Accessing Maternal Healthcare Information Using A Mobile Application

Transcription

1 Strathmore University RA K Accessing maternal healthcare information Accessing Maternal Healthcare Information Using A Mobile Application Shadrack Kioko Submitted in partial fulfilment to the requirements for the Degree of Masters of Science in Telecommunications Innovation and Development at Strathmore University Faculty of Information Technology Strathmore University Nairobi, Kenya October, This dissertation is available for Library use on the understanding that it is copyright material and that no quotation from the dissertation may e published without proper acknowledgement.

2 DECLARATION I declare that this work has not been previously submitted and approved for the award of a degree by this or any other University. To the best ofmy knowledge and belief, the dissertation contains no material previously published or written by another person except where due reference is made in the dissertation itself. No part of this dissertation may be reproduced without permission of the author and Strathmore University Approval The dissertation ofshadrack Kioko was reviewed and approved by the following: Dr. Joseph Sevilla Faculty ofinformation Technology Strathmore University Dr. Reuben Marwanga Faculty ofinformation Technology Prof. Ruth Kiraka School of Graduate Studies

3 ABSTRACT The ubiquity and penetration of mobile phones in Sub-Saharan Africa presents the opportunity to leverage maternal care information provision in both prenatal and postnatal cases. The slow progress and funding constraints in attaining the Millennium Development Goals for child and maternal health encourage harnessing innovative measures, such as mhealth, to address these public health priorities. Mobile health (mhealth) encompasses the use ofmobile telecommunication and multimedia into increasingly mobile and wireless health care delivery systems and has the potential to improve tens ofthousands oflives each year. Being pregnant can be very challenging to mothers especially ifthey are expecting for the first time. In Kenya, many women rely on information that is down from one to another which may not be accurate as experience from each pregnancy can be different from one pregnancy to the other and from one person to another. Matters are made worse when information past down is mixed with cultural taboo. The aim of this research was to determine the challenges expectant women face when accessing maternal healthcare information in Kenya, to determine the current sources of the information and their limitations, determine the design requirements, the best mobile platform to develop the mobile applicationon and lastly to develop and test the mobile application. The findings of this research show that only a few expectant women currently access information from Internet sources. In developed countries, mobile phones are widely used to provide maternal healthcare information through mobile applications, SMS. In Kenya, few women use mobile and Internet to access this information because they rely on books, stories and doctors information which they receive rarely. The research established that mhealth has a great potential in increasing access to maternal information in developing countries. LEA, a Java based mobile application, was developed to provide maternal healthcare information to expectant women. It represents a proof of concept that mobile applications lead to sustainable prenatal and neonatal mhealth services. ii

4 Table of Contents DECLARATION 1 ABSTRACT 11 TABLE OF CONTENTS 111 LIST OF FIGURES LIST OF ABBREVIATIONS......'" '" '" ACKNOWLEDGEMENT CHAPTER 1 INTRODUCTION 1.1 BACKGROUND PROBLEM STATEMENT RESEARCH OBJECTIVES RESEARCH QUESTIONS SCOPE AND LIMITATIONS Scope Limitations SIGNIFICANCE OF THE PROBLEM 4 CHAPTER 2 LITERATURE REVIEW INTRODUCTION MATERNAL HEALTHCARE INFORMATION PROVISION MODELS AND CHALLENGES Some ofthe Big Issues USAGE OF MOBILE PHONES IN KENyA LEVERAGING CELL PHONES FOR MATERNAL HEALTH THE MILLENNIUM DEVELOPMENT GOALS (MDGs) MATERNAL INFORMATION PROVISION IN INDIA INTERACTIVE VOICE RESPONSE (IVR) IN MATERNAL INFORMATION DELIVERY MAMA (MOBILE ALLIANCE FOR MATERNAL ACTION) SECURITY AND PRIVACY OF INFORMATION IN MOBILE HEALTH-CARE COMMUNICATION SYSTEMS SIMILAR MOBILE ApPLICATIONS My Pregnancy Today Mobile Midwife Text4Baby by Johnson and Johnson 13 CHAPTER 3 14 RESEARCH METHODOLOGY INTRODUCTION RESEARCH DESIGN PARTICIPANTS INSTRUMENTS DATA PROCESSING AND ANALYSIS 17 CHAPTER 4 18 DATA ANALYSIS AND INTERPRETATION OVERVIEW OF THIS CHAPTER PRE=TESTQUES11()N!'iA,IRE u, Part 1: Profile Ageofthe Respondents Place ofresidence ofthe Respondents Employment Status Educational Attainmentofthe Respondents Mobile Phone Model ofthe Respondents Data Capability ofthe Mobile Phone 22 iii VI VIII IX 1 1 5

5 Mobile Phone Technology Respondents Experience with Mobile Applications Mobile Service Provider Distribution Mobile Healthcare Applications Usage Part II: Descriptive Analysis ofthe Questionnaire Responses Question 1: Overall 1 am satisfied how 1 access maternal information Question 2: 1 have access to up-to date maternal information Question 3: 1 am confident to deal with any pregnancy complication that may arise Question 4: I am able tofully understand all the maternal information 1 receive Question 5: I have easy access to doctors, pre-natal andpost-natal information care Question 6: 1 know where to get any maternal care information and assistance in time Question 7: It is difficult to get answers on any questions I have regardingpregnancy Question 8: Ifyou know the proper maternal information, it is possible to avoidpregnancy complications Question 9: Mobile phone use makes it easy to access maternal information Question 10: Doctors and health workers do not really give all the maternal information when Question 11: It is expensive to access maternal healthcare information currently Question 12: Ifrequently use my mobile phone to access the Internet Question 13: I wouldprefer to access maternal information via my mobilephone Question 14: I always practice what I learn from the maternal information Question 15: its difficult to trust some sources ofmaternal information POST-TEST QUESTIONNAIRE ANALYSIS Level ofsatisfaction in Using Mobile Applicationfor Maternal Information Access Preferred Language ofthe Information Cost ofaccessing Maternal Healthcare information Using Mobile Application PreferredSource ofmaternal Healthcare Information 36 CHAPTERS 37 DESIGN AND IMPLEMENTATION ARCHITECTURE OF THE PROPOSED MOBILE APPLICATION DEVELOPMENT IMPLEMENTATION System Implementation System Specification DevelopmentEnvironment Client Environment WALK THROUGH THE WHOLE MOBILE ApPLICATION SySTEM Free Maternal Information How LEA IVR Works Blog Baby Due Date Calculator LEA ADMINISTRATOR BACKEND FUNCTIONALITY AND COMPATIBILITY TESTING Functional Testing Expert Usability Testing Compatibility Testing RECOVERY & SECURITY USER USABILITY TESTING QUALITY ASSURANCE 53 CHAPTER 6 54 CONCLUSIONS AND RECOMMENDATIONS SUMMARy CHALLENGES RECOMMENDATIONS FUTURE WORK 57 REFERENCES APPENDICES iv 58 61

6 APPENDIX A: PRE-TEST LIKERT SCALE QUESTIONNAIRE 61 APPENDIX B: LIKERT SCALE PRE-TEST QUESTIONNAIRE DATA WEIGHTED MEAN 63 AFTER THE DATA WAS COLLECTED FROM THE RESPONDENTS, THE WEIGHTED MEAN WAS CALCULATED AND INTERPRETED WITH LIKERT SCALE ANALYSIS.APPENDIX C: THE POST - TEST LIKERT SCALE QUESTIONNAIRE 63 ApPENDIX C: THE POST - TEST LIKERT SCALE QUESTlONNAIRE 64 APPENDIX D: THE ADMINISTRATOR BACK END 65 v

7 List of Figures FIGURE 1.1: MOBILE BROADBAND IN KENyA 9 FIGURE 4.2: AGE RANGE OF THE RESPONDENTS 19 FIGURE 4.3: RESIDENCE PLACE OF THE RESPONDENTS 20 FIGURE 4.4: EMPLOYMENT STATUS OF THE RESPONDENTS 20 FIGURE 4.5: EDUCATION LEVEL OF THE RESPONDENTS 21 FIGURE 4.6: RESPONDENTS MOBILE PHONE DATA CAPABILITy 22 FIGURE 4.7: MOBILE TECHNOLOGY OF THE RESPONDENTS' MOBILE PHONES 23 FIGURE 4.8: EXPERIENCE OF RESPONDENTS WITH MOBILE ApPLICATIONS 23 FIGURE 4.9: MOBILE HEALTHCARE APPLICATIONS USAGE 25 FIGURE 4.10: QUESTION 1 27 FIGURE 4.11: QUESTION 2 27 FIGURE 4.12: QUESTION 3 28 FIGURE 4.13: QUESTION 4 28 FIGURE 4.14: QUESTION 5 29 FIGURE 4.15: QUESTION 6 29 FIGURE 4.16: QUESTION 7 30 FIGURE 4.17: QUESTION 8 30 FIGURE 4.18: QUESTION 9 31 FIGURE 4.19: QUESTION FIGURE 4.20: QUESTION FIGURE 4.21: QUESTION FIGURE 4.22: QUESTION FIGURE 23: QUESTION FIGURE 4.24: QUESTION FIGURE 4.25: LEVEL OF SATISFACTION IN USING MOBILE APPLICATION 35 FIGURE 4.26: PREFERRED LANGUAGE 35 FIGURE 4.27: COST OF DATA ACCESS 36 FIGURE 4.28: PREFERRED SOURCE OF MATERNAL INFORMATION 36 FIGURE 29: CLIENT-SERVER ARCHITECTURE MODEL 37 FIGURE 5.30: SPLASH SCREEN.45 FIGURE 5.31: MAIN MENU 45 FIGURE 5.32: INFORMATION CATEGORIES.46 FIGURE 5.33: INFORMATION CENTRE 46 FIGURE 5.34: BLOG CENTRE 47 FIGURE 5.35: START NEW BLOG 47 FIGURE 5.36: CALENDAR DATE SECTION.48 FIGURE 5.37: BABY DUE DATE 48 FIGURE 5.38: HOME PAGE OF BACKEND 49 FIGURE D.39: HOMEPAGE WITH QUICK LINKS 65 FIGURE D.40: INFORMATION DASHBOARD 66 FIGURE D.41: BLOG DASHBOARD 67 vi

8 List of Tables TABLE 3.1: LIKERT SCALE QUESTIONNAIRE OF AGREEMENT 17 TABLE 4.2 : TYPES OF MOBILE PHONES OWNED BY THE RESPONDENTS 21 TABLE 4.3: MOBILE SERVICE PROVlDERAMONG THE RECIPIENTS 24 TABLE 4.4: WEIGHTED MEAN OF THE RESPONSES 26 TABLE 5.5: MAIN MENU OF LEA MOBILE APPLICATION 42 TABLE 5.6: LEA IVR DESCRIPTION 43 TABLE 5.7: FUNCTIONAL TESTING 51 TABLE 5.8: USABILITY TESTING 52 TABLE 5.9: COMPATIBILITY TESTING ; 52 TABLE A.I0: QUESTIONNAIRE 62 TABLE B.II: WEIGHTED MEAN CALCULATION OF RESPONSES 63 TABLE C.I2: POST-TEST QUESTIONNAIRE 64 vii

