Abstract
User engagement is often associated with successful information systems implementation, with this being particularly true in developing countries in the Global South. However, the term remains poorly understood with many seemingly conflicting definitions and the term “user engagement” has come to mean a variety of things in the literature. Also, it is unclear at what stage(s) of the design, development, implementation and use phase(s) that user engagement should apply to. This research examines the meaning of user engagement with the objective of bringing some level of clarity to suit the information communication technology for development (ICT4D) context. To this end, we propose an expanded definition of the term user engagement. The research also suggests what stages of the design, development, implementation and use phase of the technology this expanded definition of user engagement most usefully applies to by drawing lessons on user engagement in a variety of mobile health projects from the Global South. Qualitative methods of data analysis were used in collecting data which show that user engagement as applied to a specific phase of each of the projects was essential for the ongoing success of each project.
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1 Introduction
It is widely accepted that implementation of any technology-based project for development in the Global South (ICT4D) is difficult [1] and usually has a high failure rate [2]. There have been many technical [3, 4] and socio-technical [5] reasons put forward to explain this including lack of user engagement in the process. This would seem to be obvious but is problematic for a variety of reasons. Firstly, user engagement has diverse meaning and its actual form and strategies for effective user engagement are poorly defined and understood [6] with many seemingly conflicting definitions, with the term meaning a variety of different things in the literature. In addition, other similar terms such as user participation [7] have appeared to confuse the situation even further. Secondly, it is unclear at what stage(s) of the design, development, implementation and use phase(s) that user engagement should apply. This research thus perceived a gap. Based on this gap we propose the research question “how can an improved understanding of the concept of user engagement be achieved in the design, development, implementation and use of mHealth projects in Global South countries?”. The objective of this study is to provide an extended definition of user engagement and to apply this to a variety of ICT4D and mHealth projects in African and India. We do this in an attempt to show how our extended notion of user engagement elicits a better understanding of user engagement in the ICT4D context. A further objective is to show whether user engagement may have impacted the success or otherwise of each ICT4D project. In addition, this work attempts to bring some level of clarity to the situation by firstly reviewing the various meanings and interpretations of user engagement from the literature, and secondly by proposing a definition of user engagement that is appropriate to ICT4D. Finally, the work attempts to extend existing definitions of user engagement to better suit the ICT4D context. We also suggest what stages of the design, development, implementation and use phase of the technology this expanded definition of user engagement most usefully applies to. This work is supported by providing a qualitative analysis of data collected primarily by semi-structured interview from 5 mobile health (mHealth) projects in Africa and India which show that user engagement (as defined by our extended definition) as applied to a specific phase of each of the projects was essential for the ongoing success of each project. The paper concludes by suggesting that a clear, expanded and widely accepted definition of user engagement is essential in both ICT4D and mHealth, and also that some level of clarity is needed on when and how users can be engaged in such projects.
2 Literature Review
2.1 Meaning of User Engagement
User engagement within the broad field of information systems (IS), and more recently its important sub-discipline of ICT4D, has been widely discussed since the 1960’s [6]. This is an important discussion as the research suggests that higher levels of user engagement lead to a higher chance of system success [7]. This is particularly important in the ICT4D field given the estimated 80% failure rate of technology implementations in such environments [8]. Any discussion of user engagement must start with a definition of the term as this has been poorly defined in the literature [6]. User engagement usually refers to the engagement of users in the design, development, implementation and use of technology, but many other varying definitions have also been provided. O’Brien and Toms [9] propose that user engagement as a category of user experience characterized by attributes of challenge, positive affect, endurability, aesthetic and sensory appeal, attention, feedback, variety/novelty, inter-activity, and perceived user control. Furthermore, O’Brien [10] viewed user engagement as a quality of user experience characterized by the depth of an actor’s investment when interacting with a digital system.
Many aspects of user engagement have been written about including development of models for measuring and validating the factors required for successful user engagement in IS development [11]. A variety of models have also been suggested to measure this including the User Engagement Scale [12]. In addition, methodological issues around user engagement are widely discussed in the literature including by Bhatt et al. [1] who consider issues in putting together methodology that create what they call active user engagement which is designed to overcome various socio-cultural barriers such as language and culture.
