=Paper=
{{Paper
|id=Vol-2629/4_ppt_nkwo.pdf
|storemode=property
|title=Personalized Persuasive Technology for Maternal Healthcare in Nigeria
|pdfUrl=https://ceur-ws.org/Vol-2629/4_ppt_nkwo.pdf
|volume=Vol-2629
|authors=Charity Mbanusi,Makuochi Nkwo,Rita Orji,Virginia Ejiofor
|dblpUrl=https://dblp.org/rec/conf/persuasive/MbanusiNOE20
}}
==Personalized Persuasive Technology for Maternal Healthcare in Nigeria==
https://ceur-ws.org/Vol-2629/4_ppt_nkwo.pdf
Personalized Persuasive Technology for Maternal
Healthcare in Nigeria
Charity Mbanusi1* Makuochi Nkwo2, Rita Orji3 and Virginia Ejiofor1
1
Department of Computer Science, Nnamdi Azikiwe University Awka, Nigeria
2
Department of Computer Science, Ebonyi State University Abakaliki, Nigeria
3
Faculty of Computer Science, Dalhousie University, Halifax NS, Canada
chary4sam@gmail.com
Abstract. This study employs four social influence strategies including social
learning, social comparison, normative influence and recognition, to personalize
a persuasive system aimed at regular and timely ante-natal, intra-partum and
post-partum care amongst women in developing nations such as Nigeria. This
new persuasive system will take the privacy into consideration while presenting
a customized display of relevant and up-to-date maternal health information to
the potential users. It will provide avenues for expectant mothers to observe and
learn appropriate maternal health behaviors, compare their performances with
similar others’ performances, imbibe healthier and safer maternal lifestyles and
receive some form of recognition for performing target maternal health behav-
iors. Via the operationalization of these socially-oriented persuasive strategies,
we hope to investigate how the new intervention will be able to support ex-
pectant mothers to change, improve and/or reinforce a positive attitude to their
health and that of their unborn and suckling children. We contribute to research
by demonstrating how socially-oriented strategies can be tailored in a persua-
sive technology for maternal healthcare to promote information and health-
seeking behaviors amongst local women.
Keywords: Maternal Health, Socially-oriented Strategies, Social Influence,
Personalization, Persuasive Technology, ICT4D, Persuasive4D, PT4D, Africa
1 Introduction.
Persuasive technologies (PTs) are interactive systems that are designed for the primary purpose
of motivating people to change their behaviors, without using coercion or deception [6, 7, 16,
23]. PTs achieve their behavior change objectives via the use of persuasive strategies [19].
Research has shown how persuasive strategies have been effective in motivating users to
achieve specific goals in various domains such as environmental management [13, 14, 18],
education [29], physical activities [11], and even in different health domains [20, 31][35].
Maternal health is the health of women during pregnancy, childbirth and in six weeks after
delivery [2, 27]. Antenatal care (ANC) is the specialized care a pregnant woman receives dur-
ing her pregnancy through a series of antenatal visits with trained health care professionals in
order to help her attain and maintain a state of good health all through her pregnancy [2, 27].
Persuasive 2020, Adjunct proceedings of the 15th Int. conference on Persuasive Technology.
Copyright © 2020 for this paper by its authors. Use permitted under Creative Commons Li-
cense Attribution 4.0 International (CC BY 4.0).
Research has shown that each year, more than 500,000 women between the ages of 15 and
49 die of causes related to pregnancy and child birth [8]. Almost all maternal deaths (99%)
occur in the developing world, and more than half occur in Africa [8]. Proper ANC is one of the
important ways of reducing maternal and child morbidity and mortality [27]. Women’s attitude
towards antenatal care and that of the maternal healthcare providers are crucial to the expectant
mothers’ ability to access the requisite maternal healthcare.
Many studies have focused on investigating and developing fundamental programs and
strategies for persuasion in the health domain [26, 31, 36, 37]. For instance, the new WHO
guideline [37] highlighted the importance of woman-centered care to optimize the experience
of labor and childbirth for women and their babies through a holistic, human rights-based ap-
proach. Traditional media, such as radio, TV and newspapers have also been used to motivate
pregnant women to imbibe positive maternal health lifestyles [26]. However, these programs
and strategies have not been successful since most expectant mothers in the communities would
choose to continue with their negative attitudes/behavior to maternal health due to poverty,
availability and accessibility of maternal healthcare services, rural community and household
power dynamics, compliance with traditional practices, and outright ignorance [4, 5, 34].