9 LIST OF ABBREVIATIONS CCK - Communications Commission ofkenya J2ME - Java Micro Edition Mobile Application or Mobile App or App - This is an application developed for small low-power hand held devices that come either pre-installed on phones during manufacture or downloaded by customers from various mobile software distribution platforms. ITU - International Telecommunication Union IVR - Interactive Voice Response LEA - Swahili word for nurturing an infant baby. LEA is the title ofthe mobile application NGO's - Non - Governmental Organizations OTA - Over the Air OOAD - Object Oriented Analysis and Design PC - Personal Computer SMS - Short Messaging System. UML - Unified Modeling Language USSD - Unstructured Supplementary Service Data viii

10 ACKNOWLEDGEMENT I'm grateful to God for helping me make it through the entire Masters Program. I sincerely thank my supervisor Dr. Joseph Sevilla, for his guidance, feedback and keen supervision in this research. This successful completion couldn't be achieved without his invaluable support and input. I also acknowledge the feedback and ideas provided by Arnold Ogolla, Reward Wambayi, Tatiana Kioko, Edith Mutindi, James Kigen, Oscar Raywer, David Tole, Grace Mwawaza, E-Mobilis Instructors and the whole Safaricom Academy fraternity. To you all, your support is greatly appreciated. ix

11 Chapter 1 Introduction This Chapter gives a brief description of the research and is divided into 6 sections. Section 1.1 gives the background ofthe research, Section 1.2 details out the problem statement being tackled in the research. Section 1.3 gives the research question; significance ofthe study; objectives scope and limitation follow in that order. 1.1 Background Bringing a new life to the world is a wonder to everyone. Experience from each pregnancy can be different from one pregnancy to the other and from one person to another (Zantey, 2006). Matters are made worse when information past down is mixed with cultural taboos (Bronner, 2000). Healthcare information especially maternal, infant and child health are among Africa's most challenging health problems (APlC, 2010). A mechanism is required to provide a platform for accessing healthcare information cheaply and faster. Mobile technology is very well positioned to enable this. The United Nations, Media (Paper, Television, and Radio) are doing campaigns on ways to alleviate infant deaths caused by lack of maternal information. The grim statistics are that 6,150 women die in Kenya every year from pregnancy-related complications according to UNICEF Report (2010). In the field of maternal health, mobile technology should be used to provide support during pregnancy (Eugenie et al, 2011). These systems can offer general health and health-care information to pregnant women, provide emergency-care tips and alerts, and supply post-delivery support. The same systems can also be used to offer information about emerging risks to which women are frequently exposed and remind women ofthe need for preventive care. The explosion of mobile networks, and the growth in handset ownership, particularly among vulnerablepopulations-m-low..resource settings; offers...a.revolutioiiaryway to effectivelydeiiver timely information to improve awareness of critical health issues and reinforce positive health behaviours. Sending this information directly to the palms of expectant and new mothers is an innovative way to empower women in low-resource settings to take action to improve their own 1

12 health and the health of their children and families. Access to information via mobile phone can mean access to information about pregnancy, childbirth and the first year of life and empower womento make healthy decisions for themselves and their families. Using technology to reach mothers directly with health information customized to their stage of pregnancy or the age of their baby is not theoretical; nearly 25 million mothers around the world receive these types of messages through the Internet; hundreds of thousands of mothers receive them on their phone. Mobile phones are able to quickly and easily disseminate information that will inform women of ways to care for themselves during pregnancy, dispel myths and misconceptions, highlight warning signs, connect women with local health services, reinforce breast feeding practices, explain the benefits offamily planning, and make new mothers aware ofhow best to care for their babies. 1.2 Problem Statement 6,150 women die in Kenya during pregnancy and childbirth according to UNICEF (2010). Over 90% are preventable. The causes of maternal mortality are multi-faceted and deeply engrained in gender inequalities and decades ofunder investment in public health care. Maternal, infant and child health are among Africa's most challenging health problems. Currently expectant women rely on outdated sources ofmaternal information or sources that are too general to give the required information with less time, effort and cost. Most expectant women rely on information from the old pregnancy books, stories and myths while the few with who are literate and have money research from the Internet. There is a lot ofinformation widely available in printed form but usually this information is general, too lengthy and complicated. One of the many easy and fast ways to access information is the Internet. However, the information is focused on pregnancy in western world setting. There are very few available pregnancy resources for population in developing parts ofthe world. Other drawbacks of getting such information is that the lack of English language proficiency and computer literacy Majority ofexpectant women are left without the crucial information yet they have access to mobile phones either Internet enabled or not. Teen pregnant girls are too shy to come out in the open and get access to information that is so crucial to them like pregnancy complications information. This 2

13 leads to the current high rates ofinfant and child deaths. Missing doctor's appointments is a major issue affecting career men and women who have a lot to do in the office and end up missing scheduled doctor's appointments. Mobile technology can be used to schedule these appointments and remind or alert the user once the appointment time is near. Lack of a central directory listing doctors and hospitals location and price listing deny people choice of the medication that fits their budget and is within their reach. Mobile technology can provide a look-up structure ofthe hospitals and doctors' offices in respective locality. 1.3 Research Objectives 1. To investigate the challenges expectant women face in quest for maternal healthcare information as detailed out in the problem statement above. 11. To investigate the current sources ofmaternal health-care information, their limitations and the need for a mobile based system to provide the information To establish the design requirements and the best mobile platform on which a mobile application for maternal health-care information can be developed on for easy access to users. IV. Develop a mobile applicationfor providing maternal healthcare information v. Test the usability, functionality and compatibility of the mobile application with some expectant women, expert mobile programmers and medical doctors. 1.4 Research Questions 1. What are the challenges that expectant women face when accessing maternal healthcare information? 11. What are the current sources ofmaternal information, their validity and how easy to read and understand? 111. Can a mobile application make access to maternal healthcare information easy, faster and cheaper with a wide reach? IV. What are the design requirements for the maternal healthcare information mobile application? v. How can a mobile application be developed to provide maternal healthcare information? VI. What frameworks can be used to test the mobile application? V11. Does the mobile application provide a useful resource for timely and easy access ofmaternal healthcare information? 3

14 1.5 Scope and Limitations Scope The research covered the limitations of current methods of disseminating maternal healthcare information such as midwifery books, Internet information and stories in terms of relevance, reliability and ease of access. Statistics on how infant deaths are attributed to lack of maternal health care information were investigated. The researcher developed a mobile application as a proof of concept that mobile phones can be used to improve access to maternal healthcare information. Also the researcher did a study on Java and Android mobile programming platforms for developing mobile applications and chose Java mobile programming platform as the best for the target users Limitations The research did not cover web based systems and other mobile programming platforms other than the one identified by the user. The researcher also did not also cover anything not related to maternal healthcare information provision, complications aside from similar applications or models designed to provide maternal information. 1.6 Significance of the Problem Information is power. Health is a universal need that forms part of Kenya's Vision 2030 (Kenya Vision 2030, 2007) and Millennium Development Goals (United Nations Millennium Summit, 2000). Access to relevant and factual healthcare information will also empower women to exercise their right to maternal health. Lack ofthis information hampers women's ability to partake fully in safe motherhood initiatives. Access to information is at the heart of human development and realisation of human rights. Societies and governments have it in their power to address maternal, child and infant deaths by enabling access to information. Mobile technology provides cheap, faster and secure access to information through SMS, mobile application and Interactive Voice Response (IVR). This solution develops methods mobile technology can be used to enable access to information to reduce mortality rate, improve quality of maternal health and achieve Millennium Development Goals 4 & 5. 4

15 Chapter 2 Literature Review 2.1 Introduction This chapter reviews existing models of maternal care information provision, their challenges and shortcomings, review ofhow mhealth models have been used in other parts ofthe world that can be replicated in sub-saharan Africa. Millennium Development Goals, especially goals 4 and 5 which directly affect maternal and infant issues are reviewed on how mobile applications can be used to achieve them. 2.2 Maternal Healthcare Information Provision Models and Challenges Maternal, infant and child health are among Africa's most challenging health problems (AFIC, 2010). 47% of global maternal deaths take place in Africa with the highest rate in sub-saharan countries. 85% of all maternal deaths are direct results of complications arising during pregnancy and delivery. A mechanism is required to provide a platform for mothers and other community members who form the largest part of care givers to participate in addressing common facility challenges such as chronic shortage of medicines and absenteeism occasioned by theft and mismanagement. These actions could significantly improve the health of mothers, infants and children. Half a million women die each year from pregnancy-related causes 99% being from developing countries according to the UNICEF Report (UNICEF, 2010). The risk of dying from maternal causes in Western Europe is 1 in 4,000 while in Sub Saharan Africa, it is one in sixteen. Medical experts have called for urgent action to improve maternity care for women in developing countries. The annual birth rate in Kenya is birthsll,ooo population as at February 19,2010. The infant.. -mortalityrate-in-kenya-is-54;1deaths/l,ooolivebirths.thesestatisticsshow that-thetotalnational - market is about 6 million, 3 million mothers and 3 million infants per year. In Kenya, estimates show that 4 million babies die at birth every year due to lack of prenatal and postnatal care, redundancy in immunisation and vaccination. In Kenya, the infant mortality rate is high at 39.4% hence action must be taken to reduce the number ofdeaths. "Mobile Phone based Pregnancy" by Support Sunway University College (2007) is a major breakthrough approach to educate women on pregnancy, monitor their own and child's progress, 5

16 follow up with medical checkups, critical updates and post delivery support through mobile phone. This will reduce the anxiety and stress among pregnant mothers. Women in rural area can benefit through this system greatly by preparing for child birth and post delivery. Studies conducted in Peru, Egypt and Uganda show use ofict has avoided maternal deaths (lnfodev, 2006). Another approach is to provide tailored information based on individual characteristics ofa person. This works well for different patients who have their unique need (Bental et al, 1999). For example for pregnant mothers during each stage ofpregnancy the needs may be different and different types of health attention depending upon their health and physical condition may be needed (CenterSite, 2007). Telemedicine is a generic term applied in the context ofthe use ofinformation and communication technology (lct) to deliver health services, expertise and information over a distance (Zielinski et al, 2006). One ofthe major benefits oftelemedicine is improved access to healthcare information in underserved or neglected areas. Significantly, the cost reduces in terms oftransportation for seeking consultation, speciality care and other related expenditures. Enhanced continuity of medical education is a major benefit for telemedicine in terms ofcompetency building, and diminishing the feeling ofprofessional isolation by dealing with health professionals in blogs, chats and other telelearning opportunities. Patients can be educated to monitor their own health. For example in (Cafazzo, 2004), diabetic patients are given device to measure blood pressure which is transmitted through mobile device to central data repository. Clinical rules engine receives the data from mobile device and notify the patients family physician ifreadings are not within the desired range. Mobile devices can be used to provide health information based on geographical location of the person. These mobile devices are handy to use by travellers to be aware of illness in a particular loeationel(amel;~20e3};-~ ~ ~--~--~----~----~-~--~. -_..--~.--_ In urban areas, medical advice is quite easily available through clinics where most doctors are general practitioners and expert advice is expensive. Getting medical aid and advice in rural area is difficult. To reduce infant mortality and morbidity issues, mobile phone based pregnancy support system can be an effective alternative to the Internet. This system is made possible with the rapid development ofthe local IT and telecommunication 6

