Editing for Journal
The Level of Participation during the Development of a
Mobile Application for Home-Based Healthcare Data in
a Developing Context: An Actor-Network Theory
Perspective
Retha de la Harpe
Faculty Informatics & Design, Cape Peninsula University of Technology, South Africa.
ABSTRACT
The context of this study is home-based healthcare in a South African resource-restricted community. The research case involved the
design and development of a mobile care data application, created to assist community caregivers in their professional activities.
However, the development principles of a suitable mobile application for feature phones (limited functionality) in this context are not
fully established. A participatory design approach was employed using a design science research in information systems strategy. Data
was collected during the co-design sessions with the active participation of the caregivers to design and develop a suitable mobile
application to capture process and report care data. The activities of the caregivers in practice and the design and development
activities were observed. It was observed, conversely, that the level of participation of all stakeholders differed significantly during the
process. It was especially observed that the designer and end-users were less involved in the actual development of the prototype.
These differences may have an influence on the end product/result. Actor-network theory (ANT) was used to offer a new perspective
on the development processes, concepts and structures. ANT has not been used extensively in development studies and may provide a
mechanism to describe how the human and non-human actors formed relations as they participate in these processes through
translation moments. ANT also considers the ‘black-boxed’ aspect of IT artefacts during development as a single node of the network
that may need to be opened up. Considering the alignment of such networks, the coordination, devices and passages during the four
translation moments provide valuable insights in the design and development of technology products. This paper will consider these
elements in more depth. The socio-economic factors of the developing context influenced the complex sociotechnical development of
the mobile application. The role of technology artefacts to assist with the development of new IT artefacts is more complex in a
developing context since there are not enough mobile artefacts that could be used as examples to guide the developers. This aspect, as
well as the lower digital literacy of the end-users, influences their level of participation during the design and development phases.
There seems to be a large gap between mobile development in the global North versus that in the global South.
CATEGORIES AND SUBJECT DESCRIPTORS
H.5.2 [Information System]: Information Interfaces and Presentation – user-centered design;
K.6.3 [Computing Milieux]: Management of Computing and Information Systems – software development.
KEYWORDS
Home-based healthcare, participatory design, mobile application, mobile development, actor-network theory
1. INTRODUCTION
The adoption of a participatory approach for the development of
a mobile application in a resource-restricted setting is
challenging. The respective users in this environment are
mostly exposed to feature phones with limited functionality
(Van Zyl, 2011). Moreover, there were relatively few advanced
mobile applications available that could serve as examples of
how to develop interventions in such cases. This paper
discusses the design and development of a practical application
for use in a South African home-based healthcare (HBHC)
setting. This application was envisioned to assist caregivers
with capturing, reporting and sharing of patient data. The
investigators made use of a participatory design approach in the
initiation and creation of the application prototype.
The setting is typical of a developing context and as such the
study considered the issues of Information Systems
Development for Development (ISD4D). The formation of a
local network of actors designing and developing an IT artefact,
that has the potential to improve the situation of caregivers, is
considered. In development studies, a global network of actors,
provide the space and resources for projects with the aim to
improve the socio-economic well-being of resource-restricted
communities (Heeks, 2013). The evaluation of the eventual use
in practice of the practical application discussed in this paper
falls outside the scope of this paper and further research would
be required to also consider the developmental factors that are
outside the project to consider a global network.
The approach followed by this research study was to
introduce technology only if there is a need for it and then only
with the active participation of the end-users. The perspective is
of social embeddedness that which assumes the construction of
new techno-organisational structures within a given local social
context (Avgerou, 2010). The focus of this paper is not on the
potential benefit of the technology solution but rather to reflect
on the level of participation during the design and development
phases. In development, and especially with of information
communication technology (ICT), the participatory methods
should be framed by discourses on the social embeddedness of
ICT with a focus on the importance of local factors in
technology appropriation rather than just on ensuring product
quality and relevance (David, Siebieca & Cantoni, 2013). After
reviewing the literature of co-designing with communities,
David, Sabiescu & Cantoni (2013) they identified five themes
relevant for co-design with development, namely stakeholders,
context, ownership, social learning and sustainability. Of note is
social learning as a process of knowledge advancement through
exchanges as the different stakeholders interact during the codesign (David, Sabiescu & Cantoni, 2013). When there is a
large design reality gap then the proposed ICT system will most
probably fail since it will not function in practice as anticipated
(Heeks, 2009). Heeks (2009) suggests that the participation of
the local users; appropriate technology mix based on the local
context; alignment to local development goals; and
consideration of project risks during the design should result in
more successful ISD4D projects.
Caregivers participated satisfactorily within the initial product
design phase. However, they were mostly passive during the
development phase of the application. These observations of the
extent of participation by the different actors introduced an
intellectual puzzle: what was different between the design and
development phases? The author therefore considers ‘design’
and ‘development’ as the two primary phases of the application
prototype. Other project phases – e.g. an initial needs analysis
and the final testing phase – are considered elsewhere as
discrete cycles (Delen, 2010; Van Zyl & De la Harpe, 2011).
The approach of Diaz Andrade and Urquhart (2010) was
selected for analysing the design and development phases, i.e.
the translation process. Based on this approach the objective for
this paper is to investigate whether the actants’ interests were
sufficient throughout the design and development phases of the
mobile care data application. Secondly, the author considers
whether the modus operandi of the project was appropriate in
order to establish the networks of participation in a developing
context.
Actor-network theory (ANT) was considered as a possible
analytical lens to establish some insights in the formation of
stable networks aligned around mutual interests. It was decided
to separate the design and development phases to focus on the
differences between these two phases since the level of
participation changed after the first phase. The symmetry aspect
of ANT provides a possibility to follow both human and nonhuman actors – referred to as ‘actants’ – as equal participants.
ANT is a descriptive lens, telling the stories of “how” relations
between actants assemble or not (Law, 2009).