Besides, maternal healthcare facility managers and other stakeholders apply the traditional
approach of persuasion (via human-human persuasion) to motivate expectant mothers to attain
and maintain a state of good health all through their pregnancy [36, 37]. In this approach, hu-
mans or a health institutional authority tries to persuade another human – expectant mother to
perform a target behavior, manually. For instance, [3] observed that human-human social facili-
tation and cooperation is used to persuade women to go for antenatal visits to ensure that both
the mother and child remain healthy and to reduce maternal mortality. However, despite these
efforts, there are ever-increasing incidences of absenteeism, non-adherence and ignorance about
the essential maternal health behaviors and practices amongst local women. These develop-
ments ultimately lead to the constant health crises of these women, delivery of newborn babies
with serious health problems and deformities; and increase in pregnancy and child birth-related
deaths amongst the people. Therefore, there is a need for a shift; the adoption of a new ap-
proach to motivate acceptable health and information-seeking behaviors amongst expectant
mothers which can be achieved via the combination of Information and Communication Tech-
nology for Development (ICT4D) tools and relevant persuasive strategies. We refer to the inte-
gration of ICT4D tools and Persuasive Strategies in the design of indigenous and culturally-
appropriate behavior-change support systems for developing nations as Persuasive Technology
for Development (Persuasive4D or PT4D).
In a recent meta-review, we discovered that Africans are susceptible to persuasive strategies
[32, 33]. Most existing studies focus on how persuasive technology techniques could be applied
to support users to perform target behaviors in domains such as eCommerce [16, 23, 24], edu-
cation [29], environment [13, 17] and healthy eating [31]. However, there is yet no study on
what persuasive techniques could be implemented to promote positive maternal health (regular
and timely ante-natal and intra-partum care) amongst expectant mothers in Nigeria. This shows
that there is dearth of research on the application of persuasive technology in maternal health in
the developing nations of the world. To advance research in this direction, we focus on how to
design and evaluate a personalized persuasive technology for maternal health which will have
the capacity to motivate pregnant women to change/improve their attitudes and behaviors to-
wards their health and that of their unborn/newly born babies.
We contribute to research by demonstrating how socially-oriented strategies can be designed
to be culturally-appropriate [15, 22] and tailored in a persuasive technology for maternal
healthcare to promote information and health-seeking behaviors amongst local women.
2 Related Works
In this section, we review allied literatures in maternal health, persuasive designs and strategies.
2.1 Maternal Health
The overall health of expectant mothers during pregnancy, childbirth and six weeks after child-
birth is referred to as maternal health [2, 27]. Pregnant women are usually given special care
which is achieved via a series of antenatal visits to maternal healthcare facilities managed by
trained healthcare professionals. These visits are done to help her attain and maintain a state of
good health all through her pregnancy [2, 27]. However, research has shown that more than
500,000 women between the ages of 15 and 49 die of pregnancy and childbirth related cases
each year [8], with most of these deaths (99%) occurring in the developing world. These avoid-
able incidences could be attributed to women’s attitudes/behaviors towards their maternal
health (antenatal) cares. Although several strategies like the use of traditional media and manu-
al persuasion have been used to motivate women to embrace positive maternal healthcare be-
haviors, however, these programs and strategies have not been successful. Most expectant
mothers would choose to continue with their negative attitudes/behavior to maternal health due
to poverty, availability and accessibility of maternal healthcare services etc [4, 5, 34]. There-
fore, a new approach for motivating community women to change their behaviors and attitude
towards maternal healthcare is wanted since it will have the capacity to support expectant
mothers to attain and maintain a state of good health all through their pregnancy [2]. This new
approach could be achieved via the operationalization of persuasive technology strategies in a
maternal healthcare application.
2.2 Persuasive Strategies
Persuasive technologies are interactive systems which have the capacity to motivate users to
perform target behaviors or change their attitudes towards certain phenomena. Persuasive strat-
egies provide the building tools for such behavior-change support systems [13, 21]. Over the
years, researchers have come up with various strategies [7][28]. For instance, while Fogg pro-
posed eight design steps for building a persuasive system [7], Oinas-Kukkonen and Harjumaa
proposed twenty-eight persuasive strategies which are employed in designing and evaluating
persuasive systems [28]. Based on the type of support that persuasive strategies provide to the
users of a system, they are classified into four distinct categories: the primary task, dialogue,
system credibility, and social support categories [23, 28]. Specifically, the social support cate-
gory consists of socially-oriented strategies such as social learning, social comparison, norma-
tive influence and recognition, which encourage users by leveraging social influence [23, 28].
