CAF Proposal

Research – Intervention Proposal for Corporación Andina de Fomento (CAF) Project Title: The use of cellular phones among poor women in Colombia, Peru and Venezuela: potential applications in healthcare and social development Principal Investigators: Isaac Nahon-Serfaty, Assistant Professor

Daniel J. Paré, Associate Professor

Department of Communication, University of Ottawa 554 King Edward Ave, Room 207 Ottawa, Ontario, K1N 6N5, Canada

Department of Communication, University of Ottawa 554 King Edward Ave, Room 207 Ottawa, Ontario, K1N 6N5, Canada

Tel: +1 613 562 5800 x3836 Fax: +1 613 562 5240 Email: inahonse@uottawa.ca

Tel: +1 613 562 5800 x2052 Fax: +1 613 562 5240 Email: daniel.pare@uottawa.ca

Date Submitted: October 29, 2010

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The use of cellular phones among poor women in Colombia, Peru and Venezuela: potential applications in healthcare and social development Context: Mobile telephony and related applications offer tremendous potential for improving the delivery of health-related and other services to poor households. Central to the development of strategies for successfully realizing this potential, however, is the need for a better understanding of the mobile telephony practices of those who are meant to benefit the most from the integration of these technologies into enhanced service delivery initiatives. The objective of the proposed study is to develop evidence-based knowledge and strategies to facilitate the implementation of community- and policy-based initiatives for maximizing the opportunities afforded by mobile telephony in the realm of public health and social development.

Within Latin America, the exponential growth in the uptake of mobile telephony across all social strata offers a host of new opportunities for healthcare access and education among the poor and, in particular, poor women (Galperin,and Mariscal, 2007). This segment of the population plays a key role in overseeing, promoting and sustaining the health of families (Gonzalez, 1999). However, communication gaps between healthcare providers and socially vulnerable populations continue to be a key barrier to the successful provision of public health interventions especially with regard to health promotion, patient care, monitoring patient health data and dealing with chronic diseases (Blake 2008; Anta et al. 2008). All too frequently, however, in such initiatives technology is seen as a starting point or solution to a particular problem, with relatively little consideration given to contextual factors that may distort or otherwise impede the effective and sustained integration of mobile technology into the delivery of primary health care services. At issue here is what Heeks (2005, 2003, 2002) and others (e.g., Ciaborra 2005; Ciaborra and Navarra 2005) identify as the design–reality gap, that is, the difference between realities on the ground and the design of various e-health and mhealth initiatives. As a result, and despite initial successes, many such initiatives do not scale well and risk failing to sustain themselves over the long term.

The starting point for the proposed project is that the integration of mobile telephony into healthcare service delivery is both a technological and communication issue. In order to mitigate the risks associated with design–reality gaps we propose a two phase approach.

The first entails investigating the day-to-day mobile telephony and communication practices of women who reside in impoverished communities within three major urban centers in Latin American as well as those of the healthcare personnel and managers working in community clinics serving these areas. The aim here is not to introduce a new technology platform, but rather to gain an understanding of how existing technology and communication practices can inform the design of enhanced service delivery strategies.

In the second stage, the information gathered from the research phase will be used to design and implement pilot programs that focus on integrating mobile telephony based communication into local primary healthcare service delivery

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Research – intervention objectives The proposed project has three major objectives: 1. Identify current practices, needs, expectations and potential uses of mobile telephony among poor women regarding the improvement of their own health and the health of their families in Colombia, Peru and Venezuela.

2. Implement pilot programs in order to assess the impact of text messaging and other mobile phone platforms in the communication between healthcare providers and women living in low-income areas in Bogota, Lima and Caracas.

3. Disseminate and discuss the findings and outcomes of the research – intervention projects with governments, NGOs, technical assistance agencies, healthcare providers and scholars in order to better integrate mobile communication technologies in improving public health and social development in Latin America.

Strategy/Plan/Dissemination The proposed project will take place over the course of two years.

A preparatory stage which was funded by the Canada-Latin America and the Caribbean Research Exchange Grants (LACREG), Partnership Programs, Association of Universities and Colleges of Canada was completed in March 2010. This work entailed pilot research in the field and the establishment of an informal research network comprised of research teams from the University of Ottawa, Canada; Universidad del Pacífico, Peru; Universidad Javeriana, Colombia; Universidad Católica Andrés Bello, Venezuela; and health care providers and administrators from Centro de Salud San Gennaro de Villa, Lima, Peru; Centro de Salud Salesiano 20 de Julio, Bogota, Colombia; and Centro de Salud Santa Inés in Caracas, Venezuela.