Actor-network theory (ANT) has been used in information
systems research but not much with development studies
(Heeks, 2013). Heeks (2013) suggests that ANT can provide
new insights by describing processes in detail to study the
emergence of actor-network structures as well as allowing nonhumans an active materiality to expose the role they play in
development. This will help to understand agency, process and
relations among development actors better. It is this aspect of
ANT that is used in this study to understand the role of the nonhumans during the design and development of the mobile
application, namely as the IT artefacts, in terms of their level of
participation and their responses during the translation
moments.
This study draws from social and artificial sciences where, in
the case of social sciences, knowledge creation is subjective and
about human behaviour. The caregivers will use their
knowledge and common sense during their care activities by
giving meaning to them whilst responding to the context of
their environment, in this case typical of a developing context.
The concept of artificial sciences, introduced by Simon (1996)
is knowledge about how things could be (utility) through a
design process as opposed to natural sciences where knowledge
is about how things are (truth). The moment the designed
artefacts are being used, the focus changes to social sciences
where the behaviour of people using the artefacts is considered.
Examples of IT artefacts during design are models, constructs,
methods and instantiations (Hevner, March, Park & Ram,
2004).
The theoretical contribution for this study is based on a
framework proposed by Kuechler and Vaishnavi (2012) for
studies in design science research in information systems
(DSRIS) although in this study with consideration of the
developing context. They based their framework on Gregor’s
(2006) taxonomy of information systems theory. Furthermore
Gregor published with several colleagues on the theoretical
contribution of design science research in information systems
based on the initial work of March and Smith (1995) and
Hevner, et al. (2004). The general activities of the DSRIS
framework are: the construction of the artefact; the gathering of
data on the functional performance of the artefact or the
evaluation; and reflections on the construction process. This
study’s focus is only on the construction activity which is the
design and development of a mobile application for care data.
During the construction of the IT artefact prescriptive
knowledge is generated, which Gregor, Muller and Seidel
(2013) suggest is based on two constructs, namely, the problem
and solution constructs in both the instance and abstract
domains. Livari (2007) suggests that prescriptive knowledge is
its own form of knowledge that cannot be reducible to
descriptive knowledge. Descriptive knowledge is composed of
observations, measurements classified into accessible forms
(Gregor & Hevner, 2013). Prescriptive knowledge of the design
is presented as design principles of both form and function.
During the evaluation and reflection activities descriptive
knowledge is generated that Gregor and Baskerville (2012)
refer to as the following research activities for descriptive
theorizing: study of the artefact in use and test of knowledge of
the artefact in use. The reflective questions they suggest for
extracting theory for the different design components will be
used to suggest the theoretical contribution of this paper.
Although design science research has been used in information
systems before (Hevner, et al., 2004), publications, specifically
about the theoretical aspect of this approach, have only been
published more recently.
2. RELATED RESEARCH
2.1 Mobile Health (m-health)
mHealth is a component of eHealth and to date, no standardised
definition of m-Hhealth has been established (WHO, 2011). The
Global Observatory for eHealth (GOe) defines mHealth as
medical and public health practice supported by mobile devices,
such as mobile phones, patient monitoring devices, personal
digital assistants (PDAs), and other wireless devices. In terms
of healthcare, there is a need for a healthcare system that is
usable anytime, anyplace and by anyone authorised (Junglas,
Abraham & Ives, 2009; Katz & Rice, 2009). mHealth enables
the connecting of different communities to exchange data and
experience using mobile technologies. It also supports the shift
from treating acute and chronic diseases to disease prevention
and wellness promotion. South Africa has a large number of lay
health workers and most of the population also have mobile
phones or access to mobile phones and these phones can
therefore be used to improve service delivery of community
health care services – this is known as mobile health for
community based services or mHealth4CBS (Leon &
Schneider, 2012). They Leon and Schneider (2012) identified a
few challenges for mHealth4CBS and the two relevant to this
study are the poor documentation of mobile applications and
Commented [HA1]: This doesn’t make sense as is, Does the
author mean “the actants’ interests were sufficiently considered
throughout” or “whether the actants were sufficiently interested
throughout”?
best practices as well as the challenge of identifying and using
affordable open-source options.
Drivers for mHealth applications are socio-economic rather
than technical (Mirza, Norris & Stockdale, 2008; Norris,
Stockdale & Sharma, 2009). A single-solution focus on
mHealth should be replaced with it being an extension and
integrator of underlying health information systems that
support, e.g., the point-of-care for health workers (Mecheal &
Searle, 2010). Mecheal and Searle further suggest that mHealth
applications should be interoperable and integrated with
provider systems linking the most remote health worker with
the most appropriate sources of information when and where
needed. The individual care data at the home and facility level
can then be aggregated to serve as a basis for health
information.
Even though the drivers for mHealth applications are socioeconomic rather than technical, the application is still regarded
as an IT artefact. The artefact is an embodied structure, where
its structural properties include the pattern, rules and resources
inscribed during the design and development process resulting
in a relatively immutable result output (Gregor & Livari,2007;
Widjaja & Balbo, 2006). This may assume that technologies
embody specific stable structures (Orlikowski, 2000) or being
regarded as black boxed. Orlikowski however, argues that such
assumptions of technological stability, completeness and
predictability with a predefined anticipated use are not true in
practice where people modify technologies to fit their use in
practice. Software developers use existing technologies to
develop new technologies as applications, e.g. database
management systems, web services, etc. These technologies
with their anticipated in-use inscriptions may then be used
differently in practice – the appropriation of an artefact is the
combination of embodiment in-design and enactment in-use in a
specific situation, or at least to what extent the technology
allows it to be used differently (Orlikowski, 2000; Widjaja &
Balbo, 2006). An mHealth application is the result of the design
and development process based on the identified anticipated use
with the use of other technology artefacts.
2.2 Participatory Design (PD)
Participatory design (PD) is about both the process of design –
with the active participation of all participants – and research.
The outcomes of design includes artefacts, systems, services,
and the like. The outcome of research is knowledge (Spinuzzi,
2005). PD allows for participants’ interpretations to be taken
into account by envisioning, shaping and transcending the
activities until all agree with the outcomes. The participants in
PD are equal in a network aligned around a mutual interest to
create new designs and knowledge. Mosavel, Simon, Van Stade
and Buchbinder (2005) argue that the input and involvement of
community stakeholders are essential for successful research.