When implemented in a system, social learning strategy motivates a user to perform a target
behavior by allowing her to see and learn from what similar others did or is doing [23, 28]. This
strategy differs from other strategies since there is no actual comparison or competition in-
volved. The learner could only learn as a passive onlooker; by mere observation, imitation and
behavior modelling and does not have to be involved physically.
The social comparison strategy motivates a user to perform a target behavior by allowing
her to use the system to compare her performance with that of others that are performing or
have performed target behavior [23, 28]. It could be upward (when it is used for self-
improvement as people compare themselves to others who are performing well in the specified
task) or down (when it is used by people to raise self-worth as they compare themselves to
other people they performed better than) [23, 28].
Normative influence strategy takes advantage of peer pressure to motivate a user to adopt or
perform a target behavior [23, 28]. This principle could be implemented such that the system
will provide a common ground for users with similar goals to connect, share, collaborate, grow
their knowledge together, and influence one another.
The Recognition technique involves offering public recognition to a user or group of users
for performing or adopting a specific target behavior [23, 28]. By natural drive, people appreci-
ate it and tend to perform more when their performances are recognized. Recognition could be
implemented in persuasive technology (PT) via the provision of displays of best users or pub-
lishing a personal story of the people who have succeeded in their target behaviors.
Many of these strategies have been employed and have proved to be effective in developing
and evaluating persuasive technologies in various domains [10, 19][25][31]. In this study there-
fore, we will employ these socially-oriented strategies to personalize a hyper-localized persua-
sive system for maternal health for developing nations such as Nigeria.
3 Method
This section describes the current phase of our work which seeks to investigate how socially-
oriented strategies and personalization could be used to promote information and health-
seeking behaviors amongst women in developing nations. To achieve our objective, we address
the following research questions: (1) what are the obstacles to adopting proper maternal infor-
mation and health-seeking behaviors amongst women? (2) How can we operationalize relevant
socially-oriented persuasive strategies in a health intervention to motivate potential users to
adopt appropriate maternal information and health-seeking behaviors? In the following subsec-
tions, we describe our preliminary and the current studies.
3.1 Context and Initial Study Design
This study is set at Orumba General Hospital Umunze, Nigeria, where pregnant women already
receive training on monthly antenatal care visits; coaching them to access useful resources to
improve nutrition, health knowledge and promote preventive health practices. Timely and fre-
quent use of antenatal care enables delivery of essential services, including malaria treatment,
immunizations, and health counselling. After three months, there is a check of women whose
antenatal attendance is frequent and timely. This report is used to recognize publicly those who
have been consistent in coming for antenatal; they are displayed on the notice board of the
antenatal section. Through this method, it is expected that those recognized will be motivated to
continue to come and defaulters will be inspired to change their attitude and attend antenatal.
Besides, to address research question 1, we conducted a preliminary user study on the wom-
en and caregivers after the first three months of their antenatal visits (first trimester) to under-
stand the obstacles that hinder expectant mothers from adopting proper maternal information
and health-seeking behaviors amongst women. We used a questionnaire based on Busch et al.’s
persuadability inventory (PI) [1] and modified to fit into our area of study maternal health. This
was done to identify users’ persuasion strategy preferences and to construct a simple persuasion
profile for each expectant mother. The PI scales consist of five (5) items each, for measuring
social learning; social comparison, normative influence, recognition and personalization strat-
egies. We weighed up our questionnaires using the participants’ agreement to a 5-Likert scale
ranging from “1 = Strongly Disagree” to “5 = Strongly Agree”. Seventy respondents participat-
ed in the survey. According to Busch et al. [1], “Participants having higher scores in one or
more of the scales are expected to be more susceptible to these specific persuasive strategies.”
This approach is adopted to help determine persuasive strategies that are most effective and
could be employed to design our proposed app.
