1. Mphatso Nyemba-Mudenda UNIVERSITY OF CAPE TOWN 4 TH JULY, 2013 The Dynamics of Involving Intermediaries on User Experiences and Outcomes of mHealth Initiatives: The Case of a Maternal Healthcare Intervention in Malawi

2. Outline Introduction and Motivation Context Methods Results Summary

3. Introduction and Motivation Maternal health - one of the main challenges facing developing countries The use of mobile phone technology interventions has potential to reduce maternal morbidity and mortality in developing countries (Chigona et al 2012; Noordam et al 2011) Low mobile phone ownership in remote areas of developing countries(Heeks, 2009; James & Versteeg, 2007) Interventions are taking advantage of the sharing culture in developing countries and involve intermediaries like Community Volunteers as point of access for mobile phone usage

4. Objectives Little attention is being paid on effect of intermediaries Research Question: o What is the effect of involving intermediaries on the user experiences and outcomes of mHealth Initiatives? o Does this kind of intermediation allow scalability and sustainability of mHealth initiatives?

5. Context Mobile System for Safe Motherhood (MSSM) project in malawi whose objectives are to:  Maximize maternal healthcare access and utilization  Provide expecting mothers with lucid health advice and referrals to nearest health facilities MSSM Project uses two systems  toll free case management hotline Mobile phone tips and reminders service enrollment Health advice  Tips and reminders Personalized health education messages about maternal health Voice or SMS messages delivery on a weekly basis

6. Cont’d Community Volunteers ( intermediaries) Over 350 volunteers in four catchment areas (over 3000 clients) Each village has one volunteers who was given a phone and solar charger They help mothers with mobile phone access and usage

7. Methods Inductive strategy using qualitative and interpretive approach Sampling: Random and maximum variation  Sample:  12 mothers  4 Community Volunteers Data collection tools:  Semi-structured, face-to-face interviews  Participant observation  Field notes Data analysis  Thematic analysis

8. Results Effect of Personal Characteristics of CV Gender  Good relationships with female CVs Knowledge about the intervention  Good understanding of the intervention  But promoted voice message only for tips and reminders Loyalty  Committed and using own initiatives e.g., they take an extra mile, following women to their houses for them to use MSSM services

9. Results Social factors Privacy  Women were given space to talk in private so that they are free to talk without reservations Trust  Women had deep respect for CVs since they were selected by chiefs and a health committee  CVs already serving the community with health related activities long before MSSM  Trustworthy – not talking about one’s case to other people Availability  Some CVs had appointment schedules for the clients  CVs not available usually follow up on clients who came to use the mobile phone and did not find them. Support from implementer  No refresher training and proper management  Community Volunteers felt that they were on their own, working without much support and direction

10. Results Environmental Characteristics Mobile Technology  Technical condition of mobile phones – after one year of intervention over 50% of the phones not working  Expensive to provide and maintain the handsets  Replacement of mobile phones not planned for due to lack of funds Incentives for participants  MSSM did not give incentives to the participants  Community Volunteers reported of not being content with doing all the hard work without monetary incentives  Owning a mobile phone and having a branded T-shirt could been seen as an incentive in their on right and motivated their actions

11. Outcomes Convenient – access of health information from homes or communities Confidential - talked privately to someone they had never met and was able to help them with their problems Adequate time talking to the hotline workers Time-saving and money-saving since the women did not have to go to the health facility for any little medical attention

12. Summary Position of CV is vital - enabled healthcare to reach the digitally excluded in remote areas The intermediation of CV was not sustainable and scalable in this case For effective use of intermediaries, policy makers and programme implementers need to understand how the intermediaries ought to be integrated into the design and execution of the intervention. Limitations:  Time, small sample, specific case of Malawi

13. Thank You!