This paper relies on the definition of user engagement as provided by Kappelman and McLean [13] as “the total set of user relationships towards IS and their development, implementation, and use”. We rely on this definition for a number of important reasons. Firstly, this is one of the earliest and more widely accepted definitions of the term. Secondly, the definition distinguishes between engagement in the design, development, implementation and the use phases of the technology. Thirdly, it identifies behaviors and attitudes (i.e. the component dimensions) of system users in each stage of the technology development, implementation and use process. According to Kappleman and McLean [13] a user can be engaged in the development process or in the use of the product, but it is not possible for a single user to be engaged in only one of the component dimensions (i.e. behavior and attitude). Finally, the definition allows for the various ways in which users can be engaged in the processes of information technology development, implementation and use.
2.2 Various Interpretations of User Engagement and the Need for an Extended Definition
As already mentioned, a number of definitions of user engagement already exist and these are now discussed in brief. We suggest a wider discussion about user engagement in ICT4D (a subsection of Information System Development ISD) needs to occur, and that this should be based around the work already done in the field of ICT4D and the broader ISD field. This is because of the ambiguous terminology associated with the roles of system users in the process(es) of IS development, implementation and use [13]. Furthermore, ICT4D is the practice of utilizing technology to assist poor and marginalized people in developing communities, hence, the role of users in IS development and implementation has received a great deal of research focus. However, the value of such roles is mixed because social, cultural, political and environmental factors of the users are not captured as regards the various ways users can be engaged in the processes of IS development, implementation and use, especially in the Global South. This is not to say that the previous definitions of user engagement are “not correct” to a certain extent, but that the field is evolving as the subject of study becomes more clearly understood. The prior definitions played a valuable role in helping to focus on this need for clarity and hence the quest for an extended definition.
We start this discussion by looking at the existing work on user engagement in ICT4D where the notion of successful user engagement is closely tied to the success of any ICT4D project [14,15,16]. The Department for International Development in the UK (DFID) regards engagement as individuals moving from simply accessing or consuming the content and services offered by an online platform to becoming more involved in the platform, recommending or promoting it and actively co-creating the content [17]. Engagement has also been viewed as the state of mind that must be attained in order to enjoy a representation of an action so that we may experience computer worlds directly, without mediation or distraction [18]. This view aligns with the concept of “direct engagement” that focusses on the interaction between human and machine, by which users’ cognitive intentions can be realized through the physical manipulation of the interface [19]. Another view is provided by Attfield [20] who perceived engagement as the quality of user experience that emphasizes the positive aspects of interaction, in particular the phenomena associated with being captivated by technology. Additionally, Attfield [20] defined user engagement as the emotional, cognitive and behavioral connection that exists, at any point in time and possibly over time between a user and a resource. Other conceptions of user engagement have sought to shift focus from the individual user’s perspective to the designer’s perspective. One example of this is Jacques [21] who examined the ability of the system or application to catch and captivate user interest, while Quesenbery [22] looked at methods of drawing people in and encouraging interaction. Additionally, Saariluoma [23] had interest in motivating and enhancing the user experience with the use of the application, while O’Brien and Toms [12] defined engagement based on their synthesis of aesthetic, flow, play, and information interaction theories, as well as on previous work in the application areas of video games, online shopping, web searching, and educational software [21, 24]. Other definitions have been linked with user experience, specifically McCarthy and Wright’s [25] spatio-temporal, compositional, emotional, and sensual “Threads of Experience”, with many studies considering user engagement beyond user experience qualities. One example of this is Lukoff [26] who defined user engagement in connection with self-actualization and fulfilment. In addition, Lalmas [27] highlighted a broad definition of user engagement, identifying emotional, cognitive, and behavioral experience of a user with a technological resource that exists at any point in time and over time.
It is important to agree a shared understanding of the specific meaning of user engagement as the various interpretations have led to much misunderstanding [13] and it is not clear how useful these interpretations have been to practicing designers [28]. A clear and widely accepted definition of the term is also important in order to allow theorisation and a deeper understanding of how users actually “engage” with technologies, with this being of particular importance in developing country contexts. Furthermore, user engagement is a success factor in IS development, implementation and use [11].
However as already mentioned, and as in the IS literature, user engagement remains poorly defined in the ICT4D body of work [29, 30] which results in an inability of the concept to be clearly communicated amongst practicing designers [28]. While this work is valuable, we suggest that existing definitions of user engagement need to be extended for the ICT4D context. Thus, we propose an extended definition of user engagement and this is discussed in the next section.
