Information Strategy paper

DOI: 10.4018/JCIT.2020100103

Journal of Cases on Information Technology Volume 22 • Issue 4 • October-December 2020

 Copyright©2020,IGIGlobal.CopyingordistributinginprintorelectronicformswithoutwrittenpermissionofIGIGlobalisprohibited.



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Building a Critical Mass of Users for Digital Healthcare Promotion Programs: A Teaching Case Rennie Naidoo, University of Pretoria, South Africa

https://orcid.org/0000-0001-8392-1136

ABSTRACT

Despiterecenttechnologicaladvancements,theslowadoptionpatternofdigitalhealthcarepromotion programscontinuestobeamajorproblemplaguingmanyhealthcareorganizationstoday.Thehistorical teachingcasestudyisindispensableinimprovingourunderstandingofthecomplexandmultifaceted natureofcontemporarydigitalhealthcarepromotionprograms.Thishistoricalteachingcasepresents informationaboute-health,thee-commerceunitofalargemultinationalhealthcareinsurancecompany. Theteachingcaseshowshowdespitee-health’sabilitytopersuadealargeregisteredbaseofusersto trialitshealthcarepromotionprograms,over90%oftheseregistrantsdiscontinueduseafterashort trialperiodofusingthetechnology.Thishistoricalteachingcasefocusesonthesocialchallenges involved inpersuadingusers to adopt and continueusing e-health’smajor healthcarepromotion innovation:anonlinenutritioncenter.Despiteextensivepromotionsandtheuseofincentives,less than10%oftheuserbaseadoptedandcontinuedtousethishealthcarepromotioninnovation.Thecase reportsonthediscontinuanceamongdigitalhealthcarepromotionusersdespitetheintensiveefforts toretainthem.Studentsandpractitionerswillgaininsightintothekeysocialchallengesinvolved inachievingacriticalmassofusersfordigitalhealthcarepromotioninnovations.Theteachingcase requiresimportantdecisionstobemadebystudentsandpractitionersaboutpresentdigitalhealthcare promotionprogramsbydrawingon inferences frompastdigitalhealthcarepromotionprograms. Finally,thishistoricalteachingcasestudymakesaconvincingcaseforthevalueofhistoricalinsights ininformingpresentdaychallengesfacingcontemporarydigitalhealthcarepromotionprograms.

KeywoRDS Adoption, Electronic Health, Healthcare Informatics, Healthcare Promotion, Preventative Healthcare

INTRoDUCTIoN To DIGITAL HeALTHCARe PRoMoTIoN PRoGRAMS

Astheglobalpopulationrisesandlifeexpectancyratesaroundtheworldcontinuetoincreasedueto advancesinscienceandtechnologyandimprovementstosocio-environmentalconditions,healthcare budgetsarefacingenormouspressure.Onthe21stofNovember1986,theOttawaCharterinitiated theadvocacyofhealthpromotiontoimprovehealthcareglobally(WHO,1986).Healthpromotionis

Thisarticle,originallypublishedunderIGIGlobal’scopyrightonSeptember23,2020willproceedwithpublicationasanOpenAccess articlestartingonJanuary18,2021inthegoldOpenAccessjournal,JournalofCasesonInformationTechnology(convertedtogoldOpen

AccessJanuary1,2021),andwillbedistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.org/ licenses/by/4.0/)whichpermitsunrestricteduse,distribution,andproductioninanymedium,providedtheauthoroftheoriginalworkand

originalpublicationsourceareproperlycredited.

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basedonthepremisethathealthcarecannotbethesoleresponsibilityofthehealthsectorandtherefore seekstoprovidepatientswithbettercontrolovertheirhealththroughinformation,healtheducation, andlifeenhancingskills(Eriksson&Lindström,2008).Thebenefitofempoweringpatientsisnot limitedtothecostreductionofhealthcare,butisalsoariskmitigationfactorfordiseaseaswellas ahealth-enhancingstrategy.