The consultative work undertaken during the preparatory stage with health practitioners and administrators in each of the partner clinics identified three priority health issues for which they deemed mobile telephony based communication as being particularly apt given the wide-spread use of this technology among the people residing in the communities they serve:  Centro de Salud San Genaro de Villa, Lima: pre- and post-natal care, management of diabetes and cardiovascular disease  Centro de Salud Salesiano 20 de Julio, Bogota: management of diabetes and cardiovascular disease  Centro de Salud Santa Inés, Caracas: management of acute and chronic diseases affecting women

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A recurrent theme articulated by these individuals was the potential benefits to be accrued for patients and clinics alike, through mhealth interventions oriented toward improving communication and interaction with their patients. Particular interest was expressed with regard to finding cost-effective mobile telephony based strategies for improving the management and follow-up of consultations, educational programming oriented toward disease prevention, and the promotion healthy behaviors.

Drawing on these initial anecdotal findings, the starting point for the proposed project is that the integration of mobile telephony into healthcare service delivery is both a technological and communication issue. In order to mitigate the risks associated with design–reality gaps we propose a three-phased approach that builds on the work already completed.

Phase 1 (diagnostics): Identification of day-to-day mobile practices (Anticipated Duration: 8 months) The first phase of the project will entail undertaking an investigation of the day-to-day mobile telephony and communication practices of women who reside in impoverished communities within specific districts of Lima, Bogota, and Caracas one the one hand, and those of healthcare practitioners and administrators working in community clinics serving these areas on the other. The aim here is not to introduce a new technology platform, but rather to gain an understanding of how existing technology and communication practices can inform the design of enhanced service delivery strategies targeting specific healthcare priorities.

Thus, in this research phase we will develop a set of broadly applied questionnaires to survey and or directly engage with key stakeholders. The interviews and surveys will target individuals from the following categories: (i) Poor women who obtain services from the community health clinics; (ii) Healthcare practitioners and administrators working in the community health clinics; (iii) Local, regional and national government representatives; and (iv) Mobile telephony service providers.

Our aim here will be twofold. First, to identify what may be the cultural, economic, institutional, political, security, social and other barriers that may impede the integration of mobile telephony into the local delivery of health services. In this way our team will develop a better sense of the design-reality gaps that may affect the integration of mobile telephony in into the delivery of local health services. Second, to build a primary data base on which to inform the design and implementation activities to be undertaken in the next phase of the project Phase 2 (pilot program): Design, implementation and analysis of pilot mhealth interventions (Anticipated duration: 12 months) The second phase will concentrate almost exclusively on the design, implementation, and analysis of mheath pilot programs/initiatives. The product of this process will be a mhealth intervention in Lima, Bogota, and Venezuela and follow-up analyses. We cannot at this time delineate of what precisely these interventions will entail because as noted earlier these interventions will be designed in accordance with the knowledge obtained

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about local realities (i.e., community needs, contextual opportunities and constraints) identified in Phase 1. However, it is useful to point out that the interventions will be developed in collaboration with our community clinic partners and will be aimed facilitating improved communication, interaction and healthcare management between community healthcare providers and their actual clients with regard to the priority healthcare issues outlined above.

Given that the proposed study is designed to investigate the relationships between community health care providers and their actual clients, and the potential for changes to public health when mobile telephony is used to support health-related communications and initiatives, the framework process that will be adopted to facilitate the decision making process for designing and implementing the interventions will focus on a number of dimensions. These include, but are not limited to:  Information dimension – identifying the information needs of the stakeholders  Technological dimensions – opportunities afforded by the integration of mobile telephony into the delivery of local healthcare services  Process dimension – maximizing and integrating existing mobile telephony practices with the delivery and reception of healthcare services  Objectives and Values dimension – getting the stakeholders to participate in the definition of the intervention objectives and expected results The evaluative dimension of the project will programs/interventions in terms of their efficacy in:

seek

to

assess

the

pilot

 reaching the target audience (i.e. poor women)  strengthening the relationships and interactions between healthcare providers and

their clients;  reducing communication gaps between healthcare providers and their clients.

Phase 3 (dissemination): knowledge translation, diffusion and scale-up (Anticipated duration: 4 months) The third phase of the research-intervention proposal is aimed at disseminating the learning and knowledge derived from the diagnostics and pilot interventions phases in order to improve the integration of mobile phone platforms in the provision of healthcare and social services in Latin America. This will be achieved through the following actions:  An expert group meeting to discuss how mobile telephony can be integrated into the healthcare delivery services of community clinics with the participation of the network researchers, regional NGOs, technical agencies and local government officials (location to be determined)  A series of a one-day knowledge translation workshops offered in each country with local healthcare providers, governments officials, NGOs and researchers in order to discuss the results of the project and assess the possibility of scaling-up similar programs in community clinics.  The publication of a book - both printed and electronically - to disseminate the results of the project.