17 East Africa has more than 120 million citizens with a large majority living in rural areas, (Sida, 2010). Almost halfofits population is under the age of 15 years and about one third of the grown up population is illiterate. Mobile phones is one of the most widely available platforms for information dissemination since by 2009, there were almost 50 million mobile subscribers in the region, about 40% ofthe total population. Peer to peer communication i.e. voice, SMS and beeping is the 'killer application' in this region. The number of subscribers who use their phones to access Internet is however steadily growing, which opens up for a whole range of new applications and possibilities. In Peru, a partnership between Inter-American Development Bank (IDB), Cayetano Heredia University and Movistar expanded access to prenatal care for 5,000 low-income women. This was done through "Wawanet" project that uses text messaging via mobile telephones to enhance the health of mothers and infants by enabling them to receive customised advice on nutrition and potential problems during pregnancy, pregnant women in (Inter-American Development Bank in Peru, 2010). This project seeks to develop a solution to the problems ofmaternal mortality in Peru, emphasizing that an improvement in the health of mothers and infants would also contribute to Peru's attainment ofthe Millennium Development Goals Some of the Big Issues 1. Cost of healthcare - User fees for health care push 100 million people into poverty each year and block access to skilled birth attendance for those too poor to pay (OpenIDEO, 2011) ii. Healthcare personnel stretched - Just 1 more midwife could save the lives of219 women. 700, 000 more Midwives are needed to achieve the Millennium Development Goal to reduce maternal deaths by 75% by Overall the World Health Organisation has estimated that over 4 million more health workers are needed around the world (OpenIDEO, ---20Tf)~--- - ~ -.~ ~ ~--.-~-~iii. IV. General access to information and care during pregnancy and childbirth - Women need more access to basic information on safe motherhood and right to decent quality healthcare based on need and not ability to pay. Information can help empower women to claim their rights and protect the health ofthemselves and their unborn child. Gender Inequality - Women and girls have less access to education, assets and women suffer domestic violence during pregnancy in developing nations (OpenIDEO, 2011) 7

18 v. Access to education in general - Women who complete primary education marry later, exercise better birth control and are more likely to use modern health services (Oxfam GB, 2001). 2.3 Usage of Mobile Phones in Kenya According to (ltu, 2009), Kenya has the third largest number ofsubscribers in Africa, after Nigeria and South Africa. This translates to 7% of all the mobile phone subscribers in Africa. Communications Commission of Kenya (CCK, 2011) estimates that mobile subscribers hit 22 million in September 2010 in Kenya, up from 20.1 million in June This represented a growth to 9.5 percent, the highest over the last three quarters. Notably, the number of Internet users increased to 8.69 million in September 2010 from 7.8 million users in June The arrival of the undersea fibre cables in Kenya in 2009 has revolutionized the technology and economic sectors. Kenya is one of the very few countries in Africa with a comprehensive framework set up in this regard. Average national download speeds have increased from kbps to 3, kbps in 2011 (CCK, 2011). Further, mobile broadband is the ability to access data, voice and video at high speeds over an Internet connection trough a portable modem especially a mobile phone. Recently, Safaricom and Orange announced download speeds of up to 21 mbps on their 3G networks. Network operators such as Safaricom are relying more and more on data to generate massive revenues. According to CCK (2011), mobile broadband providers are making up to 19% of their revenue from mobile data services. Subscribers are now opting to access Internet, mobile applications and other web based services on the go from their cell phones and other portable modems due to the convenience provided by a wide coverage of GSM/3G networks in Kenya. The low bundle rates being offered are also a motivating ~Tacror~TGB-()Taa1a co-st~abou~fkshs.2506tastyeai-~~mp;~d-t~-~th~-~~e;;t-;;t;(~;i~~l~t~d~~~~-~_ _---- cheapest combinations) ofkshs Innovation is at an all-time high with many local applications for phones being produced and sold on application stores daily. Social and informative sites like Facebook, Twitter and the blogs are increasingly getting more mobile traffic than desktop traffic while marketing campaigns are slowly being taken to the mobile phone. Several incubation centres including Strathmore University ilabafrica, University ofnairobi FabLab, ihub and NaiLab have been started in Nairobi in the last 8

19 three years to nurture developers However, little attention is being given to mobile broadband services regarding mobile healthcare solutions (mhealth). The potential is huge in this sector for Kenya to achieve Millennium Development Goals (MDGs) and Vision 2030.,, '<if ' 1I.le 'l'\!i!i:1i1l:ll'lil'li'ail 1 l'l K:etlY<1 ~ 1\1....;. Th-etotal nlomberof mcbae seoeonoera In Kenya ~l as per the second cuene- of 21)10/2011 stood at / --- stlascrls.:'~- NlJMSEf' ~ '0< wrnen can also be represented as th~ eo.so Q to ~ 30 ~ z Source: lhub Infographic Figure 1.1: Mobile Broadband in Kenya 2.4 Leveraging Cell Phones for Maternal Health Cell phones are being used in many parts ofafrica in an effort to decrease the number ofmaternal and infant deaths. (IRIN, 2009) has reported a drop in the number ofwomen dying during childbirth in a village in South-central Ghana. Prior to 2008, approximately 20 women died in childbirth each year, bleeding to death while trying to get word to an ambulance service to take them to the hospital In 2008, after phone and Internet technology were introduces to this small village in Ghana, no women died in childbirth. In this situation, Ericsson teamed with Zain, a mobile 9

20 telecommunications firm, to install Internet access and mobile phone coverage in the village in 2006, providing free handsets to health workers and selling handsets to villagers for US$10 each. While this approach was effective in this small South - Central Ghanaian village, the ability to scale such an effort to all rural towns and villages in Africa is unknown, as attempts to lay broadband across the entire continent has been a slow and expensive effort happening over the last 10 years. 2.5 The Millennium Development Goals (MDGs) In 2000, world leaders set themselves a set of targets to significantly reduce poverty around the world (United Nations Millennium Summit, 2000). The MDGs, endorsed by 189 countries, are eight goals that promote poverty reduction, education, maternal health, gender equality, and aim at combating child mortality, AIDS and other diseases. The UN's 4 th and 5 th millennium development goals which state that by 2015, developing countries need to reduce child mortality rate and improve maternal health. Notably, MDG 5, to reduce maternal deaths by three quarters, is the most off-track ofall the MDGs. 2.6 Maternal Information Provision in India In India, ZMQ Software Systems is developing an SMS application for women in villages to receive prenatal care (The Wall Street Journal, 2008). As this Gurgaon - based mobile gaming company puts it; first, mobile phones took a stab at replacing radios, television sets and computers. Now, they'll get a shot at playing doctor, too. ZMQ develops innovative ICT solutions, software, and applications for empowering people and enabling sustainable development. They have launched a program where women in the rural areas will be able to get prenatal advice via text message. The new offering builds both on efforts to tap into the nearly 300 million mobile phone users in India and parallel attempts to use technology to get basic health care into areas that don't have it. Under ZMQ's new service, once a woman registers with her date of pregnancy, she will receive weekly tips on what to eat, what vaccines to get, and when to get check-ups. AJ:!jme_rc::~1iIIg_aIL(L~K~iting - ---'-~---~_._._- -,_.._~._,.~-_._------_._---' _._--_ _..._.-..._._ _._ _._- --_.,-----' _..._----_...._-_..._---- feature is that since men usually carry the phone, the company is tying up with network providers such as Reliance Communications Ltd to reward the user with one free phone call each time an expectant mother logs in. The use of mobile phones may also be a step away from the problems that plagued previous strategies to use technology in rural health care. Telemedicine projects, which used a centrally located doctor to provide advice through telephone and video conferencing with remote contacts, ran into difficulties ofcost and confidence. 10

21 The company is also focused on developing innovative ICT products for new markets ofthe world at the Bottom-of-the-Pyramid (BOP) by successfully reaching out to grass-root, under-privileged, and marginalized communities; based on viable and self-sustaining business models in support of the social cause. The use of J2ME technology in communication has the advantage of its use in low - cost cell phones which a huge percentage of the population in Kenya affords. It will help many women with information regarding their pregnancy and developing countries to achieve the UN's 4 th and s" millennium development goals. 2.7 Interactive Voice Response (IVR) in Maternal Information Delivery IVR is 24/7, quick and easy access to specific data without the need to speak to a customer service representative or launching a mobile app. FEP IVR provides information for and about members of the Blue Cross and Blue Shield Service Benefit Plan also known as Federal Employee Program, or FEP (Federal Employee Program, 2008). It is based in Nevada, US. The FEP IVR offers providers and facilities the opportunity to obtain eligibility, benefits, claim status, including check information and ability to request copies of remits; also Pre-certification guidelines with option to be connected to the Pre-cert area and Anthem addresses by specific state. 2.8 MAMA (Mobile Alliance for Maternal Action) The MAMA 2011 project was aimed at empowering expectant and new mothers to make healthy decisions by harnessing the power of mobile technology. Many women around the world have limited or no access to basic health information required for them to have safe pregnancies and healthy babies. These women typically live in resource-constrained settings that lack the first-line providers of such information - nurses, midwives, andtlain~~l12ijj:h_jilt~ndants.~acc~ording_to- _.._-_._~ ~ _.,_._------_...._---~----_._._._._.._---_._ MAMA, (2011) only halfofthe 123 million women who give birth each year receive the antenatal, delivery, postnatal, and newborn care they need. Health information can be critically important during the period when women and their newborns are most at-risk. Each year, in the brief window of time between the onset of labor and 48 hours after birth, 150,000 women and 1.6 million give birth completely alone. Health information can increase understanding ofproper nutrition for mother and baby and aid in recognition of warning signs that require clinical attention. 11