Community-based participatory research (CBPR) seeks, in
addition to knowledge creation, action and change as its
primary goals. Winning the trust of respective communities is
integral in the co-design philosophy. Health interventions,
therefore, need to address the multiple anxieties and lived
reality of that community (Bailur, 2007; Mosavel et al., 2005).
The participation process for this study started with forming a
trust relationship with the home-based healthcare service
provider and the participation design sessions were conducted
in their work space to cater for their lived reality.
Hussain, Sanders and Steinert (2012) identify the following
differentiating circumstances when designing with the
participation of marginalised people, namely: human; social,
cultural and religious; financial and timeframe; and
organisational. When cConsidering social development during
PD, attention needs to be given to the participatory process
(Byrne & Sahay, 2007). Their Byrne and Sahay’s (2007)
findings for the PD of a community-based health information
system indicate that it is necessary to go beyond end user
participation to also consider the persons affected through the
delivery. In the case of healthcare services the patients will be
the indirect beneficiaries of any interventions that will assist
caregivers in their care services. They also suggest that a
multilevel and multisectoral approach should be adopted and
that reflective practices to develop capacity should be enhanced.
Bailur (2007) concludes that community participation in
developing contexts is more complex than have has been
reported in the literature.
The level of participation is not always the same during all the
phases of a project (extent); it may include all the users or
representatives of users and the content may include technical,
social aspects or both (Maail, 2011). He Maail (2011) further
suggests that user participation should correspond to the
conditional factors of the context of the system development
that should rather be regarded as the optimal level of
participation than a high degree of participation. In this study it
was practical for the caregivers to participate corresponding to
the conditional factors of the mHealth application design and
development.
It is important to understand the work processes on a clinical
level before developing IT solutions for the complex
cooperative and interdisciplinary work associated with homecare services (Hägglund, Scandurra & Koch, 2010). A
participatory approach allows for the active participation
between the healthcare professionals and developers to obtain a
common understanding of the work processes in practice.
Hochheiser and Lasar (2007) caution against a focus purely on
the design of a user interface that will result in a lack of
considerations of the social, political, ethical, and societal
implications of computer systems.
Mobile development is faced with the following challenges:
to create user interfaces accessible to differently-abled users; to
handle the complexity of developing applications across
multiple mobile platforms; the need to consider context-aware
applications; and to deal with the uncertainty of specifying
requirements (Dhelinger & Dixon, 2011). Wasserman (2011)
notes that mMost mobile applications are still developed by
small teams who rarely use any formal development processes
(Wasserman, 2011). He further indicates that developers did
limited organised tracking of their development efforts and that
the existing body of knowledge is mostly pragmatic with
guidelines and code examples. This could pose a problem to
novice developers who need to consult with existing practices
and examples and this is even more problematic if the existing
limited development guidelines and code are not suitable for a
developing context. Charland and Leroux (2011) suggest the
consideration of the context (hardware, input, capability,
platform, conventions of each platform and environment) and
the implementation where the designs and code are delivered to
support the user experiences, in this case the caregivers during
their service provision. During execution time performance
needs to be considered. According to Mengesha (2010)
information systems development and implementation should
be regarded as a complex sociotechnical process and even more
so in a developing context.
All of the above aspects are considered in this paper in an
attempt to understand the perceived difficulties observed during
the design and development of the mobile application.
2.3 Actor-Nnetwork Theory (ANT)
Actor-network theory (ANT) evolved from the work by Callon
and Latour at the Ecole des Mines in Paris during the
1980seighties of the previous century (Callon, 1986; Latour,
1987). Important contributions are also made by Law (1992,
2009). ANT proposes a theory that does not privilege either
humans (actors) and or non-human actors (actants) over the
other and denies that purely technical or purely social relations
are possible. Heeks and Stanforth (2013) use ANT to provide
details about the process of technological change by “opening”
the black box of such a change. De Albuquerque, Cukierman,
Marques and Marques (2013) consider how technology moves
from the global North to the global South where such
technologies are often black-boxed based on their use in the
global North. The issue then is to consider how one can
distinguish between questions to do with the materials of
development and those to do with the strategy of development.
This study considers the development of an mHealth
application, with the use of technologies typically developed in
the global North, to be developed and used in a developing
context in the global South. The network of actors is considered
with a specific focus on the translation as they enter, (or resist
to entering), the network.
Translation has its origin in the social studies of science and
deals with how statements become facts and how that only
happens when other people accept and/or use it (Whitley &
Pouloudi, 2001). Whitley and Pouloudi further state that the
creation of facts is a collective process – translations are the
result of recording the viewpoints of the different participating
actors of the network. This process necessarily entails
interactions and negotiations between actors before any kind of
agreement can be reached about common definitions and
meanings (Warzynski, 2006). Successful translation occurs
when all the ‘voices’ speak in unison, i.e., when all agree to the
same aligned interest. By studying the translation process, it is
possible to determine to what extent the different actors are
identified and consulted. Translations may have implications for
the role and relationships of the actors within the network when
the impact of the organisation and/or stakeholders is considered
as the actors react to changes (Whitley & Pouloudi, 2001).
Problematisation is the first translation moment and can be
regarded as “how to become indispensable”. The focal actor, the
actor from whose vantage point the process is conducted,
establishes an interest that is primarily of interest to the focal
actor, but could be useful to other actors. The second translation
moment is to build an interest (“interessement”) which refers to
how the allies are locked into place in order to form a network
and to strengthen new actors’ links with the network. The third
translation moment is enrolment which refers to how other
actors decide to become part of the network. This means that
other actors are convinced that they can benefit by joining the
network and this happens when individual actors align their
own interests to that of the focal actor. They may do this
willingly or may be cajoled into joining the network. The final
moment of translation is when actors who have previously been
enrolled, become spokespersons in their own right of the focal
actor’s interest. While it is also possible that during this stage
some actors may leave the network if they feel that their
interests can no longer be sufficiently aligned with the interest
of the network, the ultimate goal of institutionalisation becomes
more of an achievable goal.