3 Extending the Definition of User Engagement for ICT4D
As previously mentioned, we suggest that it necessary to extend the existing definition of user engagement as given by Kappelman and McLean [13] to include some elements of end user experiences in the different stages of the IS. Thus, we propose an extended definition of user engagement as follows: “the total set of user relationships towards IS in their development and use stages, where this set of user relationships is dictated by users experience of interacting with the different stages of the system”. This extended definition of user engagement takes into account how users relate with the IS in each stage of the development or use, in order to improve the efficiency and effectiveness of the IS’s users. Also, it involves more than working with the users. It requires working with local ecosystem partners and to build their trust in and support for the use of the solution. We adopted three user experiences dimensions; cultural, psychological and social as described by Robert and Larouche [31] to describe user engagement in the development process and product of ICT4D or in the broader ISD domain. The user experience encompasses the attitude, behavior and cultural identity of users in the process and the product of ISD. Hence, user engagement is used here to refer to the combinations of user attitudinal, behavioral and cultural associations with the developmental process and product of ICT4D or a broader ISD. Figure 1 shows a diagrammatic representation of our proposed extension of the definition of the user engagement.
User engagement is important in ICT4D because users are making decisions about what technologies to invest their time and effort into based on how those technologies make them feel [32]. It is not only whether an application is efficient, effective, or satisfying, but how well it is able to engage users and provide them with an experience [33, 34]. This is particularly relevant to users of ICT4D-related technologies and applications as these technologies and apps need to be both functional and engaging [34].
As already mentioned, successful user engagement can result in increased success when implementing and using technology in the Global South [9], but there are a number of difficulties with existing notions of user engagement in ICT4D. It bears critical significance, not just for informing the design and implementation of the interface, but also for creating improved and advanced interfaces that can adapt to users [35]. Taking healthcare as an example, user engaged technology-enabled applications can result in improved health outcomes [36]. Bush [37] examined the impact of user engagement on mHealth technology and pregnancy outcomes and found that strong user engagement in the use of the app resulted in significant performance by community health workers (CHWs) [38]. Furthermore, Torous [39] linked successful user engagement with higher levels of engagement with mental health apps. This aligns with the view of Kim [40] that the study of users’ engagement from the use of mobile technologies can provide insights to further explain their success and continuous engagement behavior in the use of the technologies. It is believed that the ability to engage and sustain engagement in digital environments can result in positive outcomes not only for mHealth projects but for citizen inquiry and participation, web search, e-learning, and so on [41].
All of this implies that user engagement is paramount and key to ICT4D and mHealth success. This is why we are proposing an expanded definition that takes three user experiences dimensions; cultural, psychological and social into account in the development, implementation and use of the system.
4 Methodology: Data Collection, and Data Analysis
In this section we apply our extended definition of user engagement to five case studies of mHealth in India and Africa in order to provide clarity on the extent and nature of our expanded notion of user engagement in each case. The rationale for choosing these five cases studies of mHealth projects was because of the need to engage users which is among the key issues raised in e-government systems implementations and use [42,43,44,45] in different countries in the Global South. Each of the mHealth projects were partnered with government organisations and other stakeholders to ensure shared knowledge about the various mHealth projects and extended opportunities for learning and development through ICT. We also discuss briefly how user engagement has influenced the outcome and success of each case.
Qualitative research methodology was used in this research. Data collection consisted of 5 semi-structured interviews that lasted for 60 min each with key people in 5 separate mHealth projects. We focused on user engagement in the various stages of the development and use of the mHealth systems. Interviewees were identified based on their involvement in the development and use of the mHealth systems, and the interviewee had detailed knowledge of the development and use stages of the technology in each case. Each person also had in-depth knowledge of the manner and extent of the level of user engagement in each case. Each of the mHealth systems had various levels of success, with none of the 5 cases being seen as having totally failed.
All interviews were transcribed, and thematic coding and analysis were carried out using NVivo. The thematic analysis looked across all the data collected from the interviews to identify common issues that occurred around user engagement and identified the main themes that summarized all the views from the experts that were interviewed. Thereafter, a coding scheme was generated and proceeded iteratively, with constant comparisons being made between codes to identifying recurring themes. Codes that had similar elements were merged to form categories and the codes were clustered around each major theme. We arrived at three themes as follows: (1) user engagement in the development stage, (2) user engagement in the use of the product, and (3) user experience dimensions with interactive products. This method was chosen to understand expert’s perspectives and experiences in working with users in the developmental process and product of ICT4D in order to provide answers to the research question. These were formed to support the reason for our proposed definition of user engagement which are to show what stage(s) of the design, development, implementation and use phase of the technology that our definition of user engagement most usefully applies to and to include some elements of user experiences.
