Vector borne disease, diarrheal diseases, and
respiratory infectious disease?
a. For each of these categories, which are the most effective basic preventive actions
that can be undertaken by ordinary people in their communities?
b. Discuss any changes of action that would follow in a resource deprived
environment.
4. What basic health information would you consider most useful in a social milieu of
scarce resources and low levels of education? Least useful?
5. Describe any notable surprises you have encountered in infectious disease prevention and
control. What lesson should be applied from that experience?
149
CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Questions for Technology Development Experts
1. What do you see as success factors in an application?
2. What considerations should be given to establish the content criteria for an app development?
a. In creating the initial selection for an app, what is the optimal number of selections?
b. What number of layers on a decision tree is optimal for an app development?
c. What do you see as challenges in establishing content criteria?
3. Describe best or smartest practices for developing application criteria, such as basic health
education.
4. Explain how impact evaluation can be factored into the criteria development.
a. Cost
b. Use
c. Numbers for each field
150
CONDITIONS FOR AN APP SERVING UNPLANNED URBAN COMMUNITIES
Appendix D: Construct Analysis on Lessons from the Field
Field Lesson Quote PH Lesson Community Approach
Lesson
“It is always a surprise in that environment. We
often underestimate what they can do. We need to
be careful and not generalize. Make sure we are
good at variety. Give room for input when there is
not a fit.”
Take care to not
generalize problems
Diversify
Acknowledge
capabilities within
communities
Seek input
“People living off small rural agriculture have a
deeper appreciation for controlling vectors and
microbes than those in an urban environment.”
Translating what the
local rural population
knows to the urban
Discover the existing
knowledge of the
region
“There is a basic understanding of what is
needed, but they don’t have access of money to get
it. These people have to be able to access these
things in their own place and on their own terms.”
Inequity impedes
access to healthy
choices
Meet people where they
are at on their terms
“Is it the lack of education or the lack of ability?
Educating the populous may help, but I suspect
that these people already know.”
Seek solutions to the
barriers for the
community
Recognize that
communities have
existing knowledge
“The mental health aspects from the stresses of
chronic poverty revealed the importance of giving
culturally appropriate care.”
The stresses of chronic
poverty
Approaches to care &
intervention must be
culturally & locally
appropriate
“You can teach and train people with little
education how to take preventive or treatment
measures to save lives.”
Teaching and training
the community to
participate.
Respect that people
have capability to help
& care for others.
Convey dignity in
training.
“The use of Women’s Health Committees which
were local women of the communities; it was part
social and then discussed vaccination, family
planning, etc. They in turn would go in some sort
of pattern to contact people in the community,
which was very effective communication
&influential to health outcomes.”
Be open to new ways
of doing things.
Recognize that local
approaches to
accomplish the task
may be more successful
Be open to new ways of
doing things.
“The multi-dimensional and multi-disciplinary
nature of disease mitigation.”
Disease mitigation is
complex
Be open to making
contact with people in
new ways.
“I always knew how rapidly IDs could be spread,
but within the last 3 decades, the increased
densities of populations, how quickly travel can
take you changed how quickly emerging diseases
can spread throughout the world. No surprise – but
as a PH person the surprise is how fast it happens.”
Due to the recent
changes in the world,
infectious disease
disseminates globally
extremely fast.
Engage populations in
active disease
mitigation efforts
“Few people, even medical people, understand the
ramifications of a poor PH infrastructure and poor
PH protection programs…disaster defines the
public health and its vulnerability.”
A resilient PH
infrastructure is
critical, when it is poor
the M & M rise.
A whole community
approach is needed for
a healthy community.
Abstract (if available)
Abstract
Rapid unplanned urbanization is among today’s global challenges and continued escalation is predicted
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Asset Metadata
Creator
Feldmann-Jensen, Shirley
(author)
Core Title
Conditions for an app serving unplanned urban communities: integrating cell phones into health promotion messaging
School
School of Policy, Planning and Development
Degree
Doctor of Policy, Planning & Development
Degree Program
Policy, Planning, and Development
Publication Date
11/03/2014
Defense Date
09/09/2014
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
app,cellphone,community health messaging,e-health,Health promotion,ICT for social change,infectious disease in slums,infectious disease prevention,information communication technologies,m-health,mobile telephone application,OAI-PMH Harvest,public health education,slums,unplanned urban communities
Format
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Language
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Contributor
Electronically uploaded by the author
(provenance)
Advisor
Musso, Juliet A. (
committee chair
), Castells, Manuel (
committee member
), Natoli, Deborah (
committee member
)
Creator Email
feldmann@usc.edu,shirley.jensen@csulb.edu
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Tags
app
cellphone
community health messaging
e-health
ICT for social change
infectious disease in slums
infectious disease prevention
information communication technologies
m-health
mobile telephone application
public health education
unplanned urban communities