It is possible that a translation moment may fail. From a
research perspective, this is also important because explanations
and insights into how and why it failed could lead to a deeper
understanding of the interaction processes involved. ANT
allows us to model mistranslation as a possible intentional
betrayal and the reasons for this may be relevant for the
research to identify important obstacles.
3. PARTICIPATORY DESIGN AND
DEVELOPMENT OF A MOBILE CARE
DATA APPLICATION
3.1 The Context of Home-based Healthcare
Home-based healthcare in South Africa addresses the
overwhelming need for services related to the high incidence of
HIV/AIDS, TB and other poverty-related conditions
experienced in resource-restricted communities (Coovadia,
Jewkes, Barron, Sanders,& McIntyre, 2009; Erasmus, 2009;
Jack, Jenkins & Enslin, 2010; Shozi, 2012). The public
healthcare service is responsible for healthcare service
provision to the majority of the population. Formal healthcare
facilities, however, cannot meet the demand for these services
(Van Zyl, 2011). Home-based healthcare addresses this
demand, and is mostly offered by non-government
organisations. Home-based healthcare institutions rely on
external donations since patients in most cases cannot afford to
pay for delivered services (ibid.). Home-based healthcare
services are provided by informal caregivers with basic training.
In some cases, they are supported by professional nurses.
The recording of patient data is still paper-based and very
time-consuming (Van Zyl, 2011). Caregivers are generally
semi-literate and many of their patients are illiterate. There is
limited electricity in these communities but most people have a
mobile phone or have access to one. These are mostly feature
phones with limited functionality (Van Zyl & De la Harpe,
2011).
3.2 Research Methodology
The research strategy considered for this study is design science
research with a participatory approach. The research was started
with an ethnographic study of home-based healthcare services
in a developing context (Van Zyl, 2011). During this stage a
relationship was built with the NGO providing the care services
and only when this study was completed was the design process
was started. Data for the design was collected during the
problematisation and ideation phases with the use of design
probes. Other data collection methods were observations and
open-ended interviews. Several service design methods were
used during the different participatory co-design sessions. For
the purpose of this paper, the co-design stage with the low
fidelity (lo-fi) prototype is considered as the design concept for
designing the mobile user interface and navigation between the
different screens (Delen, 2010). A lo-fi prototype, in this case a
paper mock-up of the typical mobile phones used by caregivers,
wais used to facilitate discussion of user interface concepts and
design alternatives (Memmel, Reiterer & Holzinger, 2007).
The data was analysed by extracting the design principles
and reflection on the design sessions and methods used. The
qualitative data was coded and categorised to identify themes
that were then interpreted. In addition, the author, who
supervised the students with their post-graduate studies for this
case as well as the practical project of designing and developing
the mHealth application, did a meta-analysis at an ‘etic’ level of
the different activities (Kottak, 2007).
The practical design and development was done by a team of
intern students. The team consisted of an anthropologist,
designer and IT analyst, all three masters’ students. The rest of
the team was compiled of IT students. All the members of the
team were novices since they did not have any work experience.
The IT interns were not only novice developers but also came
from a developing context background.
3.3 The Participatory Design Phase
A community in the Western Cape of South Africa was selected
for this case. The research team built a relationship with a
home-based care NGO (hospice) in the area. This proved
challenging; the staff was sceptical of the many promises made
by different groups to improve their situation without their
expectations being met. The team explained that it was there to
work towards possible solutions that could improve their work
conditions. The participatory design process was explained to
them to convince them of their active role in the co-design
process. The main objective of the design phase was to identify
a real need and to then co-design a possible solution with the
active participation of the caregivers.
Using a lo-fi prototype saves valuable time and costs of
programming fully electronic prototypes and is a useful
mechanism to present abstract concepts to users with low digital
literacy as a mock-up of possible ideas. The caregivers were
able to design their own dialogue and suggest navigation
options. In Figure 1 an example of a lo-fi prototype with where
the suggested dialogue is given. The dialogue in the sequence of
the five screens is as follows: 1) Ccaregiver login; 2) Eenter
patient number; 3) Patient details; 4) Observations: temp __°C;
H/R __ bpm; 5) Care Plan: Clean wound √; Ointment √;
Dressing X.
Figure 1. Prototyping Scenario
3.4 The Development Phase
The development was done by Information Technology (IT)IT
interns from the local university who were mostly third and
fourth year students working in an incubation hub and paid a
monthly stipend. This hub was used as an interactive design
space, where top students from different disciplines, levels, and
cultural frameworks worked together on developing mobile
applications for real-life problems. Funding was obtained to
develop a practical application. The developers converted the
designs created during the design phase into code for the
proposed mobile application to capture, report and share patient
care data. The interns had no prior experience and were novices
in the project. Since the developers were from a developing
context, they were familiar with the socio-economic challenges
experienced by the caregivers. The developers were involved
from the beginning of the design process as active participants.
4. USING ANT AS AN ANALYTICAL
LENS
The term actant is used for both human actors and technology
actants when discussing their role in the actor-network. Where
necessary a distinction will be made. The following actants are
considered for the design phase: caregiver, designer, developer,
current paper forms (care record, care daily report, care monthly
report); lo-fi prototype as the design concept; care tasks; and
work tasks (design mobile interface; and recall care data
recording). The focal actor role was mostly performed by the
designer who explained the different methods as well as
facilitating the co-design sessions. The one developer could
speak the language used by most caregivers (Xhosa) and was
therefore able to act as a translator when necessary. This helped
to overcome the language barrier (Hussain et al., 2012).
The main actants for the development phase were: developers,
designer, caregivers as the end-users; the development platform;
database; designs; specifications; hand held devices; source
code; documentation; prototypes; development and testing
tasks; work tasks (design technical components, interfaces,
etc.); code; test; and document. Mobile technology includes
handsets, computers, servers, software and bandwidth
connectivity, different systems or protocols for communicating
signals that could include GPS, general packet radio
serviceGPRS, USSD, and Bluetooth (Leon & Schneider, 2012).