22 Over the past several years, there has been an explosion of mobile networks in developing countries. Mobile subscriber penetration has reached over 5 billion people worldwide out of a total world population of 6.9 billion and the UN estimates that by 2012, half the people living in remote areas will have one. More than 1 billion women in low - and middle - income countries own a mobile phone (MAMA, 2011). 2.9 Security and Privacy of Information in Mobile Health-Care Communication Systems The sensitivity of health-care information and its accessibility via the Internet and mobile technology systems is a cause for concern in these modern times. The privacy, integrity and confidentiality of all heath care information are key factors to be considered in the transmission of medical information for use by authorised users. Mobile communication has enabled medical consultancy, treatment, drug administration and the provision of laboratory results to take place outside the hospital. Medical information sharing to expectant women is made possible through mobile phones, due to the implementation of Internet and Intranets. But the vital issue in this method of information sharing is security: the user's privacy, as well as the confidentiality and integrity of the health-care information system, should not be compromised Similar Mobile Applications My Pregnancy Today It is a daily pregnancy application that guides women, from the baby due date given, gives answers and prepares for baby's birth (Baby Center, 2011). The versions available are for smart phones iphone, ipod Touch and Android. This targets high-class and tech-savvy users who have the money to buy smart phones and pay for the data charges. My pregnancy app has other features like fetal development images - these are images developed by expert medical illustrators. Pregnancy checklist is an interactive to-do list filled with activities and reminders to keep you on track with.- ---decisions;-doctor-appointments;-ancrmore~anutritiorr guide-givesthetipsandtecipes-to-help-eat- well and manage cravings. In this research, LEA mobile application that provides maternal healthcare information to expectant women was designed for Java enabled phones, targeting mostly low income users and those in rural areas. My pregnancy app has these functionality's similar to LEA; my pregnancy day by day weekly guide for daily information and device. Due date calculator; for users to figure out your due date and count down to the big day, similar to the one LEA has which uses the LMP method. Birth 12

23 clubs where users meet other moms-to-be who are due at the same time as you and get instant advice and support Mobile Midwife A mobile phone-based health education program for pregnant women and recent parents in Ghana sponsored by MoTeCH (Grameen, 2011). MoTeCH is a multi-part project that uses mobile technology to send pre-natal and post-natal health information to Ghanaian's and allows community health workers to collect and share health data. Women register for the program and receive either SMS or voice messages with health information. The organization designed the messages to be applicable to both men and women, as they anticipated that both partners would listen to the messages (the report found that 99% of respondents chose to receive voice messages). The messages were designed to tell women what to expect during pregnancy, dispel myths and cultural practices, and provide general health information. The design of Mobile midwife and LEA is the same but the model of delivery is different. Mobile Midwife uses SMS while LEA uses a mobile application and IVR. Ghana is similar to Kenya in that both are developing countries and face similar challenges in maternal healthcare provision Text4Baby by Johnson and Johnson (Brian, 2010) Johnson & Johnson has launched a mobile health initiative similar in aim and execution to Text4Baby for the more than 20 million expectant mothers in China, India, Mexico, Bangladesh, South Africa and Nigeria. Johnson and Johnson estimates that 1.1 billion women in those countries have a mobile phone today and are likely to sign up for its new program, Mobile Health for Mothers, which includes free mobile text messages on prenatal health, appointment reminders and phone calls from health coaches. This will have a great impact and reach to the users since all mobile phones are enabled to receive text messages; they are confidential compared to mobile applications as a way to provide maternal care information. Johnson & Johnson also launched its BabyCenter mobile campaign with mobile agency Velti in 2007, first in India (Sailesh et ai, 2011). The target was young, pregnant women since PC Internet availabilitywas VefYPoofwithinlts demographic;pregnantwomenwereinvitedtotext theirduec date to a short code to join the community and receive advice on maternal information. 13

24 Chapter 3 Research Methodology 3.0 Introduction In the previous chapter, maternal care information provision in Sub Saharan Africa, the challenges and similar mobile applications for provision of maternal information are discussed. From the research objectives, parameters for designing materials, tests and questionnaire are drawn out. Chapter Three is divided into four sections. Research design provides general information about the study. The other parts participants, instruments and materials, data analysis and processing ofthe research are described in details. 3.1 Research Design In this research, quantitative data collection methods were used as they are centred on the quantification of relationships between variables. These quantitative data-gathering instruments established relationship between measured variables in the demographic, mobile device specifications and survey proper sections of the questionnaire used. Through the use of these methods, the researcher was detached from the study and the final output was contextfree. Quantitative approach is useful as it helped the researcher to prevent bias in gathering and presenting research data. Quantitative data collection procedures create epistemological postulations that reality is objective and unitary, which can only be realized by means oftranscending individual perspective (Ivythesis, 2011). The quantitative data gathering methods used were very useful since the study needed to measure the cause and effect relationships evident between the existing methods ofaccessing maternal healthcare information and the use ofa mobile application to access the same information. The purpose of the quantitative approach in this research was to avoid subjectivity by ' ' ' ----_._ _...._----_..._-- means ofcollecting and exploring information which describes the experience being studied. Simple random sampling was done for the sample selection. This sampling method is conciucted... "".', '._',',,,_',"_',', '_,','._, _~.,,_ oo_,_~, _,_~,_,,,_,,,._,.,.,, ~._,.._~.._,.~,,,-,---,-,.,-_.,-,,---.' ',',,---,-.-,., ".-.,---, "..,".--.--"'".".' ",...-.,.---'''-"-, ,-.--~--'"-.-' ""...~-'' ,,..--,,"' -" ,,-.. -,,~,,--.-~.--,-,,---"-..--' '-.,,--_ ".,------,- ". "' ,--- where each member of a population has an equal opportunity to become part of the sample (Coventry University, 2005). As all members ofthe population have an equal chance ofbecoming a research participant, this is said to be the most efficient sampling procedure. In order to conduct this sampling strategy, the researcher defined the population first, listed down all the members of the population and then selected members to make the sample. For this procedure, the lottery sampling 14

25 or the fish bowl technique was employed. This method involves the selection of the sample at random from the sampling frame through the use of random number tables (Saunders et al, 2003). Numbers were assigned for each person in the master list. These numbers were written on pieces of paper and drawn from a box; the process was repeated until the sample size was reached. A research questionnaire was used for data collection since respondents are more truthful while responding to the questionnaires regarding the subject title of study in this research due to the fact that their responses are anonymous. A drawback with questionnaires is that majority of the people who receive them do not return and those who do might not be representative of the originally selected sample (Leedy and Ormrod, 200I). This research study was done in a pre-test and post-test design. After the sample population filled the first questionnaire (for pre-test purposes), LEA mobile application was installed in their phones. The users were given two weeks to use the application then they filled the post-test questionnaire. This was done to test the experience the users had using the mobile application to access maternal information, as compared to other sources ofmaternal information. 3.2 Participants In order to determine the challenges expectant women come across when accessing maternal healthcare information, a total of 15 respondents were asked to participate. Of the total 15 respondents, 5 from rural areas and 5 from slum areas and 5 from middle class and high class urban areas. To achieve pertinent information, certain inclusion criteria were imposed. The participants who qualified for the sample selection were currently expectant women or had already given birth, each owning a mobile phone. This qualification ensured that the participants understood the nature of the questionnaire and its use for access to maternal healthcare information, making the survey items easy for them to accomplish. The population was divided into three categories. The first category was the geographical location: urban and rural areas. Urban areas were further classified into two: slums and middle class/high class areas. The second category was literacy level: literate, semi-literate and illiterate. The third category was employment status: unemployed and employed. The assumption was sample population living in middle and high class who are literate and employed have a stable source of income leading to easy access to maternal care information from 15

26 different sources, easy access to doctors and are well educated to understand any information. Sample population in slums have low literacy levels, low income, and some are ignorant hence it is difficult for them to access maternal healthcare information, access to doctors and it is challenging for them to understand the information they receive. Sample population in rural areas have limited access to doctors and sources of updated maternal healthcare information since they have to travel to the traditional sources of this information like hospitals, clinics. This increases the cost of travelling, waste oftime and other expenses. The assumption was that they rely on outdated sources ofthe information, midwifes with no professional medical experience. 3.3 Instruments The survey questionnaire was used as the main data-gathering instrument for this study (see Appendix I). The pre-test questionnaire was divided into three main sections: a profile, general mobile device information and the survey proper. The profile contains socio-demographic characteristics of the respondents such as age, education level, employment status, place of residence. The mobile device section has general information of the mobile device, the mobile service provider and Internet access information. The survey proper explored the perceptions ofthe maternal health-care access challenges, particularly on how mobile applications can facilitate easy and reliable access of maternal health-care information to expectant women. The questionnaire proper section also contains questions that identify the advantages and disadvantages of using mobile application to provide access to maternal health-care information. The post-test questionnaire had only one section of survey proper. This questionnaire mainly aimed at finding out if accessing maternal healthcare information through mobile application is easier and timely than accessing the information from traditional sources. In this research, the access to maternal healthcare information through a mobile application - ~_.._--~",_._----' "-'"-----'-'----'----"'--.._----_.._ , _.._ _.._----_.--_._ _. -' ---_._ _._._---_.._.._ _._ _.._..._------_ _-_..._----,.._------_..----,-,. (independent variable) was monitored alongside the dependent variables of safe motherhood practices, mothers' awareness of pregnancy complications, infant and maternal mortality causes. Data gathered from this research instrument were then computed for interpretation. Along with primary data, the researcher also made use of secondary resources in the form ofpublished articles and literature's to support the survey results. The questions were structured using the Likert format. In the Likert survey type, five choices are provided for every question or statement. The choice represents the degree of agreement each 16

27 respondent has on the given question. The scale below was used to interpret the total responses of all the respondents for every survey question by computing the weighted mean: Range IInterpretation e----- I IStrongly Agree IAgree Neutral Disagree Strongly Disagree Table 3.1: Likert Scale Questionnaire of Agreement The Likert survey was the selected questionnaire type as this enabled the respondents to answer the survey easily. In addition, this research instrument allowed the researcher to carry out the quantitative approach effectively with the use ofstatistics for data interpretation. In order to test the validity ofthe questionnaire used for the study, the researcher tested both questionnaires with five respondents. These respondents as well as their answers were not part of the actual study process and were only used for testing purposes. After the questions were answered, the researcher asked the respondents for any suggestions or any necessary corrections to ensure further improvement and validity of the instrument. The researcher revised the survey questionnaires based on the suggestions of the respondents. The researcher then excluded irrelevant questions and changed vague or difficult terminologies into simpler ones in order to ensure comprehension. 3.4 Data Processing and Analysis After gathering all the completed questionnaires from the respondents, total responses for each item were obtained and tabulated. In order to use the Likert Scale for interpretation, weighted mean to represent each question was computed. Weighted mean is the average where every quantity to be average has a corresponding weight. These weights represent the significance of each quantity to the average. To compute for the weighted mean, each value must be multipliedbyitsweight. Products should then be added to obtain the total value. The total weight should also be computed by adding all weights. The total value is then divided by the total weight. Statistically, the weighted mean is calculated using the following formula: Weighted = Swx, where x = the data values and w = relative weight assigned to each observation, expressed as a percentage or relative frequency. 17