Overtheyears,ICTbegantobeintegratedintohealthsystemsandservicesworldwide.During the1990s,e-commerceemergedandenablednewways toconduct transactionsvia the Internet. eHealthwasalsoenabledby theInternet.The termeHealthrefers to theuseof informationand communication technologies to improve health and the health care system (Oh, Rizo, Enkin & Jadad,2005).TheInternetreferstothegloballyconnectednetworkofcomputers.Althoughtheterm InternetisusedinterchangeablywithWorldWideWebor‘theWeb’,theWorldWideWebrefers tomultimedia-baseddocumentsthatcanbeaccessedonline,overtheInternet(Lupton,2014).This becameknownastheWeb1.0eraortheso-calledbrochurewebera.TheWeb1.0erabeganrapidly in1990sbecauseoftheavailabilityofbrowserswithuser-friendlygraphicalinterfaces.TheWorld Wide Web had become avaluable channel for accessing and seeking health information. Rapid improvementincommunication,hardwareandsoftwaretechnologiesalsoledtonewandbetterhealth serviceofferingsviatheInternet.Bytheearly2000s,therewasanoticeableshiftintheuseofthe webandthedevelopmentofweb-basedapplications.ThiswastermedWeb2.0andinvolvesusers creating,organizing,sharing,critiquingandupdatingcontent.Web2.0connectspeopleandcontent inuniqueways.Web2.0facilitatesan‘architectureofparticipation’–adesignthatencouragesuser interaction,empowermentandcommunitycontributions.PopularWeb2.0applicationsincludeFlickr, Wikipedia,Facebook,MySpace,TwitterandYouTube.Bythemid-2000s,Healthcare2.0emerged totakeadvantageofthenetworkofWeb2.0applicationsandservicesdeliveredthroughtheWeb platform.Health2.0usessocialnetworkingsites,blogs,email listservices,onlinecommunities, podcasts,search,tagging,videos,andwikistopersonalizehealthcareandtocollaborateandpromote healtheducation(Lupton,2014).

Recentadvances inprocessor,memory,anddiskstoragecapacityhavemadedigitaldevices relativelyinexpensiveandaccesstoonlineplatformshavebecomemoreubiquitous.Consequently, increasinglysmallerdigitaldevicesfromthepersonalcomputertothetablettosmartphonestowearable computersarebeingbeenusedinhealthcare(Lupton,2015).m-Healthormobilehealthisdefined astheuseofmobiledevices,suchasmobilephones,patientmonitoringdevices,personaldigital assistants(PDAs),andotherwirelessdevicestosupporthealthpractices(Bert,Giacometti,Gualano& Siliquini,2014).Forexample,trackingdevicescanbeusedtomonitorapatient’scalorieconsumption, exerciseandmetabolicrate.Thesedevicesarebeingintegratedwithsocialmediatoprovidesupport andmotivation.ExpertspredictthattheWebwillevolveintoWeb3.0orthe‘SemanticWeb’(Giustini, 2007).TheSemanticWebaimstoimproveuponthemeaningfulnessofinformationontheWebthereby improvingcooperationbetweendigitaldevices,healthcarepractitionersandpatients.

Apartfromthecreationofdigitalcontentbyhealthcareuserswhentheyuploadinformationto theInternet,sensorsembeddedinhealthcaredigitaldevicesandphysicalhealthcareenvironmentsare alsogeneratingmassivedatasets(NevesStachyra,Rodrigues2008;Panesar,2019).Thesemassive datasetsarereferredtoas‘bigdata’.Cloudcomputingtechnologiesarebeingusedtofacilitatethe production,storageandsharingofthesebigdatasetstoprovidedigitalhealthcaresolutions(Darwish, Hassanien,Elhoseny,Sangaiah&Muhammad,2019).Artificialintelligenceandmachinelearning arebeingused touncoverhiddenconnectionsandpatterns in thesemassivedatasets toprovide evidence-baseddigitalhealthcaresolutions(Panesar,2019).Today’shealthcareICTecosystemis muchmorecomplexandinvolvesnetworkproviders,networkoperators,digitaldevicesuppliers, platform,contentandapplicationsproviders,healthcarecompanies,healthagencies,governments andpatients(Fransman,2007).Theterm‘digital’isnowbeingemployedtodescribepaper-based elementsthathavebeentransformedintodigitalformats,andthedevices,communicationnetworks andsoftwareapplicationsthatusetheseformats.

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ICTshaveplayedacrucialroleinprovidingadigitalplatformforpublishinganddisseminating healthalertsandinformationtothegeneralpublic,scientistsandhealthcareprofessionals.eHealth innovations like electronic health records, computer assisted prescription systems, and clinical databases have already directly benefited many patients and holds great promise for the future. Digitalplatformsareplayingandwillcontinuetoplayacrucialroleinhealthpromotion.eHealth innovationsareexpectedtoempowerandprovidecost-effectiveapproachesforpatientcareandtohelp governmentagenciesandhealthcareorganizationstocopewiththechallengesofincreasinghealthcare costs.However,theevidenceshowsthatthelevelsofuseruptakeformanyoftheseinnovationsare currentlyverylowandthatthediffusionofmanyoftheseeHealthinnovationsisbeingimpededby anumberofsignificantbarriers(Oderanti&Li,2018;Gugglberger,2018;Parasuraman&Colby, 2007).Despitethetechnologicaladvancementsandthepotentialofdigitalhealthpromotiontotackle theglobalhealthcrisis,someresearchersarguethatthattherecontinuestobeacrisisindigitalhealth promotiondelivery(vanGemert-Pijnen,Nijland,vanLimburg,Ossebaard,Kelders,Eysenbach& Seydel,2011;KeshavarzMohammad,2019).Thekeychallengesarenottechnologicalbutsocial.