4.1 Problematisation
The designer explained the need to design the mobile user
interface to the caregivers participating on behalf of the others
and became the gatekeeper of the co-design process. The
aligned interest was to design the user interface together and
introduced the lo-fi prototype was introduced as a useful actant
to help them with the co-design process. The designer also
convinced the developers that the proposed co-design method
would result in a better design for the mobile user interface. The
current paper forms used for recording the care details of the
patients were also introduced as actants for the co-design
process. T and the care tasks and work tasks to design the
mobile user interface and how they recalled the recording of
care data also became actants required for the co-design
process.
During the development phase the designer acted as the focal
actor introducing the design to the developers as part of aligning
the interest to develop the mobile prototype. The question posed
to the developers was how to develop the mobile prototype
based on the design to simplify the capturing and reporting of
patient data by caregivers. The participation of the developers
during the co-design phase allowed them to already have their
interests aligned to the problem. The technology actants were
required for converting, through a series of translations, the
design into the mobile prototype. It was already clear at this
stage that the mobile prototype would consist of many parts to
support the user interface design as could be seen from the
number of technology actants required. These different parts of
the prototype – e.g., user interface, database, backend code, and
the like – are all separate technology actants interacting with
each other as well. The developers became the designer’s main
allies since they participated in the co-design phase and were
therefore familiar with the design created as an outcome of the
design phase.
4.2 Interessement
The designer planned the co-design sessions carefully and had a
few meetings with the relevant stakeholders to convince them
of the importance of the co-design session. After the co-design
sessions, the designer reflected on the design process and
designs created to plan for the next sessions. There were no
actants who were not interested in the proposed session and this
is probably because the decision for the mobile application was
taken by the facility management and the co-design sessions
were arranged to be during the regular training sessions. No
specific incentives were used and it was observed that the
caregivers enjoyed the participation process since it provided
them with recognition for the important work they are doing.
The other actants from the development team and design
concepts were properly introduced and relationships formed
through the interaction sessions. The facility manager and carecoordinator became valuable allies since they supported the
project and even participated in the co-design process from
time-to-time. The use of the lo-fi prototype allowed current care
data recording practices to be challenged and for new
possibilities to be introduced and considered that were easy for
the caregivers to relate to their potential use.
The designer not only put together a convincing case for the
developers but the outcome of the co-design already created an
expectation by the end-users, (the caregivers,) of how they
could benefit from the proposed mobile care data application.
Although the technology actants were identified to be crucial
for the development of the mobile prototype, the purposes for
which they were originally designed were not completely
aligned with the purpose for how they would be used in this
case. In the original design the manners in which they were to
be used were inscribed in them and since mobile development
was new, these actants’ purposes were not well-aligned to
mobile development. It became increasingly more difficult for
the designer to interact with the technology actants since he was
not familiar with the technical aspects of development. At this
point the end-users, (the caregivers), were also unable to
participate because they were lost with the technical aspects of
the process. The developers took over the role of focal actors
with the designer and end-users “leaving” the network. This
aspect is important and will be discussed further on.
4.3 Enrolment
It was not necessary to persuade and convince the actants to
participate in the co-design sessions since they related well to
each other and the lo-fi-prototype made it possible for them to
interact with an abstract concept of interface design in a real
manner allowing them to make suggestions. The developers
also related well to the method which was new to them and
interacted with the caregivers without dominating the co-design
session. The roles of all the participants were clear and the lo-fiprototype made the bargaining and compromising process
easier to manage.
The enrolment of the actants in the development network was
problematic. The identified technology actants were necessary
for the development of the mobile prototype but because they
were designed with specific inscriptions for specific uses that
were difficult to adapt to mobile development in this context,
they, in a way, resisted enrolment. These technology
components were typically developed as IT artefacts to assist
with development but did not seem to be appropriate for a
developing context. This resulted in a continuous process of
negotiations between the developers and technology actants that
could be seen as processes of translations for the developers to
learn how to use these actants and for the actants to respond in
ways that made it possible for them to be used for developing
the mobile prototype. In addition to the essential technology
actants the developers also continuously experimented with
other technologies therefore replacing some of the technology
actants with others. These replacements resulted in the need for
new enrolment strategies, i.e. the new technology actant had to
be considered for the problem, being “made” interested before
being enrolled into the network. These negotiations seemed to
exclude the designer and end-users from the network because
they did not seem to understand the “technology” language used
by the developers interacting with the technology actants. The
developers continuously had to learn how to use the different
technologies and were unable to translate that to the designer
and end-users.
4.4 Mobilisation
The design network became stable after all the actants
progressed through the translation moments and the designer
became the spokesperson for the network. He was able to do
this since he understood the purpose of the method and was able
to present the user interface design as the outcome of the codesign sessions. He was able to translate the perceived care data
recording activities on paper to the anticipated activities in the
mobile application. The caregivers who did not participate in
the co-design sessions were well-represented because their care
activities were standardised by the facility. They also mostly
had the same background and training.
It took a long time for the development network to become
stable and most of the negotiations between the developers and
technology actants were invisible in terms of the progress
during the development phase. The emulator software
specifically was a technology actant that resisted its use since
the emulation that worked on the computer did not work in the
same way on the handheld mobile devices. Even code that
worked on one device, e.g. Nokia, did not work the same way
on another device, e.g. Samsung. Writing code for feature
mobile phones was extremely difficult because there were no
other examples of how this could be done. It seemed that smart
phones quickly became the preferred mobile devices in the
global North and that may be the reason for the lack of
examples for feature phones. Testing was a challenge due to
connectivity issues; differences in mobile phones (– there were
no standards); transferring data to the backend system; etc. The
continuous replacement of some of the technology actants to
experiment with them resulted in the network remaining
unstable with difficulties for the actants to remain enrolled. This
resulted in a situation where it took a very long time for the
network to reach a mobilised stage. There was not a specific
spokesperson for the development network since different
interns worked on different parts of the development until a
project coordinator was formally appointed. This person then
became the spokesperson for the network. The end-users and
designer, who were no longer enrolled in the development
network, had to be re-enrolled to test the usability of the mobile
prototype. It was a new negotiation process that required again
an alignment of interest. An example was when the developers
illustrated the prototype and it did not work because of
connectivity, version and server issues resulting in the end-users
being perplexed when the developers used a “technocratic”
approach – “it does work, you just press here and then…”. It
seems as if the end-users never re-enrolled in the development
network and this problem now has to be addressed during the
deployment phase with a specific strategy to enrol the end-users
again.