28 4.0 Overview of this Chapter Chapter 4 Data Analysis and Interpretation In this chapter, the data gathered from the sample group in relation to the research objectives is analyzed and interpreted. This chapter discusses the result of the pre-test and post-test questionnaires responded to by the 15 selected participants. Before the initiation of the pre-test research questionnaire, the significance, rationale and purpose of the study were provided to the respondents. Furthermore, the respondents were given the assurance that all the data they will give are used for the purpose of the research and their identities will be confidential. The object in the pre-test questionnaire was to determine the challenges facing the users in accessing maternal care information and ifuse ofmobile technology to provide this information can solve the problem. The post-test questionnaire aims to establish how expectant women compare mobile application and other sources of maternal information in terms of easy of access, cost of access, easy of understanding, timely access. This is the manner unto which the research study accounts the factors and the perception on the criteria themselves. The conduct of the pre-test questionnaire entails a detailed account of the demographic profile of the respondents. It is assumed that the attributes of the respondents influence their behaviour and answers on the survey questions. Of particular significance to the achievement of the goals and objectives ofthe study is to be able to answer the research questions. 4.1 Pre-test Questionnaire Part 1: Profile The profile of the respondents is looked upon in terms of age, place of residence, educational attainment and employment status Age of the Respondents Figure 4.2 below shows the age range of the respondents. Fifty eight percent (58%) of the respondents were years old, showing that most of them were already considered as young 18

29 ~--~-".- ~._- adults. Six percent (6%) ofthe respondents were between years old. Lastly, there is thirty six percent (36%) ofrespondents who are in the ages between years old. The apparent diversity ofthe maturity ofthe respondents reflects several implications in the study's findings. In relation of the age bracket of the respondents, the researcher could presume that in the said percentage, a considerable number could be among the young adult members ofthe population. This population group is active in adopting use ofmobile phones. Age isl Figure 4.2: Age Range of the Respondents Place of Residence of the Respondents The intent ofthis question was to get the number ofrespondents who live in rural areas, slum areas and middle class/ high class areas. From the responses, 25% live in rural areas, 40% live in slum areas while the remaining 35% live in middle class / high class areas. Based on figure 4.3 below, the dominated area ofresidence is the slum areas. This shows that there are mostly expectant _.. wornen itrslumareaswho h-ave-intefest-iu participalmgmtliisiesearchstiidydueiothe sttuatio~ currently. 19 """".4'~

30 ---~---"-"._.'---.~" ~ Residence Area ~Rural III Slum o Middle Class & High Class Figure 4.3: Residence Place of the Respondents Employment Status Figure 4.4 below shows the employment status ofthe respondents. 47% ofthe total respondents, which is the dominated response is employed. 30% ofthe respondents are self-employed. There is only 23% who are unemployed and house wives from the fifteen respondents. As the figure was interpreted, there is a little percentage ofunemployed respondents. Employment Status _._ ,~.._-"- - - ~Employed i'" O""T ~, o Unemployed Figure 4.4: Employment Status of the Respondents 20

31 Educational Attainment of the Respondents Likewise, the respondents were asked for their educational attainment and the report shows thirty three 33% ofthem are graduates. The survey indicates that most ofthe respondents are high school graduates at forty nine 49%. Eighteen percent 18% are primary school graduates. Figure 4.5 below shows that majority ofthe respondents are literate. Education level f!eii Primary School f!eii High School o Graduate Figure 4.5: Education level of the Respondents Mobile Phone Model of the Respondents -~~--o- Th llected data sh d 'd - f mobile OTh dels fr, ~ Phone Manufacturer Respondents Percentage (%) Nokia % Samsung % Huawei Ideos % Ericsson 1 6.7%...TOTAL f Table 4.2 : Types of Mobile Phones Owned by the Respondents The Nokia mobile phones had the highest percentage (53.3%) of mobile phone models owned by the respondents. This means that half of the respondents owned Nokia mobile phones. Samsung mobile phones were the second popular among the respondents, with 26.7% ofthe total number of respondents. Huawei Ideos was third with 13.3% while Sony Ericsson was the least owned by the population with 6.7%. 21

32 The collected data shows that ifthe mobile healthcare applications could be optimized for the Nokia mobile phones, a larger number of people would benefit, than having it optimized for another mobile manufacturer's devices Data Capability of the Mobile Phone Among the mobile phones owned by the respondents, thirteen (86.7%) ofthem had data capability meaning they can access Internet, while two respondents (13.3%) did not have data capability. Figure 4.6 below shows the distribution of the respondents mobile phones, based on the data capability oftheir mobile devices. Mobile Phone Data EillJ Data Enabled II Non Data Enabled Figure 4.6: Respondents Mobile Phone Data Capability This shows that 86.7% ofthe respondents are able to work with mobile healthcare applications that require data capability, while 13.3% will require other means of mobile healthcare information provision like IVR, SMS, and USSD Mobile Phone Technology Among the mobile phones owned by the respondents, 67% ofthem were Java enabled while 33% were not. This means that a substantial number of the respondents would benefit from a J2ME mobile application, while a number ofthem will not be able to operate such an application on their mobile applications. In conclusion, there is need to build the applications based on other technologies e.g. Android to accommodate respondents whose phones are data enabled but not Java enabled. Figure 4.7 shows the mobile technology ofthe mobile phones owned by the respondents. 22

33 Mobile Technology II Java II Android Figure 4.7: Mobile Technology of the Respondents' Mobile Phones Respondents Experience with Mobile Applications The adoption and usage of a mobile health care application would be more successful ifthe target population has experience in using other mobile applications, e.g. games, social network applications, mobile banking and money transfer applications and other information oriented information, e.g. weather, dating or news. As per the collected data, 60% of the respondents had used another mobile application. Figure 4.8 shows the distribution of respondents based on their experience with mobile applications. Mobile Applications Experience II Yes iii No Figure 4.8: Experience of Respondents with Mobile Applications This implies that the deployment of a mobile healthcare application among the respondents will have a positive reception. Also, because oftheir experience with other mobile applications, training them to use a mobile healthcare application will not be an uphill task. 23

34 Mobile Service Provider Distribution The successful deployment and adoption ofa mobile application also depends on the mobile service provider, because of considerations such as data capability and the cost of sending and receiving information in the network. Table 4.3 shows the distribution of the respondents among the local mobile service providers. Service Provider Respondents Percentage (%) Safaricom % Airtel 1 6.7% Orange 0 0.0% Yu 1 6.7% TOTAL % Table 4.3: Mobile Service Provider among the Recipients According to the table above, Safaricom had the highest number ofrespondents, composing 86.6% of the total recipients. Airtel and Yu Mobile shared the 2 remaining respondents while no respondent used Orange. The table above implies that if the mobile application was designed targeting Safaricom mobile service provider, more users would experience better performance and cost effectiveness of the application on their mobile phones Mobile Healthcare Applications Usage The popularity of mobile healthcare applications was low among the respondents, with only 15% reporting that they had ever used a mobile healthcare application. Consequently, 85% of the respondents had never used any mobile healthcare application. This implies that the popularity of mobile healthcare applications is low as compared to the respondents experience with other mobile applications. 24

35 Mobife Healthcare Applications Usage IIiHUsing III Not Using ~~ Figure 4.9: Mobile healthcare applications usage Despite the fact that exposure ofmobile healthcare applications to the respondents is low as shown in Figure 4.9, majority of the respondents were already using their mobile phones and the Internet to gain information on maternal healthcare as well as communicate to their doctors and physicians. Analysis of the respondents showed that they have been using their mobile phones to get information for the following maternal healthcare related services; general maternal healthcare information, lifestyles' during the expectancy period, what foods to eat, clothes wear and which exercises to do during the expectancy period. They also communicate with doctors, paediatrics and other specialists. Respondents also collaborate with other expectant women, share experiences over the Internet using mobile phones and personal computers (pes). The respondents went a step further and gave suggestions on how they would like to use their mobile phones to enhance their access to maternal health care information. These include periodic SMS reminders, directory listing all health care centres and hospitals around the respondents; booking appointments, scheduling and inviting friends for events like baby shower and more. The response concerning the usage of mobile phone in maternal healthcare showed that the respondents understood that they can use mobile phones to transform their expectancy experience. Also, the numerous ideas given by the respondents on how they can use mobile applications to access maternal healthcare and more other related services formed the basis and motivation ofthe design ofa mobile healthcare application Part II: Descriptive Analysis ofthe Questionnaire Responses This section provides the discussion and analysis of the perception of respondents based on the 25

36 weighted mean calculated from the collected data. Below is a table with the calculated weighted mean ofall the questions and the responses. Question Number Weighted Mean Interpretation Neutral Neutral Disagree Neutral Neutral Agree Neutral Agree Agree Disagree Neutral Disagree Agree Neutral Neutral Table 4.4: Weighted Mean of the Responses Question 1: Overall I am satisfied how I access maternal information As shown in Figure 4.10, the respondents agree that they are quite satisfied with how they access maternal information. Respondents whose education level is secondary school and graduate agreed strongly in this question. This implies that education level plays a major role in understanding maternal healthcare information and those expectant women whose literacy level is low need to get an easier way to access this information. The researcher suggests use of vernacular language and.. Swahtlilangiiagenndeliverrrigtliis iiiformanontothern~prefei adlyinassms

37 ~~._--_._------~- Question 1 m Strongly Disagree i mdisagree o Neutral o Agree III Strongly Agree Figure 4.10: Question Question 2: I have access to up-to date maternal information Though many respondents agree to have access to maternal healthcare information, only a substantial number have access to up-to date maternal information. This is primarily due to the lack ofa central updated database. Users get maternal information from sources that are not updated frequently, some not from certified sources. A maternal healthcare mobile application that provides easy and fast access to maternal healthcare information will alleviate the problem that many users have especially those in rural areas. Question 2 III Strongly Disagree Disagree o Neutral o Agree III Strongly Agree Figure 4.11: Question Question 3: I am confident to deal with any pregnancy complication that may arise Pregnancy complications are a nightmare to any expectant woman, but access to the right maternal care information can help them take preventive measures against these complications and if they occur, women have the information or where to get it. The respondents agreed that they are not fully confident to deal with the pregnancy complications that may occur during that period. 27

38 "--~-_._----~---- Question 3 III Strongly Disagree III Disagree o Neutral o Agree III Strongly Agree Figure 4.12~ Question Question 4: I am able to fully understand all the maternal information I receive Getting the maternal information is one part but understanding it is the major part. From the data analysis of the respondents, majority agreed that they understand the maternal information they receive. The only barrier is access to updated maternal healthcare information that can be solved by a mobile application that provides updated information and access all times from any place anytime. Question 4 IillI Strongly Disagree III Disagree o Neutral a Agree III Strongly Agree ~~ ~" '. Figure 4.13: Question 4 4. {2 ~ 5Question5:I-hav-eeasy-accesstodoctors-, pre;;natatand-post-nalal information care Access to doctors and pre-natal clinics is majoriy dependent on the area of residence of the respondents. Those in rural areas had little access to doctors and these clinics since they are fur and transport means are not reliable. Respondents in urban areas: slum areas, middle and high income areas easy access to doctors and pre-natal clinics. The only barrier is sometimes the cost that they have to pay for doctor's consultancy and fee. 28