Healthcare promotion innovations have earned a reputation for diffusing relatively slowly comparedtootherhealthcareinnovations(Rogers,2002;Rogers,2010;Greenhalgh,Robert,Bate, Macfarlane&Kyriakidou,2008).Itmaybesimplistictoassumethatstrongmonetary,andother formsofincentivesforprevention,willresolvethecomplexproblemofconsumerhealth(Reichheld &Schefter,2000;Jost,2007).Despitethemixedviewsabouttheefficacyofhealthcarepromotion programsintheliterature(Adam&DeBont,2003;Bandura,2004;Lister,West,Cannon,Sax& Brodegard,2014),informationandcommunicationtechnologiesaredeemedtobeimportantenablers inhealthcareservices(Larkin,2001;Schraefel&Churchill,2014;Sulaiman&Wickramasinghe, 2014;Orji&Moffatt,2018).However,healthcarepromotionprogramsarequitecomplex(Solberg, Kottke,Conn,Brekke,Calomeni&Conboy,1997),yettheycontinuetobehandledpoorlyandfail todeliveronanticipatedbenefits(Ward,2013;Ginter,Duncan,&Swayne,2018;Greenhalgh,2018). Tomanagethiscomplexity,somescholarshavesuggestedthattheseinterventionsneedtoaddress thesocialchallenges(McLeroy,Bibeau,Steckler,&Glanz,1988;Green,Richard,&Potvin,1996; Iyengar&Nair,2000;Schlosser,2002;PorterandTeisberg,2006).

Thiscaseisaboutthedifficultiesinvolvedindigitalhealthcarepromotionprogramsattaininga criticalmassofusers.Asstudentsexplorethecasetheywillberequiredtoaddressthemanysocial challenges raised by digital healthcare promotion programs. This case highlights the challenges experiencedbye-Health,thee-commercechannelforHealthInsuranceCompany(HIC),anditsOnline NutritionCenter.AfterabandoningtheOnlineNutritionCenter,some15yearsago,HICisrevisiting whetherornottopursueadigitalstrategyforthepromotionofnutritionamongitscustomers,given thelatestadvancesintechnology.Beforeproceeding,theExecutivehasconcludedthatareviewof thepastOnlineNutritionCenterinitiativeisneeded.Theybelievethatsuchanassessmentofthe pastcouldprovidevaluableinsightsandlessonslearnedtoinformtheirdecisionaboutthefuture.

SeTTING THe STAGe

Introducing the e-Health Case Study TerryRossiburst intohisoffice,walkeddirectly tohisdeskandslumpedintohischair.Hehad justarrivedfromanother toughExcomeeting.Thecommitteewasconcerned that the“wellness innovations”deliveredontheWebhadsofarappealedtoonlyaminorityofcustomersandnotthe highnumbersthathadbeenpromisedbye-Health.Atbest,thehealthcarepromotionprogram,the onlinenutritioncenter,wasservingasacomplementarychannelforasmallcaptiveaudience.Terry wonderedhowhewasgoingtoimprovetheperformanceoftheonlinenutritioncenter.Terryknew that ifhewere toconvince theExco that thishealthcarepromotionprogramwasa success, this programwouldhavetoattainacriticalmassofusers.Hewasconsideringthestepshecouldtaketo ensurethate-Healthbuiltacriticalmassofusers.

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CASe DeSCRIPTIoN

e-Health’s Nutrition Centre E-HealthistheindividualbrandnameofthewebsiteforHealthcareInsuranceCompany(HIC)(Figure 1).HICiscomposedoftwootherbusinessunits:WellnessScienceCompany(WSC),acompanythat providedwellnessandloyaltyprogramsforcustomers,andBritishHealthcareInsuranceCompany (BHC)whichfocusesonoffering“consumer-engagedhealthcareproducts”forUK’sprivatemedical insurancemarket.TheaimofWSCistoprovidememberswithtoolsto“preventdiseaseandimprove theirwell-being”.WSCwaslaunchedin1997inresponsetothegrowingtrendtowardsahealthier, moreactivelifestyle,basedonthepremisethathealthierlifestylescouldtranslateintolong-termsavings onhealthcarecosts.WSCprovidesmemberswithaccesstoselectedhealthandfitnessfacilities,and createsstrongincentivesfortheircustomerstousethem.Membersarepersuadedtoearnincentive pointstoimprovetheirwellnessstatus.Thegreaterthestatus,themoreaccesstobenefits,suchas discountedtravelandleisureprices.WSCalsoprovidesallsortsofincentivestousee-Healthand e-Health’sNutritionCenter(Figure2).Bytheendof2005,HICwascoveringmorethan1.8million lives(Figure6)whileWSCwascoveringmorethan1.2millionlives(Figure7).Atthesametime, e-Health’sregistereduserbaseexceeded430,000(Figure8).