For ethical and confidentiality reasons each case was assigned a case number from 1 to 5. Also, the experts interviewed are assigned with E1-E5, with these designations being associated with each case (i.e. E1 is the interviewee associated with Case 1, E2 is the interviewee associated with Case 2, and so on for Cases 2–5). The cases are as follows:
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Case 1: Gender based violence and child protection in Malawi - this project uses a mobile app to record child protection and gender-based violence data. The targeted users of the app were CHWs.
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Case 2: Diabetes control in India - this project is focused on the development, implementation and use of an app to test diabetes in remote areas of India. The targeted users of the apps are ASHAs (Indian CHWs).
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Case 3: HIV & TB in Africa - this project consists of an mHealth initiative that was conducted in four countries; South Africa, Mozambique, Zimbabwe, and Malawi. The project was based on clinicians using an app to collect data on routine viral load of each patient. The data was recorded, and the result was then sent to patients in the form of an SMS.
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Case 4: Handover report in India - this is an mHealth project based on a handover report system. The project was conducted in India, and the users of the handover report system were nurses. The technology was designed for handing over reports about patients within hospitals at the end of the nurses shifts.
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Case 5: Pregnancy care in India - this is an mHealth project based in India. It uses a mobile app to provide education and counselling to pregnant women on how to take care of themselves and babies when they are delivered.
5 Findings and Discussions
As previously stated, user engagement is used here to refer to the combinations of user attitudinal, behavioral and cultural associations with the developmental process and product of ICT4D or a broader ISD. The three user experience dimensions (psychological, social and cultural) were used to show users’ attitudes, how the importance of users’ relationships with other stakeholders can impact in the development, implementation and use of the technology, and how the user experience can contribute to defining user’s cultural identity. In order to give a clear view of our extended definition, we organized our findings around three key themes from our proposed extended definition: (1) user engagement in the development stage (2) user engagement in the use of the product (3) user experience dimensions with interactive products. These themes are explained in greater detail below.
5.1 User Engagement in the Development Stage
The first theme involves examining how users were engaged during the development stages of the project and what made the projects succeed or not. Each of the mHealth projects were partnered with government organisations, research or academic institutions, NGO or not-for profit organisations, private organisations and the wider community to ensure shared knowledge about the various mHealth projects and extended opportunities for learning and development through ICT. According to E5 in Case 5 “end users were very involved in designing the app. Tested with 10 ASHA’sFootnote 1, focus groups, observation, etc. There was lots of feedback from ASHA’s for over 1 year, and they got a lot of quality feedback”. In the same vein in Case 3, “end users in Zimbabwe and Malawi were involved in focus groups and they provided information whether SMS with cryptic message would be available for them”.
Another important point was that users of the app could record messages that were provided to pregnant women with their local dialects during the development stages of the app. E5 stated that “The entire app was translated to Hindi. Local health workers have recorded the messages in local dialect. Images were adapted to suit local contexts. The local health workers recorded their voice in the local language on the app in Hindi and the local dialect.” The conscious intent of engaging users at the development stage of the project created personal experience for the users which resulted in improving users’ confidence. E5 stated that “The voice on the phone is the ASHAs, but they sometimes tell the patient that the voice is from a doctor in Delhi. The whole thing has improved both the ASHAs confidence in themselves, and other people’s confidence in the ASHAs.” This supports the reason we extended the definition we relied on, to include users’ experience dimensions. The project was implemented successfully because of the feedback sessions provided by the ASHAs. E5 stated that “There was a significant amount of feedback in the first year during the app development and there was newborn component every month and Prenatal app was good enough. When project becomes very big, reinstall a new version. 285 ASHAs involved in 285 villages provided feedback.”
This applies to our extended definition of user engagement because it clearly shows users relationships towards the development stage of the app by providing their local language and images in the app to engage users.
5.2 User Engagement in the Use of the Product
Next, we asked the interviewees their thoughts on how users were engaged in the use of each of the mHealth products. We are examining our expanded definition of user engagement in the context of the use of each of the mHealth products. In Case 5, it was explained that the pregnant women preferred listening to the voice from a male doctor or ASHA based in Delhi as opposed to other doctors or ASHA that are based locally. The male doctor voice engaged the pregnant women and they always gather around to share information (E5).
In Case 3, patients were engaged in always checking for their viral loads. According to E3, “all information about patients’ viral load was encrypted and patients logged in with a unique id”. E2 believed the cause of users’ engagement with the app was because users received SMS that were encrypted.