5. DISCUSSION
5.1 Alignment
According to Diaz Andrade and Urquhart (2010), alignment is
to what extent actants agree to translation. Through these
translations the actants move towards an agreed aligned interest.
The stability of the network depends on how well the interests
are aligned to the interest that describes the purpose of the
network. It can also be regarded as when the network grows
with continuously more actants being enrolled than actants
leaving the network.
In the case of the design network it was clear that the
translations were supported by the use of the lo-fi prototype –
this actant played an important role in assisting with the
translation process between the end-users and designer that
resulted in the creation of another actant, the design of the
proposed mobile prototype. The outcome of the design network
not only resulted in a stable well-aligned network but also in the
enrolment of an actant that was created based on the successful
translations of the other actants, namely the design for the
mobile interface. One can therefore conclude that the co-design
process was successful and that design concepts are useful
actants that can assist with translation of abstract concepts such
as converting the recording of patient data on a paper care
record to a recording it electronically with a mobile application.
Another finding is that a design was created as a good
representation of the anticipated use as a result of successful
alignment of the actants of the design network. The
embodiment in-design is therefore close to the possible
enactment in-practice.
The alignment of the development network was problematic
with the technology actants making translations more difficult.
The alignment between the developers and technology actants
required many translations, some miss-translations when the
conversion of the design into the prototype just did not work.
The technology actants are the results of the creation of these
artefacts based on how they will be usedthe uses that are
inscribed into them – this also was the result of a process of
translations and thus alignment but for another purpose. Using
these actants for mobile development required them to be used
differently to their original intended use and that resulted in the
need for many translations between the developers and
technology actants to align them to the conversion of the mobile
prototype based on the design of the prototype. The processes,
interests, identities, values, etc. inscribed in the technology
components used for developing the mobile prototype were not
suitable for a developing context. The reason why the end-users
and designer were excluded from the alignment process of the
development network was that the translations required by the
development process were just too technical to them. Again the
mobile prototype is a new actant that is the result of the
alignment of the other actants, and how good it is will depend
on how well the prototype represents the design of the mobile
interface as the representation of the anticipated use.
It is possible that the technology actant can influence the
outcome of the development of the mobile prototype if, for
example, the backend technical design cannot support the
navigation required by the user interface design. The design of
the mobile interface only represents the part of the interface
visible to the end-users as that is the only part that concerns
them directly. In reality this design has to be supported by
additional technical designs of the other parts of the mobile
prototype, e.g., database design, activity diagrams, workflow
designs, etc. These technical designs are introduced during the
development phase as the outcome, i.e. new actants of the
network, of the interactions between the developers and the
technology actants required to do these designs. These
technology parts of the mobile prototype are essential for the
mobile application to work and all contributed to the formation
of the development network as they are enrolled.
The translation of the design into the mobile prototype is
complex and requires many translations between the
developers, technology actants and designer. The new actants
created through the alignment process are also technical and
may not always be a good representation of the design.
5.2 Coordination
Coordination is the degree to which the interpretive flexibility is
restricted by rules or conventions (Diaz Andrade & Urquhart,
2010). In the case of the design network the interpretive
flexibility was influenced by the lack of technology knowledge
of the end-users rather than rules and conventions of the design
process. Participatory design implies that the design process is
started with no pre-conceived idea of the solution but to allow
the end-users to determine the pace and direction of the process
with the designer being more in the role of facilitator suggesting
possibilities with the use of design concepts. The use of the lofi prototype made the interpretation easier because the
caregivers could relate to it without feeling intimidated by
technology. This allowed them to experiment with different
options for the navigation, displayed text and options for
entering the care-patient data. The designer was given the
opportunity to learn the “language” of the caregivers in their
own environment and to observe their work practices – this
provided him with a better understanding of the possible
solutions for their data capturing problems.
The co-design process allowed for interpretive flexibility by
continuously responding to the environment in which the
process took place. Although the design process was not
influenced by rules and conventions, the manner in which the
caregivers capture the patient data and the type of data recorded
and reported are restricted by the rules and conventions of their
work practices that again have to comply to the rules and
conventions of the healthcare professional practices as well as
to the legal requirements of the authorities to which the homebased healthcare service provider reports.
In the case of the development network the interpretive
flexibility was influenced and mostly restricted by how the rules
and conventions were inscribed into the technology actants for
their specific uses that could not easily be adapted for mobile
development. The definitions of patient data; data transmission
protocols; coding and other standards; etc. have to comply with
the rules and conventions of the agreed standards of software
development. These rules and conventions do not only have to
be considered but are inscribed into the different technical
designs and the mobile prototype, i.e. the new technology
actants will have these inscribed into them. There were also not
yet any standards for mobile development that could be used by
the developers.
5.3 Devices and Passages
The main activities of home-based healthcare are to provide
care services to patients at their homes. A sub- activity is the
recording, reporting and sharing of care patient data which is
still paper-based in most communities. The care patient data
represents the details of the patient’s diagnosis, observations
and care activities and can be regarded as the substantive device
for aligning a network around home-based healthcare. During
the design phase the representation of the care data, i.e., the
design of interface to the data can be regarded as the substantive
device to align the network around the interest to facilitate
easier data recording and processing. The means supporting the
design is the design concept, in this case the lo-fi prototype and
the procedural device to facilitate coordination and
communication around the design is co-design activities to
design the navigation of the identified data elements according
to the work practices associated with the care data recording of
the patient.
During the development phase the actants are enrolled into
the network around an interest to convert the design of the care
data interface into a mobile care data prototype. The substantive
device in this case is the representations of the caregivers
anticipated care data processes and the means for this are the
different technology actants that support the coding into the
mobile prototype. The procedural devices are the interactions
between the developers, the technical tools and each other to
develop the code for the prototype.