TheNutritionCentrewasconceivedin2002.Theobjectivewastoprovideanonlinemechanism thatpromotedhealthyeatinghabitsamongWSC’smembers.Thedesignprocesswasmanagedby awellnessnutritionpanel,composedofdieticians,cliniciansandnutritionacademics.Therewasa hugeemphasisondesigningthetoolwithastrongscientificbasis.

TheNutritionCentreprojectteamaimedtoestablishanintegratednutritionprogrammeusing ‘scientificguidelines,periodicreviews,anddatacollection’.Meanwhiletheclinicalteamwhowere nowdrivingtheprojectselectedapanelthatconsistedofthreenutritionacademicsfromthevarious UniversitiesaroundSouthAfrica.Thispanelwastaskedtoreviewthedesignoftheapplicationand provideguidance.Theywerealsoinvolvedinanumberofworkshopswiththesoftwaredevelopment team.Thedesignofthetoolhadtogettheirstampofapprovalspecificallyonthe“scientificbasis”.

Figure 1. HIC’s organisation structure

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Despitethisaim,thereweredifferentopinionsamongthepanelmembersaboutcertaintopics,such asthefibrecontentofahealthydiet,andsoon.

AtthetimetheNutritionCentrehadnotputinanyspecificprogramsthatinvolvedmembers goingtoconsultregistereddieticians.Whilememberscouldgoandseeadieticiantherewasnothing inplacethat“pushed”memberstodieticians.Sotheonlywaythatmemberscouldgetnutritional informationinitiallywasviacommunicationthroughthemagazine,emailandtheweighlessprogram. Howevertheweighlessprogramdidnotappealtoeverybodybecauseitwasobviouslyseenmoreas aprogramspecificallyforpeoplewhowantedtoloseweightandtheobjectiveoftheonlinenutrition centrewastoappealtoabroaderpopulation.Thepanellistshadtheviewthattheteamneededto createanonlinedieticianandthedevelopmentteamweretransfixedbythisconcept.Itsoonoccurred tothepanelthatjusttheconceptofprovidinganonlinemealplannerforauserwasacomplicated task.Userinputswererequiredforgender,activity,height,weight,waist,andbloodtype,among otherinputs.Thetoolalsohadtorelyontheself-reportedmeasurementsoftheusertoestablishthe effectivenessoftheproposeddiet.

Whenusingtheonlinenutritioncentreatacoffeeshop,theuserremotelyoperatestheirnutrition self-assessmentformsothatthesystemcouldprovidethemwithamealplanrecommendation.In thisprocesstheusercapturesarangeofinputsrelatedtotheircurrentweight,age,height,andwaist measurementsintothesystem.Thus,itenablestheuserscontrolbyactingatadistance.Therationale isthatthereisnoneedtoscheduleanappointmentwiththeirdietician.

WhiletheNutritionCenterdidattractusers,itwasnotaspopularastheapplicationsthatwere concernedwiththemembers’healthplans.Themonthlymanagementreportindicatedthatapplications relatedtohealthplanissues,suchastheonlineclaimstrackerapplication,wereusedasmuchas threetimesforeverysingleuseofthenutritioncentre.Pageimpressionswereonaveragefewerthan 3000perweek.

ThesurveyresultsreportedinFigure3showsthatdespitethehighlevelofawarenessasespoused bythediffusionofinnovationtheory(Rogers,2010;Ward,2013),andagreementbyusersonthe utilityandeaseofuseasespousedbythetechnologyacceptancemodel(Davis1989;Holden&Karsh, 2010),discontinuanceoftheNutritionCenterremainedextremelyhigh.

Figure 2. Screen shot of e-Health’s landing page (2004 website redesign)

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Promoting the Adoption of Healthcare Promotion Programs Terry’sstrategytomarkettheNutritionCentreresultedinenticingmanyuserstoregistertotrial thetechnology.Thecampaignspromotedthecompany’svisionof“improvingpeople’shealth andenhancingtheirlifestyles”inanonlineenvironment.TheNutritionCentrewaspromoted invariousmediums:

• Healthcare Insurance Fact File:TheNutritionCentrewaspromotedinthefirm’sfactfile. The fact filewasabooklet thatprincipalmembers receivedannually toexplainhowtheir healthplanworks.