The findings from our preliminary studies uncovered various socio-cultural factors which
affect the adoption of proper maternal information and health-seeking behaviors amongst wom-
en. Some of these obstacles are: religious and cultural beliefs, aversion for caesarean sections,
high hospital bills, poverty and outright ignorance. For instance, many of the respondents think
that “safe delivery is only a function of belief in God” and “God has promised they shall deliv-
er their babies like the Hebrew women in the bible”. On the other hand, some of the respond-
ents failed to attend antenatal sessions and engage in proper health and information-seeking
behaviors due lack of time and outright carelessness. These attitudes deter them from seeking
proper health checkup during pregnancy. The rising rate of pregnancy and childbirth-related
deaths in developing African nations confirms this finding [8, 27]. In addition, we discovered
through our study that many of the women make use of mobile phones and computers, while
some have internet access. These findings are essential because research has shown that ICT4D
has created opportunities for users to connect, share, collaborate and learn new things [18, 24].
3.2 Application Design
This is the current phase of our research. We are employing Fogg’s eight-step processes [6, 7]
to develop our persuasive technology for maternal health. The steps includes: 1) Target a sim-
ple behavior, 2) Know the target audience, 3) Discover obstacles to performing the target be-
havior, 4) Use technology channel familiar to users, 5) Identify appropriate persuasive technol-
ogy examples, 6) Emulate effective examples, 7) Evaluate and repeat fast, 8) Expand on suc-
cess. We chose the Fogg’s persuasive design steps because it provides us the opportunity to
iteratively design a maternal healthcare intervention that will be culturally-appropriate and
suitable for the delivery of healthcare services to our target population.
Specifically, we sought for a simple behavior, which was motivating expectant mothers (tar-
get audience) to attend antenatal visits at local maternal healthcare facilities. These health cen-
ters are government owned and they provide free services for expectant and newly delivered
mothers who registers with them. Besides, the findings from our initial study (section 3.1)
shows that religious and cultural beliefs, aversion for caesarean sections, high hospital bills,
poverty and outright ignorance are some of the obstacles preventing local women performing
the target behaviors. Again, based on our findings, we chose to employ an integrated platform
(mobile and desktop) as our technology media since both media are common gadgets familiar
to the women and the caregivers in the maternal healthcare facility. In order to identify appro-
priate persuasive technology example to use in our study, we conducted a systematic review of
related literatures and uncovered that social influence strategies along with other persuasive
strategies have been effectively used to develop and motivate attitudinal and behavioral chang-
es in various domains [19][30]. For example, Nkwo et al. [19] employed social learning, social
comparison, recognition and personalization to design a persuasive system for promoting clean
and sustainable environment. We emulated that design to start off the development of our per-
suasive technology for maternal health which will have the capacity to motivate expectant
mothers to change and/or improve their health and information-seeking behaviors. Our design
will utilize four socially-oriented strategies (social learning, social comparison, normative in-
fluence and recognition) from the persuasive system design framework [28] to personalize and
tailor important maternal healthcare services to the potential users of the system.
3.3 Implementation of the Socially-oriented Persuasive Strategies
Social Learning Display: This strategy is usually implemented in such a way that users will be
able to observe other’s performances, learn new things and find out best practices which they
could passively learn from [12]. Specifically, we plan to operationalize our social learning
display to show a graphical view of the number of pregnant women and the points earned for
frequent and timely attendance to antenatal sessions each month, see figure 1.
Y-axis
35
30
25
20
15
10
5
0
6 12 18 24 30 31
X-axis
Fig. 1 Proposed Social Learning Performance Display
The Y-axis depicts the number of users while the X-axis depicts the performance points based
on the number of visits to antenatal care sessions. We expect that the display will help to model
the attitudes of pregnant women towards their antenatal care visits and support them to adopt
positive maternal healthcare behaviors.
Social Comparison Display: We plan to operationalize this strategy via an instant messaging
component. This feature will allow users to share and compare information related to their
maternal health (good health of the mother and the child). Here, the logged in user of the sys-
tem will see a display of her real name and her own maternal healthcare progress information
shared on the application. However, she would only be able to see the maternal healthcare
progress information of other registered pregnant women with pseudo-names. The display will
be limited to like seven users per screen to make it easier for the logged in user see and com-
pare her performance with that of other expectant mothers registered in the system. The logged-
in user will also have the opportunity to send personalized feedbacks (reaction) using any of the
three keys: Okay, Surprised, and Oh No. The app will be automatically updated with new rec-
ords such that users could have the opportunity to compare attendance as time progresses.