39 ~-~-~~- Question 5 m Strongly Disagree II mdisagree o Neutral o Agree III Strongly Agree Figure 4.14: Question Question 6: I know where to get any maternal care information and assistance in time Majority of the respondents strongly agreed that they know where to get maternal healthcare information. The challenge was how to access this information since costs are incurred in some cases. Also, updated versions ofthe information are also hard to find in cases where the information is not indexed. QuestionS m Strongly Disagree III Disagree o Neutral o Agree IIStrongly Agree --~ _..--_._. Figure 4.15: Question 6._M _.... Qu~s1iQnZ:I~j~_dJffic:adttj)getanswers_onany:questionslhave..-.. '. _ -. regarding pregnancy During expectancy period, women have a lot of questions that can be answered by the relevant, updated maternal information accessed easily and in time. The respondents agree that it is not that easy to get an answers for the questions they have regarding pregnancy. A maternal healthcare application that has blog functionality will enable users can ask, share and contribute on all questions, and seek clarification on pregnancy issues that they don't understand. 29

40 ~---~~~_._~--_. Question 7 1m Strongly Disagree 1m Disagree o Neutral o Agree Strongly Agree ~'--'-_._-'" Figure 4.16: Question Question 8: If you know the proper maternal lnformatlon, it is possible to avoid pregnancy complications The respondents strongly agree that with access to maternal healthcare information, it is possible to avoid pregnancy complications. This would greatly reduce cases of infant deaths and maternal deaths. Question 8 Iii Strongly Disagree ii Disagree o Neutral o Agree Strongly Agree Figure 4.17: Question Question 9: Mobile phone use makes it to access maternal Having used the mobile phones for other data services, the respondents strongly agreed that mobile phones make it easy to access maternal health care information. Expectant women will have no problem in using a mobile application to access maternal healthcare information. 30

41 -'--~---~~--'. -~--~_...---~~-_._._-'- Question 9 ~ Strongly Disagree ~Disagree o Neutral o Agree l!ii Strongly Agree Figure 4.18: Question Question 10: Doctors and health workers do not really give all the maternal information when Respondents indicated that doctors and health workers fail to deliver all information due to barriers like language, or talk on this sensitive matter makes them uneasy. Question 10 m Strongly Disagree mdisagree o Neutral o Agree l!ii Strongly Agree Figure 4.19: Question Question 11: It is expensive to access maternal healthcare information currently _Ihe.99~tQf~99~~~ingm'~J~maLh_ealthkarejnfDrmationis~urrentl}'-expensi\le.especiallytoexpectant--.. _. women in the rural areas as indicated by the users who disagree in Figure 4.11 below. Respondents in urban areas disagree with this though because they can get the information easily within their reach. 31

42 ---~ ~--- ~---~~--~- Question 11 Il1Y1 Strongly Disagree Disagree o Neutral o Agree l1li Strongly Agree Figure 4.20~ Question Question 12: I frequently use my mobile phone to access the Internet Majority of the respondents agreed that they use their mobile phones to access the Internet - for social networking purposes, mobile banking, and more as shown in Figure This shows that the respondents will have no problems in using a mobile application to access maternal information. Question 12 Il1Y1 Strongly Disagree Disagree o Neutral o Agree II! Strongly Agree Figure 4.21: Question Question 13: I would prefer to access maternal information via my mobile phone In Figure 4.22, majority of the respondents agreed that they are willing to receive maternal information through their mobile phones. 32

43 -~~~-~~~------~ Question EJStrongly Disagree iii Disagree o Neutral o Agree iii Strongly Agree Figure 4.22: Question Question 14: I always practice what I learn from the maternal information Respondents indicated that they practice what they learn from the maternal information - exercises, diets and more as shown in Figure More detailed information can be provided to them as they progress in the pregnancy period. Question 14 EJStrongly Disagree Disagree o Neutral o Agree iii Strongly Agree Figure 23: Question Question 15: its difficult to trust some sources of maternal information Some sources of maternal information are difficult to understand or the respondents find them difficultto understand as indicated in their responses in Figure

44 Question 15 o Strongly Disagree iii Disagree o Neutral o Agree II! Strongly Agree Figure 4.24: Question 15 Post-test Questionnaire Analysis After the participants completed the pre-test questionnaire, LEA mobile application was installed in their mobile phones and they were given two weeks to test and use it. After the two weeks, the participants fined in the post test questionnaire. Satisfaction Using Mc~bil!e AppIUc~ltio'n mtormauon Access After testing LEA maternal healthcare application, 90% ofthe women were satisfied by using a mobile application to access maternal information as shown in Figure They described application as a convenient source of information, a companion during the pregnancy period since they can access it anytime anywhere they need to know something or to ask, share or contribute something to the blog. The 10% unsatisfied with LEA mobile application indicated that they are new to using mobile application and need more training to understand how to use it. Others were unwilling to change since they trusted doctors because of the personal interaction and other sources and did not believe the information on mobile application was true. o Satisfied II Unsatisfied 34

45 ----~---~_.._-_._-_._~---- Figure 4.25: level of Satisfaction in Using Mobile Application To all participants, LEA acted as a support by providing general information for pregnancy and baby birth, making them more confident to deal with any complications that may arise during pregnancy. Its worth mentioning that expectant women can anticipate what will happen during the whole pregnancy period, including information about emerging risks to which women are frequently exposed and remind women ofthe need for preventive care Preferred Language of the Information Though 93% participants understood the information wen in English, some of them wanted it in Swahili language and possibly translated to their vernacular languages. This way they can easily read and understand the information. Figure 4.26 below represents the mobile application users with their preferred languages m Prefer English m Prefer Other Language Figure 4.26: Preferred language Cost of Accessing Maternal Heafthcare information Using Mobile Application. In Figure 4.27 below, 87% ofthe respondents were ofthe opinion that cost ofaccessing maternal ----healthc:ill;~ infonnation through the mobile was cheap. This is highly attributed to the lowering of data costs -~;~~bil~-p;~~iders-duefostlff-competition_user~ ~n even redeem their loyalty points for free browsing. The remaining 13% maintained that the cost-~fd~~~i~;tilihighduelo-siow-- In some cases a user cannot purchase data mobile subscribers and some require subscription of a certain amount. 35

46 ~-_.~-~.,.~--~-~~_ Cost is low!ii Cost still high Figure 4.21: Costof Data Access The participants whose mobile phones have access to Internet did not prefer calling and listening to the information. The participants whose mobile phones cannot connect to the Internet used the IVR functionality of the application to dial and listen to the information. Majority of the respondents proposed the use of SMS for periodic alerts, reminders. This will have reach to all users despite the mobile phone they have Preferred Source of Maternal Healthcare Information Figure 4.28 is a comparison of mobile application to traditional sources of maternal information. 95% of the participants greatly appreciated that mobile applications provided timely pregnancy advice unlike other sources of this information like books, doctors who are not always within ones reach every time Mobile Application III Traditional Sources Figure 4.28: Preferred Source of 36

47 ChapterS Design and Implementation 5.0 Architecture of the Proposed Mobile Application The researcher developed a mobile application caned LEA using the client-server architecture. LEA is a Swahili name for nurture. The client-server model is a computing model that acts as distributed application which partitions tasks or workloads between the providers of a resource or service, called servers, and service requesters, called clients. In this mobile application the clients are the mobile devices that the users have while the server resides on other hardware. The server hosts the maternal healthcare information. When a user is accessing the maternal information, a request is sent via the internet to the server. The server fetches the specific maternal information that the user needs and displays it to the user. If the client cannot connect to the server due to lack of Internet connection, an error message is displayed. This model is demonstrated in Figure 5.29 below. The clients in this case are mobile phones. Internet Source: Wikipedia Figure 29: Client-8erver Architecture Model This client-server model was chosen since the mobile phone has memory constraints on the size of information that can be stored on the phone. The information is stored on the server side; hence the.memoryonthe.clientside-is.reserv.edforprocessing.t:w:o~thismodelmakesth.emobileapplication. dynamic in that the information can be updated anytime without affecting the client side. This enables the researcher to provide the relevant information to the users easily. The client-server model acts as a distributed computing platform where many clients can access one resource leading to more productivity and providing several points of access. 37

48 LEA mobile application client side is downloadable to mobile phone while the backend is managed from a website by an administrator from a PC. It was developed on Java NetBeans platform and PHP. 5.1 Development In the System Analysis and Design phase oflea mobile application, the Object Oriented Analysis and Design (OOAD) was used since it has the benefits of Reuse of classes and code improving system quality and robustness. With reuse, a developer only needs to connect the right classes giving industrial - strength applications that run correctly the first time, allowing for extension, robustness, avoiding over cost projects, late project deliveries and error free development. Data analysis was done using Unified Modelling Language (UML) to understand the domain ofthe system. Figure 5.30 is LEA Use Case Diagram showing the interactions between actors and modules ofthe mobile application. 38

49 User Figure 30: LEA Use Case Diagram data flow diagram in Figure 5.31 explains the process model ofthe system. 39

50 --' 1.01 Register mer details '"" I!-Save user details Users Details L-eonfirm registration I Input User Information Ask/contribute in blog Retrieve information----, Get maternal information FMI FMI View all maternal information IPush adverts Push adverts 3. I' Slog Join best mommy community IBlogs & comments Delete 4.~ Maintenance IDisable - Push adverts Delete! '"' I Advertisements 7.01 Maintenance 5.01 Maintenance Input adss---- r"",--i Get ads Run Adverts -Get blog threads Delete Adverts Get adverts ;- Disable 6.~ Maintenance users -----FigufeS;31:-Arehiteeture-oflEAMobileApplieation Implementation System Implementation During implementation the necessary programs for LEA were coded, debugged and documented. Testing the application during development was done using both 840 and 860 mobile phones. 40

51 5.2.2 System Specification - DuelO-the-constraiiitsamolJileClevicefaces;rewpackageswereused as many packages would cause memory problems. The compatibility oflea between different mobile devices operating systems was a major concern and tests were done with a variety ofmobile phones, especially those the questionnaire respondents had Development Environment Software Tools used i. Software: Net beans Language: PHP 111. Web Server: MySql. IV. Database: SQL Server. v. IVR: XML hosted by Voxeo in US. The system is developed in J2ME for the client side, PHP for the server side and the central database is based on SQL Server. The Interactive Voice Response is developed in XML Client Environment A J2ME enabled mobile device with minimum free space ofabout 600KB. The mobile device should also be data enabled to initiate download ofthe application and connect to the server to retrieve information when using the application. Required is any mobile device to test the IVR functionality, since the IVR does not need any special requirements, just a mobile phone that has airtime. 5.3 Walk Through the Whole Mobile Application System First, a user has to initiate a download the mobile application using (Over the Air) OTA method and install the application on his phone. A first time user will be prompted to register withher details in 41