• Healthcare Magazine:TheNutritionCentrewasalsopromotedinahealthcaremagazine.When comparedtothedifferentawarenessmediumsthemagazineappearedtobethemosteffectivein promotingtheonlinechannel.Themagazineconsistentlyfeaturedarticlesexplainingthebenefits oftheNutritionCentretomembers.

• Email Newsletter Campaigns:Theseemailsweretobecomeavitalcomponentoftheemail promotioncampaignforpromotingtheNutritionCentre.

Other avenues for promoting the Nutrition Centre were employers, brokers and the call centreagents.

• Incentive Points:Memberswereremindedthattheycouldearnpointsbyinteractingwiththe onlinechannelandspecificallytheWellnessapplications.Itwasspecificallytheabilitytoreap rewardsfromcertainbehaviour,andgoingonlinetogatherrewards,suchascheapergymnasium fees,cheaperflightsandholidayaccommodations,thatledtoasignificantincreaseinthenumber ofregisteredusers.

Figure4showsthatasaresultofthesepromotions,asmanyas60%oftheregistered userbaseregisteredtousetheNutritionCentre.DespiteeffortsatpromotingtheNutrition Centre, However, Figure 5 shows that over a short period of time as many as 90% of registrantsneverreturnedtousetheNutritionCentre.Thisisinstarkcontrasttothehealth insuredmemberbasechurnor lapse rateof3 to4%.DespiteTerry’sefforts toattaina criticalmassofusers,theNutritionCentrewaseventuallydisbandedbecauseofthehigh userdiscontinuance.

Figure 3. Nutrition center survey. Source: Bataleur, Customer Satisfaction Survey.

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PoST IMPLeMeNTATIoN ReVIew: LeSSoNS FRoM THe PAST

Thefollowingproblemscontributed to theslowuptakeandnegatively impacteddiffusionof the NutritionZone.

Lesson 1: The Constraining Role of Broader Socio-economic Structures TheInternethighwayasastopforonlinewellnesstoolsisnowcompetingwiththemoreresilient structureofourroadnetworks.Eversincethegrowthofcarsalesandthesubsequentgrowthofsuburbs, growthwhich roadnetworkshadencouraged, fast foodorganisationshavegrown into sprawling multinationalsbyexploitingprimelocationswithin thesehighwaynetworks.Evenindeveloping countries likeSouthAfricaand in factmanyothercountriesaround theglobe,corporations like

Figure 4. Share of active nutrition center users. Source: Internal Report - Statistical analysis of retention.

Figure 5. Leaky bucket problem – losing users over time. Source: Internal Report - Statistical analysis of retention.

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McDonaldshaveexportedthevaluesandtastesoftheirlocalculture.Withthishomogenisationof internationalfastfoodculture,countrieshavenotonlylosttheiridentityintermsofhow,whereand whattheyeat,buttheyhavealsoexposedthemselvestomajorhealthrisks.

Asaresultofthepervasivenessofthesebroadersocialstructuresinmodernsocietybehavioural changesaredifficulttomakeevenwiththeguidanceofapractitionerletaloneviaadigitalhealthcare promotiontool.ThefollowingexcerptbyoneofHIC’swellnesspractitionersdescribesthechallenge:

Behaviourchangeisanextremelycomplicatedthing.Itis.Imean,everybodywhohasbeenon aweightlossprogramknowsthatyoucanbeasdisciplinedand,youknow,withexerciseaswellfor twoorthreeweeksandifyouskiptheweek,youhavetostartfromscratch.Imean,peoplegointothe behaviourchangeforsixmonths,andtheyleaveandthentheyhavegottostart,andthentheyhave lostallthatmotivation.So,ifpeopleloseinterest,thethingis,ifthey,iftheyhadlearnedwhatthey wantedtohere,theywouldactuallycomebacktokeeponmotivating.Becauseweneedtosustain thatdevotion.Iftheyhavelostinterest,theyarealosstothecause;theyarebacktooldbehaviour. That,thatiswhatIhavelearned,youknow,throughexperience.

Lesson 2: Intense Competition for the Customer’s Attention Thereareothermarketmechanismsoutsideof thehealth insurancefirmthatarevyingfor the consumer’sattention.Thecontentdeliveredbythemediaplaysacentralroleinhowconsumers constructtheirvaluesandrulesofbehaviour.Inaneconomicsystemthatfocusesonthenarrow dictatesofprofitability,obesityhasbecomebigbusinessfortheverysystemthatinfluencedit. Indeed,consumersareoverwhelmedbythevarietyofdietschemesandweight-lossadviceand productsthatareavailableinthemarketplace.Furthermore,foodisanimportantfactorinour day-to-daysocialpractices.