In Case 2, the AV tool brought out conversations about diabetes which engaged people. E2 believed that what caused this engagement was because of the local dialects used in the AV tool. This facilitated engagement in conversations among the patients and created personal and emotional experiences for the patients. One major outcome highlighted by E2 was that the AV tool caused the patients to discuss subjects that were traditionally taboo, the stigma of diabetes, the genetic component and the implications this might have for marriage prospects for them and their daughters. This reflects on the important point that users engaging in the product creates experiences for the users.
5.3 User Experience Dimensions with Interactive mHealth Applications
We discussed three user experience dimensions to explain how mHealth apps were used and users’ experiences. Every product creates an experience for its users, and that experience can either be the result of planning and conscious intent or the unplanned consequence of the product designer’s choices [46]. According to E1 in Case 1, “The project is run by community volunteers as well as community child protection workers and community development workers. The Government employs the health workers to record the data on mobile phones. The data includes age, gender, incident, how incident was resolved, etc.” These community workers understand the language, culture, and needs of the users and that made easier communication with the users.
Robert and Larouche [31] explained psychological dimension of user experience as when respondent talks of the emotions generated by the interaction with the product, of the impact of the product on his/her attitudes, opinions, motivations, identity, satisfaction. S/he discusses the underlying values of the product in relation with his/her own emotions. In the mHealth project, the experts discussed emotions generated by the interaction with the product, of the impact of the product on users’ attitudes, opinions, motivations, identity, satisfaction. In relation to Case 4, E1 stated that “An issue was getting the nurses to understand that there is no extra work involved, you are only pressing a number of buttons, there is no extra work.” This was because the nurses felt that they were doing an extra work by working with the app.
Robert and Larouche [31] explained social dimension of user experience as the respondent talks of the importance of others (e.g., parents, friends, work colleagues, etc.) and his/her relations with them when s/he uses the product. S/he talks of the impact of different representatives of enterprises on his/her relationship with the product (e.g., customer service). This dimension arises in the case studies as the experts talked about the importance of users’ relations with their friends, relations when using the product. In Case 5, E5 stated that, “Family members of literate ASHA’s were trained. They could help ASHAs to use the phone and the app.” The trained ASHA’s family members were literate, and they assisted in the challenge of bringing low literate ASHA’s to level of literate users. This resulted in successful implementation of the project and assisted in providing education and counselling to pregnant women on how to take care of themselves and babies after giving birth.
6 Summary and Conclusions
User engagement in ICT4D and more broadly ISD is important because of the link between higher levels of user engagement and a better chance of system success. It is, therefore, important to provide a clear and extended definition of user engagement. We did this and applied our new extended definition to five cases of mHealth projects in the Global South. The objective of this study is to show how our extended notion of user engagement may have impacted the success or otherwise of each case. The reason for the extended definition is to capture and include the experiences created by users from the design, implementation and in the use of the technology.
Also, this work brought some level of clarity to this situation by firstly reviewing the various meanings and interpretations of user engagement from the literature, and secondly by proposing a definition of user engagement that is appropriate to ICT4D. Finally, the work extended existing definitions of user engagement to better suit the ICT4D context. We also suggested what stages of the design, development, implementation and use phase of the technology this expanded definition of user engagement most usefully applies to.
We demonstrated how users were engaged in the cases of the mHealth projects and explained how our extended version of user engagement impacted each project. This is important because it clearly showed how engaging the use of the technology created experience for the users.
This is a complex context for research and design which presents many opportunities for future work. It should be emphasized that this is a call to action for other researchers to work on this because little attention has been paid to integrate measures of user engagement within a design, and implementation process of mHealth apps. We plan future interactions to include more focus groups and interviews from developers, design exports, local partners and end-users in order to measure and evaluate user engagement in line with our expanded definition of that term.
Notes
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An ASHA is an accredited social health activist or CHW usually based in India. The ASHA programme was initiated by the Indian Ministry of Health and Family Welfare may years ago.
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This publication has emanated from research supported in part by a grant from Science Foundation Ireland under grant number 18/CRT/6222.
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Ikwunne, T., Hederman, L., Wall, P.J. (2020). Understanding User Engagement in Information and Communications Technology for Development: An Exploratory Study. In: Stephanidis, C., Marcus, A., Rosenzweig, E., Rau, PL.P., Moallem, A., Rauterberg, M. (eds) HCI International 2020 - Late Breaking Papers: User Experience Design and Case Studies. HCII 2020. Lecture Notes in Computer Science(), vol 12423. Springer, Cham. https://doi.org/10.1007/978-3-030-60114-0_46
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