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 The launch of a web site to disseminate the results of each-one of the project phases and expand the relationships and collaborations of the network with other scholars, healthcare providers, technical assistance agencies and NGOs. Partners As previously noted, an informal research network comprised of research teams from the University of Ottawa, Canada; Universidad del Pacífico, Peru; Universidad Javeriana, Colombia; Universidad Católica Andrés Bello, Venezuela has been established. The individual members and their respective university affiliations are listed below: Arlette Beltran, Professor, Universidad del Pacífico, Lima, Peru; Harold Castañeda, Professor, Universidad Javeriana, Bogota, Colombia; Alejandro Ríos, Research Fellow, Universidad Católica Andrés Bello, Caracas, Venezuela Each of the three community clinic partners s are located in impoverished districts of their respective cities and provide primary and secondary care to the populations living in the immediate vicinity. These clinics are: 

Centro de Salud San Genaro de Villa: A member of the public healthcare network of the Peruvian Ministry of Health. It is located in a marginal urban district of Lima that is comprised of three sectors: Barranco, Chorrillo and Surco. The clinic attends to a population of seventy thousand, 50 percent of whom are living in poverty, and 25 percent extreme poverty. It offers 24/7 healthcare services, including emergency care, pre- and post-natal care, mental health services, nutrition education, external consultations, rehabilitation and laboratory services.



Centro de Salud Salesiano 20 de Julio: A member of a community complex managed by the Catholic Salesian Congregation. It is located in one of the most impoverished districts of Bogota, 20 de Julio district. The bulk of the clinic’s work centers on managing of chronic ailments such as diabetes, cardiovascular diseases and nutritional issues.



Centro de Salud Santa Inés: A member of the Parque Social Manuel Aguirre, S.J., a social complex managed by the Company of Jesus. It is located adjacent to Antimano, one of the poorest areas in west Caracas. The clinic focuses mainly on the delivery of primary and secondary care and sees some 400 patients per day, 65 percent of whom are women. Their services cover a wide range of health domains, including teen pregnancy prevention, reproductive care, chronic ailments and aging-related conditions such as Alzheimer’s.

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Outputs: The results of this project will be disseminated in a variety of forms including: (i) working papers to be produced as and when particular stages of the research are completed; (ii) a project-specific website providing immediate access to the working papers and other project outputs; (iii) an expert group meeting to discuss how mobile telephony can be integrated into the healthcare delivery services of community clinics; (iv) a series of a one-day workshops offered in each country; (v) the publication of a book (both printed and electronically) to disseminate the results of the project.

Estimated budget (in US dollars)

Phase I (diagnostics) Principal investigator Associated Investigator Research Assistant Survey agents Travel/transportation Lodging Miscellaneous Administrative expenses Sub-total phase I Phase II (pilot program) Principal investigator Associated Investigator Research Assistant Survey agents System development User trainer Equipment (server + laptop) Travel/transportation Lodging Miscellaneous Administrative expenses Sub-total phase II Phase III (dissemination) Knowledge translation (KT) workshop Local KT workshops Book Website design/translation/management Sub-total phase III Budget summary Total 3 phases

Colombia

Peru

Venezuela

Network

Total

$5,000 $2,500 $1,500 $5,000 $600 NA $1,500 NA $16,100

$10,000 $4,500 $2,400 $5,000 $600 NA $2,000 $5,500 $30,000

$4,000 $2,000 $1,500 $2,500 $500 NA $1,000 NA $11,500

NA NA $5,000 NA $7,000 $3,000 $3,000 NA $18,000

$19,000 $9,000 $10,400 $12,500 $8,700 $3,000 $7,500 $5,500 $75,600

$5,000 $2,500 $1,500 $5,000 $8,000 $5,000 $12,000 $600 NA $2,500 NA $42,100

$10,000 $4,500 $2,400 $5,000 $7,000 $5,000 $12,000 $600 NA $3,000 $5,500 $55,000

$4,000 $2,000 $1,500 $2,500 $6,000 $4,000 $12,000 $500 NA $1,000 NA $33,500

NA NA $5,000 NA NA NA NA $7,000 $3,000 $3,000 NA $18,000

$19,000 $9,000 $10,400 $12,500 $21,000 $14,000 $36,000 $8,700 $3,000 $9,500 $5,500 $148,600

NA $5,000 NA

NA $5,000 NA

NA $5,000 NA

$20,000 NA $10,000

$20,000 $15,000 $10,000

NA $5,000

NA $5,000

NA $5,000

$5,000 $35,000

$5,000 $50,000

Colombia $63,200

Peru $90,000

Venezuela $50,000

Network $71,000

Total $274,200

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Timeline MONTHS 1 2 3 4 5 6 7 Network Phase I: diagnostics meeting: Launch network launch website phase I

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10 Network meeting: launch phase II

11 12 13 14 15 Phase II: pilot programs Diffusion papers with results phase I

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17

18

19

20

21

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23 Experts meeting.

Diffusion papers

24 Local workshops.

Book publication

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25

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