Lesson 3: The Relativistic View of Dietary Science Eventhedieteticpracticeitselfissubjectivewithdifferentschoolsofthoughtmakingdissimilarclaims aboutthebestapproachforweightloss.Forinstance,somefocusoncaloriereduction;othersfocus onthetypesoffoodgroups(protein,carbohydrate,fat)suchaslowGI(glycaemicindex),andthe useofsupplementsandsoon,allservingtoconfusetheconsumer.TheNutritionExpertdescribed thedifferentperspectivesimplicatedinthedesignoftheonlineNutritionCentreasfollows.

Therewere a lot of challenges Imeanwithin anypanelyouaregoing tohavediffering opinions.Although theyareallexcellentacademics in theirownright therewasofcoursea certaindegreeofnotnecessarilyconflictbutdifferencesofopinions incertainaspects.You couldcertainlypickupthedifferentslantsintheirparticularfieldofinterestsandorpassion. Soforexampleonewouldconstantlybeharpingaboutfibreorlentilsandtheotheronewould beharpingonaboutyouknowvariousdifferentangles.Sotakingthescienceandtranslatingit intoaninteractivetoolwasquiteachallenge.

Lesson 4: Delegating Tacit and Uncodified Knowledge to Technology Havingbeenapracticingdietician,theNutritionExpertsuggestedthatbecausefoodandeatingisa veryemotiveissue,the“real-world”dieticianoftenhastoplaytheroleofapsychologist,partcoach, partfriend,andpartdietician.Adieticianalsospendsanenormousamountofeffortinmotivatinga patient.Andevenduringthefollow-upsessions,thedieticianbecomesthemotivatorandthecounsellor. Thelimitationsofdelegatingtheroleofthedieticiantotheself-servicetoolaresuccinctlydescribed bywayofexamplebytheNutritionist.

Thosearethekindofthings,thesmallnuancesthatareimportant,tobearinmindbecauseofthe factthatthiseatingissomethingwealldoeverydayanditishighlyemotiveandsohighlyeffected bythetypeoflifethatyoulead.Sotherearesomanyfactorsandnotevennecessaryreallytobe writtendown.Youknowyoujustpickthesethingsup.It’sreallyaboutgatheringinformationand

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thentailoringit.Becauseweknowwithcompliance,withanykindoflifestylechange,themoreyou personaliseit,themoresuitableitistotheperson’slifestylethemoresuccessyougoingtohave.

Theadvantagesofgoingtoadietician,yougointoaprofessionalenvironment,youarehaving thatcontactwiththedieticianwhocanreadyouandbuildarelationshipwithyouandbecomea partnerinthisprocess...Ithinkattheendofthedayit(theonlinetool)isnosubstituteforthathuman contact…WhatImeanisthatthebodylanguageandthepersonalityandyougettoknowtheperson, andyougettounderstandthemandunderstandtheirlifestyles.

Lesson 5: Context-Transferability Challenges TherewasincreasingfrustrationamongthedevelopmentteamrepresentingtheUKpartner,onthe logicofbasingtheUKfunctionalityontheSouthAfricanperspective.OneoftheunhappyBusiness Analystsmadethefollowingcomment:

Firstofall,youcan’tjustplugandplayitfromonecountrytothenext...Andalso,whatone marketingteamwanteddifferedfromtheother.So,itstartedoffsaying,oh,yes,wearegoingtouse thisconcept,andthemoreandmoreyoudelveintoit,themoreandmoreitmovedaway.

Forexample,theconceptionsofanonlinenutritiontoolinscribedwithaSouthAfricanperspective requiredmodificationstosuittheUKcontext.Bringingatechnologytoanewlocalcontextinvolves someexplicitandimplicitelementsofculturaltransferandmutuallearning.Thefollowingcomment byourNutritionExperthighlightshow theUK requirementswereatoddswith the localSouth Africanrequirements:

TheUKsystemusestheimperialsystemwhileweusethemetricsystem.Thisaffectedrecipes, portionsizesandbodymeasurements.ThedieticianintheUKhelpeduswithtranslatingtherecipe measurementsandportionsizesfrommetrictotheimperial,whichinvolvedcalculatingtheequivalent ounceswheretherecipesstatedgrams,millimetresorlitresandconvertingkilogramstopounds. Someofthemeasurementslookedridiculousanddidn’tseemtomakesense,sowehadtotryand converttohouseholdmeasurementswherepossible.Forexample–1teaspoon,Icupetc.Regarding thebodymeasurements,oneofthetoolsinthenutritionprogrammeinvolvescalculatingyourbody massindex(BMI).Thisrequiresyoutoenteryourheightinmetresandyourweightinkilograms. NaturallywehadtomodifythistooltoallowfortheUKmarkettoentermetricfriendlydatasuchas feetandpounds.Thiswasn’tdifficultasitwassimplyacaseofapplyingconversionfactors.