52 the application. These details are required for blogging purposes. The main menu in Table 5.5 is the landing page with the functionalities oflea. Table 5.5: Main Menu of LEA Mobile Application Free Maternal Information The main menu has the free maternal information as the initial tab. This opens the categories available for the information. The user can click on any category and read on maternal information for free. The main menu form, categories form and information form are shown below respectively How LEA IVR Works This functionality enables users to dial and listen to the information through an Interactive Voice Response mechanism. The user navigates through the categories by pressing keys on the mobile phone keypad as directed by the voice prompts. Table 6 is a description ofhow LEA IVR works. 42

53 After the information is over you are prompted to press another category or exit. Ifyou press key for a category that does not exist e.g. 0 or 9, an error message is read to you. Table 5.6: LEA IVR Description g Navigating through the main menu gives the blog tab. This functionality enables users to ask, share and contribute to maternal issues, pregnancy complications and more. The user is prompted to register if new or login if already registered. Once the user is logged in, access to the blog is granted Bahv This functionality opens the calendar and prompts the user to select the last date of menstruation. The baby due date is calculated using the LMP method. 43

54 Below is a detailed description ofhow LEA mobile application works and is managed. 1. The splash screen displays adverts as the app loads 11. The main menu 111. Categories ofinformation IV. Free Information Centre v. Register to Blog VI. Login to Blog V11. Blog Centre V111. Calendar to Pick last menstruation date IX. Baby Due Date Calendar x. Dial and Listen 44

55 Figure 5.30: Splash Screen Figure 5.31: Main Menu When the user launches the application, the splash screen in Figure 5.30 above is displayed as the appiicafiontoaas:-fhemammenuill Figure 5.31 is the landing page with the functionalities that provide access to the maternal healthcare information. 45

56 \!lbral:ion i!; off Figure 5.32: Information Categories Figure 5.33: Information Centre The maternal information is provided in 8 categories as shown in Figure These are; pregnancy signs, trimesters, givmg-b1rth~ babycare--centre~-things to avo-id,anailiings todo during pregnancy, pregnancy complications, what to eat and wear during pregnancy. These categories open links to the information centre pregnancy. A sample ofinformation in the categoryofpregnancy signs is shown in Figure

57 Fiaure. 5.35: Figure 534 enables users to ask, share and contribute to the quesuons, compucaaoas have during pregnancy Users get expert advice through this blog, invite others for shower events and othermatemafhealt1:icafe--evenlsorganrsed-- by"n6e?s;-hospitals-and--othercan stan new bing as sbtjrwn

58 \fib!'atic<n is df _ t'191jire 536 C~dioub:ttes ~ This helps the parents to plan in advance where the baby will be born, events like baby shol~'er. scbedule 3.l~Lnttm;,"llts with doc;tor, nlol1>lie application is managed fi:mclli}nahtit~s of backend is to add, and disable users registered

59 mobtie apj>licati(m can dashboard in Figure In the dashboard, the Blog interactions orthe users are manat!ed..ine admmtstmtor can delete blogs and comments flagged as iu ltppropnate users. When users are accessing the information, they receive adverts paid for by medica] carepnkblcts. Figure 5.38: Home Page of B8ckend COlrnp;mb'dtty Testing molbtie apljllc;ation was tested on users to find out if it makes access to materaal he~tlttilcalre -application was on mobile to rntemied faactionalities is campatible. Medical alsotested sure the tnt;ornlatllon nr{'iv~f~ed medieallv correct The tables 'holm" 49 oottt

60 been extracted from the Test Template Report conducted on LEA mobile application by Reward Wambayi, Mobile Applications Developer in Safaricom Academy on 15 th, December 2011 and Ms. Edith Mutindi, doctor at Nairobi Hospital on 27 th December Based on the feedback obtained from the Mobile Expert and the User who is also a Doctor, the mobile application was fine tuned for the best functionality and usability experience Functional Testing Table 5.7 below summarizes the results offunctional testing: MODULE DESCRIPTION EXPECTED OBSERVED VARIANCE COMMENT TESTED OF TEST BEHAVIOUR BEHAVIOUR CARRIED OUT Splash Viewed splash Loads and The splash Well Nice image disappears. changes with Designed for the screen application orientation theme. Registration Tried to register Insert my Usemame field Not big. Validation details and is not Works well required on register completely the usemame llv validated field. LogIn Logged in Login OK Put a longer notification not time on the easy to see. alert or Disappears notification, very fast. Home Viewed interface Functional Buttons Similar Try shorter and tested buttons and function well. adverts on working buttons nice adverts Ticker is slow ticker that and tried reading and could be are easier to advert on ticker presented read better. Information Tested the Click quickly Working well Well Replace ('pntrp l...,,,,....l, '---. vu...'" -J UUL.P~' DUX the items. and view blogs cumbersome to with list for and comments operate easier,.'.., Blog Tried to read Click on a Working well. Have to go Wrap the box blog and topic and view to different around the comments details forms to text to view prevent comments. scrolling and a lot ofspace on the form. Baby Due Tried to Select date and Calculates A Date. Calculate Due submit Works well 50.

61 ~v... w"u.,.... ~~~~w...w... «f'w..w.. ~,..w..w... ~..WN".w..w..w.'"...~.w.v.w ~ ,...w...~~...""...,...u.... ~. "'y.w...n"...vu...w...-. Calculator Date Dial and Listen Tried to dial and listen Easy Navigation Well audible. ~.~,.v "' ~"'".wu ~w..w.w..w,,.. '".,w.,, w.v w.w... Table 5.7: Functional Testing Expert Usability Testing Table 5.8 below summarizes the results ofusability testing: MODULE DESCRIPTION EXPECTED OBSERVED VARIANCE COMMENT TESTED OF TEST BEHAVIOUR BEHAVIOUR CARRIED OUT._.- Splash Nice picture and Add other loading images Registration Tried to register M Easy flow and Some fields are Make it input oftext not validated simpler. well.. Log In Tried to log in Easy log in User can be Place a log in confused because there is button on the form no log in button but forgot code button is there Home Views the details Easy navigation. Good Shorten the and tested the navigation. ticker and buttons Ticker should be make it faster improved for easier reading. Information Tried all the Easy selection Too much Use a list and Centre features. and viewing of selection and click once 51

62 I klog l ~ ~".--" details. clicking on the combo box.- c--~ :-- Tried adding a Easy addition Very many Could be topic and and reading of forms for better ifa comments topics and viewing blog form could comments. and comments have the topic with the comments and not on different forms ---- IVR Tried to dial and Easy Navigation Well audible listen 1- - Table 5.8: Usability Testing Compatibility Testing Table 5.9 below shows the compatibility testing results of how the LEA mobile applications works with two Java enabled phones. The Nokia 2730 is a low end phone and the Nokia N97 is a high end phone. Nokia N97 Yes (OK) 5.6 Recovery & Security Table 5.9: Compatibility Testing A forced system failure was induced to test a back up recovery procedure for file integrity. Inaccurate data and blank fields were used to see how the system responds to terms of error detection and protection. Related to file integrity was a test to demonstrate that data and programs 52

63 are secure from unauthorized access. 5.7 User Usability Testing LEA mobile application was given to the participants who had filled in the pre-test questionnaire to use for two weeks. This was done to test if the users find it easy and timely to access maternal healthcare information through mobile phones as compared to other sources of maternal information. After the two weeks, the participants filled a post-test questionnaire to give a feedback on the experience of using mobile application to access. From the results, majority of the respondents preferred mobile application over other sources ofmaternal information due to the ease and timeliness ofaccess. This is discussed more in detail in the previous chapter. 5.8 Quality Assurance The documentation is a mainframe for LEA apart from inline documentation while coding. It will help in coding, help files corresponding to each program to be prepared so as to tackle the persondependency of the existing system. A user manual has also been designed to help in easy understanding and use ofthe mobile application. 53

64 Chapter 6 Conclusions and Recommendations 6.0 Summary This dissertation has provided a proof of concept that maternal healthcare applications can be accessed easily through mobile phones by the use of mobile applications. To achieve this, the researcher has demonstrated that mobile phones are able to quickly and easily disseminate information that will inform women ofways to care for themselves during pregnancy, dispel myths and misconceptions, highlight warning signs, connect women with local health services, reinforce breast feeding practices, explain the benefits of family planning, and make new mothers aware of how best to care for their babies. LEA mobile application model has achieved the status of"so far so good". Further examination of, and testing with, new data would probably show that this model still needs further fine tuning and integration with other modules like SMS. LEA is precisely what a maternal healthcare mobile application should provide; updated information, easy to read and understand, accessible anytime, anywhere at the users' convenience. This dissertation therefore can be seen as an initiative attempt to this goal. Harnessing the power of mobile applications in delivering maternal healthcare information is a solution to reduce infant mortality rate, it's a step towards achieving Millennium Development Goals 4 & 5 and Kenya's Vision Conclusions "You have no choice but to operate in a world shaped by globalization and the information revolution. There are two options: adapt or die." - Andy Grove, Chairman, Intel. The explosion ofmobile networks, and the growth in mobile phones ownership, particularly among vulnerable populations in low-resource settings, offers a revolutionary way to deliver -_._ timely information to improve awareness of critical pre~~~t~l ~d p~~t~~atal issues and reinforce health behaviours. Sending this information directly to the palms of expectant and new mothers is an innovative way to empower women in low-resource settings to take action to improve their own health and the health oftheir children and families. 54

65 The current traditional sources ofmaternal healthcare information do not provide timely access to the information as women have to travel to obtain the information from these sources. This makes it difficult for women to make informed choices on maternal issues, infant baby care and pregnancy complications. It is easy for the literate expectant women to read the maternal information and understand it. For the illiterate, it is difficult especially when the information is in English language. They prefer the information in Swahili, vernacular language or explained to them by another person. Access to maternal healthcare information via mobile phone brings about timely access to information about pregnancy, childbirth and the first year of life and empowers women to make healthy decisions for themselves and their families. The research has established that access to maternal healthcare information in Kenya, remains a challenge even with the high rate Internet and mobile phones penetration. The cost of Internet and access to hospitals remains relatively high for the common citizen. Few mobile based applications and SMS and IVR applications have been developed to provide this crucial information. The application was developed on J2ME platform since from the data collected from the respondents majority of them have mobile phones that are java enabled. For users with low end mobile phones that cannot access the Internet, IVR will provide the information in place ofa mobile application. After development, LEA mobile application was tested by both experts and users. Experts suggested changes in navigation to make it easier, user interface and the system notification messages. After the changes were made, the users tested the application for two weeks and from their responses, accessing maternal information using a mobile phone was timely, reliable, cheaper, easy and faster than the other sources. LEA mobile application has acted as a proofof concept that maternal healthcare information can be accessedeasilyusingrnobnephonesfrom rul"aiareasand~rb~hm~~sb8thsi~~, ~iclcll~ ~cl high... class areas. For users who cannot understand English language, Swahili language and vernacular languages can be used. 55