Normative Influence Display: This strategy entails leveraging social or peer pressure to in-
crease motivate a user to perform or adopt a target behavior. We plan to implement normative
influence by allowing users to use their mobile devices to view pictures of newborn babies with
serious health problems and deformities due to the mother’s inability to attend antenatal care
frequently and timely. We hope that this display will awaken their consciousness on the dan-
gers of absenting or irregularly attending antenatal care (ANC). Also, we plan to use this dis-
play to encourage the delivery and receipt of essential maternal healthcare services such as
malaria treatment, immunizations, and health counselling. Besides, since our proposed system
is an integrated platform (mobile and desktop system), we plan to ensure that the aforemen-
tioned displays are also shown on a public LCD (Liquid Crystal Display) located in a strategic
location in the antenatal section of the maternal healthcare facility, where everyone can see it.
We are confident that these persuasive displays will potentially increase the likelihood that a
user will adopt or perform target behaviors.
Recognition Display: We will implement recognition in our new system by allowing users to
view through their mobile devices, a list of expectant mothers who have regularly attended
antenatal visits over a given period, and have successfully performed assigned target behaviors.
The system will also publish personal success stories of successfully delivered mothers and
what they did to achieve that feat. Again, since our proposed system is an integrated platform
(mobile and desktop system), we plan to ensure that the recognition displays are also shown on
a public LCD (Liquid Crystal Display) located in a strategic location in the antenatal section of
the maternal healthcare facility, where everyone can see it. Progressively, the list will be auto-
matically updated using attendance points entered for each user after three months calculation
of how frequent and timely are the antenatal visits of these pregnant women.
Personalization: A system that offers personalized content or services has a greater capability
for persuasion [9]. We will operationalize personalization in this system by providing a unique
identification card number to the women at the point of registration. This interface will show
contents that are pertinent to the expectant mothers. For example, through personalization, the
logged-in user (expectant mother) can be able to envisage and compare her attendance to that of
other women performing the same task. She can equally react (send her feedback) by using any
of the three keys: contented, astonished, and discouraged.
Moreover, we are iteratively developing an integrated system for maternal health which will
offer diverse but personalized persuasive interfaces of the four social influence strategies to
support and inspire potential users (expectant mothers and caregivers) to perform target behav-
iors. We are taking security and user’s privacy into consideration by ensuring that user login
credentials (username and unique card numbers) are authenticated and abstracted with pseudo-
names to check against illegal access and other harmful activities.
4 Study Status, Future Work and Expected Outcome
The persuasive technology for maternal health is currently at the development phase. It will be
integrated with the relevant persuasive strategies described above in order to motivate users
(expectant mothers) to adopt positive maternal healthcare behaviors. We will evaluate a clicka-
ble prototype of the system by testing it with the potential users (expectant mothers and care-
givers) of the system.
In specific terms, we plan to conduct usability evaluation with individual users to get a
feedback about the effectiveness and value of our design concepts in terms of: (1) motivating
users to learn new things and find out best practices, (2) encouraging users share and compare
information related to their maternal health (good health of the mother and the child), (3) awak-
en users consciousness on the dangers of absenting or irregularly attending antenatal care
(ANC), and (4) inspiring users to adopt positive maternal health and help-seeking behaviors.
Through this evaluation, we hope to learn about the effect of the different persuasive displays
on the users and discover how persuasive systems can be tailored to support pro-maternal
healthcare services in developing African nations. We will compare our findings against the
current maternal healthcare practices to show its obvious benefits.
5 Conclusion
Persuasive technologies (PTs) are interactive system that is designed for the primary purpose of
motivating people to change their behaviors, without using coercion or deception. In this early
work, we used four social influence strategies (social learning, social comparison, normative
influence and recognition) to show how the persuasive system will be personalized to promote
regular and timely ante-natal and intra-partum care amongst expectant mothers in developing
nations like Nigeria. This new persuasive system would take the privacy of users into consider-
ation while it presents them with a customized display of relevant and up-to-date maternal
health information. Generally, through the operationalization of these socially-oriented persua-
sive strategies, we hope to investigate how the new intervention will be able to support ex-
pectant mothers to change, improve and/or reinforce a positive attitude to their health and that
of their unborn and suckling children. In addition, we will measure user behaviors and compare
them with what it used to be before the introduction of the automated persuasive system in
other to see the benefits of the new intervention.
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