5.4 Applying ANT
ANT provides the mechanism to follow the actants of the
design and development phases to establish to what extent they
participated in the respective networks. This provided insights
in the design and development processes and specifically how
the technology actants made the participation easier as in the
case of the lo-fi prototype in the design network and more
difficult in the case of the development network. This could be
contributed to the fact that mobile development is not yet
matured as indicated in the literature and that the learning
process made participation with the technology actants more
difficult – one can assume that knowing how to use the tools
(technology actants) should makde the development easier. The
social learning during the design phase applied to all the
participants – the designer and developers learnt more about the
caregivers’ data capturing practices and the caregivers learnt
more about the possible technology solution. Social learning
during the development phase was mostly applicable to the
developers who learnt more about the use of the technology
actants but the learning could not be shared with the designer or
end-users. The challenge here seems to be the difficulty in
communicating the technology actants’ roles to the actors
without the technological background. The developers involved
in ICT solutions for developing contexts may not have the
necessary technical knowledge or access to materials that could
guide them and therefore may struggle to use the technology
components in the way their use is already inscribed. It is then
possible that the design-reality gap may increase when the
technology and environmental constraints influence the
translation from the design to the ICT solution.
Another reason for the challenges experienced during the
development phase is that the inscriptions of the technology
artefacts used for the development, may not support the way
they should be used in mobile development. The participation
approach worked well during the design phase and all the
actants actively participated in the process. The technology
actants had to be adapted to be used in the particular context
that was constrainted by socio-economic factors. The lack of
involvement of the caregivers, as the representatives of the
community considered, not only affected the development
process negatively but also influenced the research outcomes
even though the lived reality of the community was inscribed in
the design outcome (Mosavel et al., 2005). It may be necessary
to consider the involvement of participants without the
necessary technical knowledge to see how they can participate
during the development stage. It is possible that the level of
participation during the development may be lower due to the
nature of the development process and in this case it may be
necessary to determine the optimal level of participation of all
participants to proceed with the process without the end-users
becoming totally uninvolved.
In both the design and development networks new actants
were created as the result of the participation of the other
actants and it can be concluded that the level of participation
will determine the quality of these new actants (design and
mobile prototype). Having this view can assist with dealing
with the context when similar solutions are considered for other
contexts – the focus then on the participatory process where the
designs and prototypes are actants of new networks where the
outcome could be different.
Responding specifically to the use of ANT in developing
studies, it was possible to describe the design and development
processes in detail to show how the actor-network structures
emerged (Heeks, 2013). It was also possible to expose the roles
that the IT artefacts play in development. The IT artefacts that
could not so easily be adapted to the developing context as the
design probe did, resulted in several difficulties experienced
during the development of the mHealth application.
Contributing to this problem was the inexperienced developers
who could not easily learn how to use the IT artefacts in
development. In a developing context there will often be less
experienced developers who do not have the luxury of being
sent for expensive training by their companies or who are not
able to work in teams with more experienced developers. The
black box nature of IT artefacts used during development
influences the manner in which they enrol in the network since
the purpose for which they were designed may not be well
aligned to that of developing a mobile application in a
developing context.
It was also interesting to note that the spokesperson of the
network during the mobilisation translation moments changed
from the designer to a developer and it will be interesting to see
if the spokesperson of the eventual solution would be a
community representative. Studying the level of participation
and especially the “failed” translation moments should provide
more insights on aspects that need attention as can be seen by
the alignment problems of the development network.
Table 1, appended as Appendix A to this paper, presents the
key findings of the alignment, coordination, devices and
passages of the design and development networks with possible
implications.
6. THEORETICAL CONTRIBUTION
This study considered the following cognate disciplines:
information systems, development studies and design. It used a
DSRIS framework to allow for theory development. The DSRIS
framework does not provide for development studies and the
suggestions of Gregor et al. (2006, 2012, 2013) also do not
consider development studies specifically. There is therefore a
need to develop a framework that also provides for
development studies, maybe a DSRIS4D? The use of ANT as a
suitable lens for development studies as suggested by Heeks
(2013) is an attempt to also include the insights gained from this
analysis.
The framework proposed by Gregor et al. (2013) is now used
to extract design theory from this study for the following design
theory components: purpose and scope; principles of form; and
principles of function.
The problems the researchers originally perceived were that
care services were hampered by the manual data recording;
many mistakes were made when completing the paper forms;
and this data recording process was very time-consuming. The
problem was not identified by the caregivers since they work in
a resource restricted setting that does not allow for “nice-tohave” solutions. Their current paper-based system works and
supports the care services. In a developing context it may often
be the case that people accept a situation because there are not
resources to improve the situation. The proposed mobile
application is not a novel solution but developing a solution that
is appropriate for their situation provided a utility value – a
mobile application could be useful and has the potential to
improve the quality of care services in developing contexts and
result in better quality data for decision making. The design
concept was the mobile care data application (CDA) and the
focus with the caregivers’ participation was on the user
interface. The concepts came from a developing context and it
was possible to reach a proof-of-concept stage. The evaluation
in practice was outside the scope of this paper. There are
potential problems that could influence the actual
implementation of the mobile application that were identified
from the ethnography study and theseat are: connectivity issues;
cost of the mobile application; crime target (if criminals hurt
caregivers to steal their mobile phone), etc.
The principles of form are the material properties built into
the artefact to enable it to achieve its purpose. The principles of
form observed are the menu design based on the users’
preferences for the data capturing sequence; data elements on
the screen should be minimal and easy to navigate; and familiar
terminology should be used. Rather use drop-down lists than
entering text; use, where possible, short-cut keys, e.g. #3. Care
plan; the use of directional buttons (up, down, left and right) for
selection of options; to enter the minimum text. The contextual
conditions observed to enable the emergence of the desired
affordances are the type of mobile devices used by the
caregivers that is typical of a developing context, e.g. feature
phones; and the data collected are the data observations typical
of a developing context, e.g., has the patient taken the medicine;
is there enough food; are the children looked after, etc. The
caregivers, as the user group, perceive the functional
affordances of the artefact that represent their care activities.
The active level of participation of the care- givers provides the
justificatory knowledge that the material properties should
achieve the artefact’s goals.