66 6.2 Challenges The main obstacle to the use of technological innovations in the delivery ofhealth-care services in the developing world is access to these technologies but this is no longer a problem in the case of mobile phones, which are increasingly used for health purposes. According to Vital Wave Consulting (2009), there are 2.2 billion mobile phones in the developing world and by 2012 at least half of all individuals living in the remote areas of the planet will have regular access to this technology. In data collection, some users found it difficult to trust mobile phones to deliver the information they have entrusted with Midwives and doctors. They did not want to lose the personal touch established with the doctors and midwives. Several challenges were encountered during the project development of LEA. The major challenge was the constraints that a mobile device faces. These make the functionalities of the applications limited to the constraints ofmemory, processing speeds and formats supported. Testing of the applications was challenging due to lack of existing testing standards and frameworks that the researcher could use, compatibility with different models ofmobile phones. 6.3 Recommendations Partnerships with doctors, hospitals and healthcare NGO's especially in slums and rural areas should be done to ensure the maternal information they provide, prenatal clinics, health events and more can be informed the target population via mobile applications. Programmers should set up a program code repository in SVN, Git or Mercurial for the program code functionalities that they develop to share with other programmers. This will reduce the time of coding. Code reuse should be encouraged more and the coding specifications should be followed more. To reach the semi-literate expectant women with maternal information easy to understand, Swahili and vernacular languages should be used in the cl1anne1spi'ovidiiig the iiiformation. 56

67 6.4 Future Work In future, partnerships with NGO's, medical institutions should be done to identify new ways of providing the information through mobile technologies to the most remote areas and the East Africa. SMS applications should be developed and deployed to schedule appointments with doctors and reminders besides making it further easier to access maternal healthcare information. A directory listing all the hospitals especially for children and maternity homes around the locality ofa user should be developed and accessed by all expectant users. The directory should also include the medical services and the price quotes available in those hospitals. This will help the expectant women to get the best bargain and plan in advance where to give birth in and where to get birth care. A centralized database should be developed and managed to store all the maternal information required. This will save users the agony of wasting time, effort and money to obtain this crucial information. The mobile phones should be used more to disseminate this information. Incorporating an expert knowledge system and development of intelligent agent that provides personalised information according to the specific needs ofthe mother. 57

68 REFERENCES Africa Freedom ofinformation Centre AFIC, (2010). Statement to African Heads ofstate and Government, Access to Information Central to Improving Maternal, Child and Infant Development in Africa. Baby Center App (2011). My Pregnancy Today Mobile Application. Last accessed on 10/10/ Coventry University (2005). Simple Random Sampling. Last accessed on 14/01/ Eugenie L, Susan M, Ibrahim M (2011). Womens Health and the World's Cities. University of Pennsylvania Press, Philadelphia. Page Government ofthe Republic of Kenya (2007). Kenya Vision 2030, The Popular Version. Last accessed on 18/02/ vision 2030 abridged version.pdf ICT R&D Centre, School of Computer Technology, Sunway University College(2007). Mobile Based Pregnancy Support System. Last accessed on 12/12/201l. ehealthasia07abs 116.pdf ihub, Kenya's Mobile Subscribers, Penetration & Internet (2011). Last accessed on 14/01/ InfoDev (2006). Improving Health, connecting people: the role of ICTs in the health sectorof developing countries. InfoDev, World Bank. Inter-American Bank, (2010). Pregnant women in Peru will improve their health via cell phones. Last accessed on 07/02/ IRIN (2009). Ghana: Cell phones cut maternal deaths. Last accessed on 09/02/2012: ITU (2006). Universal Access to Telecommunication Services: Are Current Practices Keeping Pace 58

69 with Market Trends? International Telecommunication Union. Last accessed on 18/01/ en.pdf ITU (2009). Information Society Statistical Profiles 2009 Africa. Last accessed on 18112/ Ivythesis (2011). A Sample Thesis Methodology. Last accessed on 22/12/ Johan H (2010). Innovative use ofmobile Applications in East Africa. Sida Review 2010:12. Kamel Boulos MN. (2003). The use of interactive graphical maps for browsing medical/health Internet resources. Last accessed on 18/ Kelly Zantey (2006), Pregnancy Symptoms & Signs ofpregnancy - A Comprehensive List. Accessed on / pregnancy, Krzystof Z, Mariusz D, David I (2006). Information Technology Solutions for Healthcare. Health Informatics Series. Page Leedy, Paul. D, and Ormrod, Jeanne E. (2001). Practical Research: Planning and Design. 7th Ed.. Upper Saddle River, NJ: Merrill Prentice Hall. Mobile Alliance for Maternal Action (2011). Last accessed on 14/08/ MoTeCH - Grameen Foundation, (2011) Research: How MoTeCH uses mobile for maternal health ninghana.aeeessedon~()/-10/~()1-1-;- mobiles-maternal-health-ghana --- NyongesaO,-AbidoyeP;(~()l l};ensuringtheseeurity-andprivacyofinformationinmobilehealth,, care communication systems. South African Journal of Science. Last accessed on 05/12/ OpenIDEO Challenge(2011), How might we improve maternal health with mobile technologies for 59

70 low-income countries? Oxfam, Nokia & IDEO. Last accessed on 22/12/ Sailesh C, Jessica R, Akhtar B. (2011). Technology at the Margins, How IT meets the needs off Emerging Markets. John Wiley & Sons. Page Saunders, M., Lewis, P. and Thornhill, A. (2003). 3 fd Research Methods for Business Student, Prentice Hall T. Tamrat, S. Kachnowski, (2011) Special Delivery: An Analysis ofmhealth in Maternal and Newborn Health Programs and Their Outcomes around the World. Maternal and Child health Journal. The Wall Street Journal, (2008). For women in villages, prenatal care will be just an SMS away. Last accessed on 22/12/ UNICEF, (2010) Mama's million shillings chain, Media Centre. Last accessed on 14/10/ html United Nations (2000), The Millennium Summit Declaration. Last accessed on 18102/ Vital Wave Consulting (2009), mhealth for Development: The Opportunity ofmobile Technology for Healthcare in the Developing World. Washington, D.C. and Berkshire, UK: UN Foundation- Vodafone Foundation Partnership Yvonne Bronner (2000), Nutrition and Pregnant Adolescent "Cross-Cultural Issues During..._Pregnancy.andLactation:ImplicationsfoLAssessmentand_Counseling",page113., Communications Commission ofkenya (2011), Quarterly Sector Statistics Report. 1st Quarter, July-September Last accessed on 12/ STATISTICS REPORT Q pdf 60

71 APPENDICES Appendix A: Pre-Test Likert Scale Questionnaire Shadrack Kioko Strathmore University Msc. Telecommunications Innovation & Development Dissertation Research Questionnaire. Specific questions adapted for expectant women in Kenya both in rural and urban areas indicating important determinants regarding access to maternal healthcare information. Part 1: Profile Q rt~ [~~ U ~uestion ;elect your age bracket ndicate your area ofresidence lelect your employment status Unemployed Self - Employed Employed lelect your level ofeducation IPrimary School Secondary School LGraduate Level ILevel Level Part 2: General Mobile Phone Service and Device Information 1. Do you own a mobile phone? Yes ( ) No ( ) -- Manufacturer Nokia ISamsung Motorola Ericsson Others.. {sp~~ijyij~i~:wl - - "-..PhoneModel --r 2. Is your mobile phone Internet enabled? Yes ( ) No ( ) 3. Is the Phone Java enabled? Yes () No() I don't Know () 4. Do you use your phone to browse the Internet and other programs such as games, social network applications e.g. facebook? Yes ( ) No ( ) 5. Who is your Mobile Service Provider? Safaricom () Airtel () Orange () YU() 61

72 Part 3: Survey Proper i i r Question Overall I am satisfied how I access maternal information I have access to up-to date I maternal information I am confident to deal with any pregnancy complication that mayanse I am able to fully understand all the maternal information I, receive I have easy access to doctorsi I St.rongly IDisagree I 'I-Disagree I Neutral _. 2!LL Agre e 3 Strongly Agree I and pre-natal clinic 1 I know where to get any maternal care and assistance that I need 7 It is difficult to get answers on I any questions I have regarding nregnancy If you know the proper information, its possible to! avoiid pregnancy comp1"" lcatlons I I I -+-- I 9 I Mobile phone use makes it. easy to access maternal information 4 Table A.10: Questionnaire 62

73 Appendix B: Likert Scale Pre-Test Questionnaire Data Weighted Mean N(Number of Weighted Interpretation Respondents) Mean Ql Neutral Q Neutral Q Disagree Q Neutral Q Neutral Q Agree Q Neutral Q Agree Q Agree QI Disagree Qll Neutral Q Disagree Q Agree Q Neutral Q Neutral Table 8.11: Weighted Mean Calculation of Responses After the data was collected from the respondents, the weighted mean was calculated and interpreted with Likert scale analysis. 63

74 Appendix C: The Post - Test Likert Scale Questionnaire Shadrack Kioko Strathmore University MSc. Telecommunications Innovation & Development Dissertation Research Questionnaire. Specific questions adapted for expectant women in Kenya both in rural and urban areas indicating their experiences in using mobile application to access maternal healthcare information after testing LEA mobile application for two weeks. Post-T Strongly Disagre Neutral IAgree Strongly Disagree e Agree Question Overall I am satisfied by use of mobile application to access maternal information 2 It's easier to access maternal information through mobile application than through other I methods I am confident to deal with any pregnancy complication that,-may arise - 4 I am able to fully understand I all the maternal information I receive through the mobile application. I 5 The mobile application I I provides support during or after pregnancy 6 Itsdieapert() access maternal! healthcare information through mobile application 7 Its easier to get answers to questions I have regarding pregnancy through mobile application._ I prefer calling and listening to L the information than using the mobile application Table C.12: Post-test Questionnaire 64

75 administrative task from the dashboard below FibUMD.39:with Hn1<s lanmngpage above for the administrator provides link to the functionalitiesofthe backend. administrator can manage adviemare and to run for specrtied

76 ViewInformation (All, Paginated or by Category), Edit, Add or Delete Information from the menu below Figure D.40: Information Dashboard The information that users receive needs to be revised periodically. The portal above enables the users receive is updated an the time and in future changed depending on the pregnancy stage. View, Add, and Delete Blogs and Comments from the Menu below 66

77 Figure 0.41: 810g Dashboard The portal above enables the administrator to view blogs and comments added by users, delete those flagged by users as abusive. From the blogs, the administrator notifies doctors and medical experts on issues that users have which need expert attention. This ensures that users can interact withdoctors on pregnancy issues timely and easily. 67