TheUKnutritionistalsorevealedthedifferencesandidiosyncrasiesthatwereconcealedbeneath theapparenthomogeneityoftheUKrequirements.WhileonthesurfacetheUKandSouthAfrican culturemayappeartobesimilar,thisevidenceiscountertotheglobalhomogenisationnotionwith respecttoICTimplementations.TheUKusersappropriatedthetheonlinenutritioncentre,differently asaresultoftheirspecificgeographies,histories,standardsandlanguages.

At firstwe thought itwouldsimply involve removing theSouthAfrican foods, forexample biltong3fromtherecipesandmenusonthemealplansandreplacethemwithfoodsfamiliartopeople intheUK.SoweneededtofindoutwhatequivalentfoodswouldbeavailableintheUKtouseas substitutes.Thenwerealisedwealsohadtochangethenamesofcertainfoodsthatwerecommonin bothcountries,butthatwerecalledsomethingdifferentintheUK,likeeggplantinsteadofbrinjal, whichaffectedrecipesandmenusthatcontainedthesefoods.Wealsohadtochangethenamesof recipes,suchas‘potjie’tosomethingmoreUKfriendlylikecasserole.Toensurethatallfoodswould berecognisabletoUKconsumers,weenlistedthehelpofaregistereddieticianintheUK.

AmajornutritionalissueintheUKisintoleranceorallergytowheatandtherearemanymore vegansthaninSouthAfrica.Wehadnotcateredforwheat-freeandveganmealplansontheSA NutritionCentreandtheUKofficerequestedthatwedesignsuchoptionstosuittheirmarket.This involvedtheUKdieticiansupplyinguswiththenamesofproductsavailableintheUKthatcouldbe usedassubstitutesforwheatandanimalproteinfoods

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Lesson 6: The Abuse of Incentives by Consumers ManyoftheusersthatwereenrolledontheNutritionCenterwerelateridentifiedas“pointschasers”. Theyusedtheincentivepointsinanunanticipatedway.Ratherthanfollowtheassignedwayofusing theNutritionCenterto“improvetheirhealth”,theanti-programof“pointschasers”emergedasa resultoftheincentives.“Dealloyalty”emergedwhereusersweremoreinterestedinmovingstatuses withminimalbehaviouralchangestotheirlifestylestoobtainhigherincentivesandthereforehigher discounts.Theonlinefeedbackbelowdemonstratesauser’sinterestinobtainingpointsasopposed tothecontentoftheassessment.

Ihavebeentryingtocompletethefourexamsforthenutritionsectionofthewebsitetogetthe 500Wellnesspoints.Ipassedthelastthreebutcan’tgetthe1st(basic)examtodisplay.Mygirlfriend logsonandsees(andcompleted)allfoursoitcan’tbemyPCitmustbesomethingtodowithwhat happenswhenIlogontothewebsite.PleaseadvisehowIcangetthe500points.

UponreflectingontheNutritionCenter’sabilitytoplaytheroleofadietician,ourNutrition Expertadmittedthisasamistake.

Tryingtofigureouteverythingadieticianwouldwanttoknowfromapersonandtryingtoput thatinsomekindoftoolwasactuallyamistakebecausewereallydidn’tintendtobecomeorreplace theservicesofaregistereddietician,thereisabsolutelynowaythatwecouldpossiblydothatand yetweweretryingsohardtogettothatpointofbeinganonlinedietician.

CURReNT APPRoACHeS To PRoMoTING NUTRITIoN

Overmorethanadecadeorsoago,therewouldbeadecliningemphasisontheonlinepromotion ofnutrition.TheonlineNutritionCenterwouldalsoberemovedfrome-Health.Therewasa radicalshiftinnutritionfromtheonlinetothe‘physical’world–inotherwords,towardsthe organization’s‘realworld’networkofpartners.Today,e-Health’sroleislimitedtoproviding genericcontentonhealthyeating,food,nutrition,aswellashealthyrecipesandtipsfromthe organization’s leadingnutritionexperts.Thenutritionprogramcontinues toencourageand rewardmembersforhealthybehaviour.However,cashrewardshavereplacedtheredeemable pointsbasedsystemandisawardedforpurchasinghealthyfoodandmakinghealthiermeal choiceswhendining.Customersarerewardedwithcashbackforpurchasinghealthyfooditems atselectedretailpartners.Customersarealsorewardedwithcashbackformakinghealthier mealchoiceswhendiningoutatselectedrestaurantpartners.Thisincludesapartnershipwith UberEats.Meanwhile,thefirmhasalsobegunopeninghealthyfoodstudiosinmajorurban centres to teachbasiccookingskillsandencouragebothadultsandchildren tocookusing unprocessedandseasonalingredientstosupporthealthyeatinghabits.Nutritionassessmentsare nolongerdoneonline.DieticiansinHIC’swellnessnetworknowdothenutritionandweight assessments.Whileredeemablepointsfornutritionassessmentsarenolongerofferedonline, pointscanbeareearnedfordoingtheseassessmentsataccreditedwellnessnetworks.HIC’s nutritionexpertusestheYoutubevideo-sharingcommunitytoprovidedietlessons,eventhough theviewsareverylow.Thefirmalsooffersincentivesforphysicalactivity.Asmartwatchis offered toqualifying customers.The smartwatchmeasures thewearer’s activity levels and setspersonalisedweeklyfitnessgoalsbyconnectingtothefirm’sfitnessapp.Thecompany claimsthattheyhaveobservedincreasedactivitylevelsamongmanyoftheparticipantsusing thesmartwatchrewardprogramme.Today,HICoperatesinmorethan15countriesandhas over10millioncustomers.Thecompanyfocusesonusingsmartphones,wearabledevicesand gamingelementstopromotehealthcare.Successinthediffusionofthesedigitalhealthcare promotionprogramscontinuestobemixed.