The principles of function are difficult to present since the
artefact was never implemented to be used in practice. During
the testing phase it was difficult for the users to see how the
artefact could be used in practice since there were technical
problems, e.g., there was a problem for the mobile phone to
connect to the server; there were version problems – it was clear
that the gap between the lo-fi prototype and actual mobile
application was too big since the users were not participating
during the development stage. The necessary actions to bring
about the desired outcomes are to find a way to make the
development activities more visible to the users without
exposing them unnecessarily to the technical aspects of
development.
Responding specifically to the use of ANT in developing
studies, it was possible to describe the design and development
processes in detail to show how the actor-network structures
emerged (Heeks, 2013). It was also possible to expose the roles
that the IT artefacts play in development. The IT artefacts could
not so easily be adapted to the developing context as with the
design probe, resulting in several difficulties experienced during
the development of the mHealth application. Contributing to
this problem was the inexperienced developers who could not
easily learn how to use the IT artefacts in development. The
black box nature of IT artefacts used during development makes
it difficult to “open” it to adapt components for more
appropriate use. It therefore seems that it is necessary to
develop an IT “toolkit” with IT artefacts that are more suitable
for the developing context or at least have a repository with
such tools with sufficient guidelines to use them.
Reflecting on this research the following were observed: it is
important to build a relationship with the user group or
representing organisation before starting with the design
process. There are far too many empty promises made to
communities in need or too many solutions with limited utility
value “given” to them. Once the relationship is strong the users
must become active co-designers of their own solutions with the
designer/developer more in a facilitating role. It is important to
design the solution first to a point where the possible solution is
a good representation of what can be expected when it is
completed before starting with the development of the IT
artefact. Developers should be involved in the co-design
sessions to obtain a good understanding of the required solution
but also to learn more about the users’ mental processes.
Specific IT artefacts that are suitable for a developing context
should be developed to be used as developing tools during the
development process. These development tools should be more
flexible, easy to be used and shared by less experienced
developers.
7. CONCLUSION
Actor-network theory provided a sufficient mechanism to
establish how actants participated during the design and
development phases of a prototype for a mobile care data
application and the stories of the relations between the actants
and the level to which these relations were formed were part of
this descriptive study. Design science research is a suitable
research strategy and the participatory design a suitable
approach for these kinds of development for information
systems. This approach provides for the considerations of the
context by giving the community representatives a voice. Even
though the evaluation and reflection activities of DSRIS were
not done, there are already sufficient insights in the design and
development activities to contribute towards the development of
mobile applications as part of an information system in a
developing context.
Mobile development has many challenges and by
areccounting the stories of how mobile applications are
developed, and especially the role of the technology actants and
how all the actants interact with each other, can provide
valuable insights. This is especially valuable in a developing
context where there are limited resources. When the designers
and developers are immerseding in the developing context they
obtain a better understanding of the local context and therefore
the perspective of social embeddedness seems to be appropriate
for the developing contexts. The dynamic of role allocation for
participation also seems to be an important aspect of the
formation and sustaining of sociotechnical networks. The use of
suitable design probes increases social learning and
communication but this seems to be more complex for the use
of technology components during development. It seems that
the design-reality gap increases during the development phase.
The research question posed for this paper can be answered as
follows: the interests of the actants during the design phase
were sufficient but less sufficient during the development
phase. The modus operandi to establish the network using
participatory design was appropriate for the design phase but
did not work so well during the development phase when both
the designer and end-users became inactive due to the technical
nature of participation. Further research is required to obtain a
better understanding of the reasons for the level of participation
during the development phase and how to deal with technology
actants and to determine the optimum versus high level of
participation. Furthermore the investigation of the role of
coordination ofas the rules and conventions during development
will provide more insights into the difficulties experienced
during the development of software in general, and mobile
applications in particular, a developing context.
Further research is also required to focus more on the
interactions between the actants for mobile development; the
role allocation during participatory design and development; the
factors leading to an increase in the design-reality gap; the
translations during the iterations of development; and the
inscriptions of the technology components.
8. ACKNOWLEDGEMENT
INDEHELA-ISD4D Project: A Holistic Information Systems
Development Approach for Societal Development – funded by
the Academy of Finland-.
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APPENDIX A
Table 1. An ANT Analysis of the Participatory Design and Development Phases of a Mobile Care Data Application
ANT analytical construct
Design Network
Development Network
Possible implications
Alignment
A design concept allows for the
assembling of good relations between the
design actants that results in a strong
alignment between all the actants
A participatory approach provides for a
situation where all the actants have the
ability to actively participate in the design
process
The technology actants influenced the
level of participation with the
developers having complex relations
around the translation of the design
into the mobile prototype and with
the designer and end-users becoming
inactive
Alignment is difficult with different
levels of complex translations
required
The degree of participation influenced how
the design and development of the care data
processing were done. During the design
phase the degree of agreement between the
actants was high whereas during the
development phase it was low
Coordination
The rules and conventions of home-based
care services are embedded in the work
practices of the caregivers that were
represented in the design of the mobile
data application
The co-design process allowed for
flexible interpretations of the possibility
of the mobile application and with the
designer more in the role of a facilitator
The interpretation flexibility was
restricted by the rules and conventions
of how these were inscribed into the
technology actants used to develop the
solution as well as the accepted
standards of software development
Understanding of the rules and conventions
of the work practices in a particular context
are well represented when a participatory
process is used to provide active
participation of the end-users who are
knowledgeable about their rules and
conventions. There seems to be an
insufficient understanding about the rules
and conventions of development as well as
how these are inscribed in the technology
actants
Substantial devices
The representation of the care data as part
of the proposed interface
The representations of the care givers’
anticipated care data processes in the
form of technical designs and code
Identifying the substantial devices of the
design and development networks provided
a better understanding of the key purposes
of these networks
Material devices
The design concept, namely the lo-fi
prototype
The technology actants supporting the
conversion of the care data processes
into the mobile prototype
Consideration of the material devices
provided insights in the interplay with the
material and procedural devices
Procedural devices
The co-design activities
The interaction between the developers
with each other and with the technology
actants and the designs
Insights in how the design and development
proceeded and the underlying assumptions
were obtained by considering how the
actants interacted