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yoUR CHALLeNGe AND TASKS

TheHICexecutiveisreassessingtheirdigitalstrategyfornutrition.Theyhavereachedouttoyouand yourteamofconsultantstoadvisethefirm.Theoverarchingobjectiveistwofold:

1. Toassesshowwelldigital technologieshaveprogressed todateand towhatextent they canaddresssomeofthesocialchallengesexperiencedinthepastiterationsofthenutrition center(assessment);

2. Toproposewhethertomoveforwardandhowtomoveforwardwiththeirdigitalstrategyregarding nutrition(recommendations).

NoTeS

Sincetheorganizationpreferredanonymity,allnameshavebeenfictionalised.

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APPeNDIX

Table 1. Exhibit 1: Summary of key global health statistics

Subject Measures

Underweightchildren(developingcountries) Overweight(worldwide) Deathsfromobesity-relateddiseases Lungcancerfromsmoking Men Women Globaldeathsfromtobacco-relatedcauses Globaldeathsrelatedtoalcohol Physicalinactivity (causesabout15%ofsomecancers,diabetesandheart disease) HIV/Aidsinfections Globalburdenofinfectiousdiseases Chronicnon-communicablediseaseburden (Fiveriskfactors:unsafesexualpractices,alcoholuse,indoorair pollution,occupationalexposures,andtobaccouse) Lifeexpectancy(globalaverage) 1950 1998 Europe Low-andmiddle-incomecountries

170million 1billion 0.5millionperannum 90% 70% 8.8%(4.9millionperannum) 4%(1.8millionperannum) 1.9milliondeathsperannum 40millionpeople 30% 20% 46years 66years 73years 68years

Source:WHO(2002) Anumberofdeathsordiseasesarerelatedtocausesthatareviewedtobewithinthecontrolofindividuals.Forexample, chronicnon-communicablediseaseswhicharelinkedtofactorssuchassmoking,obesityandasedentarylifestylecause 20%ofthesociety’sdiseaseburden.

Figure 6. Exhibit 2: HIC’s rapid health membership growth

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Figure 7. Exhibit 3: WSC’s rapid wellness program membership growth

Figure 8. Exhibit 4: e-Health’s user registration growth. Source: eHIC’s Management Reports (totals are as at financial year-end (June) and not calendar year). 2005 shows almost 430,000 registered users.

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Rennie Naidoo is an associate professor at the School of IT, Department of Informatics, University of Pretoria. He has served a number of clients on a number of IT projects in both the public and private sectors over a 20-year period. Naidoo is also an NRF-rated researcher. His research interests are broadly about information systems and organisations with a particular focus on IT value, IT human resources development and end-user issues. He has published articles in leading international outlets such as the Journal of Strategic Information Systems and the Information Society Journal. He lectures topics on IT investment and enterprise systems to postgraduates at the university.

Table 2. Exhibit 5: Summary of key user characteristics

Subject Measures

Registration based on gender Male Female Active use based on gender Male Female Registered User Age Group 20-25 26-30 31-35 36-40 40-45 Greaterthan45 Preferred Language of Registered Users English Afrikaans Wellness Schememembersonwellnessprogram Wellnessmembersaspartofonlineregistereduserbase

53.37% 46.63% 48% 52% 21.91% 32.02% 23.60% 6.74% 8.43% 7.30% 56% 44% 70% 92%

Source:InternalManagementReport(2004) ThemajorityoftheusersappeartobeyoungerandaffiliatedtotheWellnessprogram. Themeasureofactiveuseisbasedonloginspermonth