Case Paper

DOI: 10.4018/JCIT.2020100103

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

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

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

ABSTRACT

Despiterecenttechnologicaladvancements,theslowadoptionpatternofdigitalhealthcarepromotion programscontinuestobeamajorproblemplaguingmanyhealthcareorganizationstoday.Thehistorical teachingcasestudyisindispensableinimprovingourunderstandingofthecomplexandmultifaceted natureofcontemporarydigitalhealthcarepromotionprograms.Thishistoricalteachingcasepresents informationaboute-health,thee-commerceunitofalargemultinationalhealthcareinsurancecompany. Theteachingcaseshowshowdespitee-health’sabilitytopersuadealargeregisteredbaseofusersto trialitshealthcarepromotionprograms,over90%oftheseregistrantsdiscontinueduseafterashort trialperiodofusingthetechnology.Thishistoricalteachingcasefocusesonthesocialchallenges involved in persuading users to adopt and continue using e-health’s major healthcare promotion innovation:anonlinenutritioncenter.Despiteextensivepromotionsandtheuseofincentives,less than10%oftheuserbaseadoptedandcontinuedtousethishealthcarepromotioninnovation.Thecase reportsonthediscontinuanceamongdigitalhealthcarepromotionusersdespitetheintensiveefforts toretainthem.Studentsandpractitionerswillgaininsightintothekeysocialchallengesinvolved inachievingacriticalmassofusersfordigitalhealthcarepromotioninnovations.Theteachingcase requiresimportantdecisionstobemadebystudentsandpractitionersaboutpresentdigitalhealthcare promotion programs by drawing on inferences from past digital healthcare promotion programs. Finally,thishistoricalteachingcasestudymakesaconvincingcaseforthevalueofhistoricalinsights ininformingpresentdaychallengesfacingcontemporarydigitalhealthcarepromotionprograms.

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

INTRoDUCTIoN To DIGITAL HeALTHCARe PRoMoTIoN PRoGRAMS

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

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

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

originalpublicationsourceareproperlycredited.

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

Overtheyears,ICTbegantobeintegratedintohealthsystemsandservicesworldwide.During the 1990s, e-commerce emerged and enabled new ways to conduct transactions via the Internet. eHealth was also enabled by the Internet. The term eHealth refers to the use of information and communication technologies to improve health and the health care system (Oh, Rizo, Enkin & Jadad,2005).TheInternetreferstothegloballyconnectednetworkofcomputers.Althoughtheterm InternetisusedinterchangeablywithWorldWideWebor‘theWeb’,theWorldWideWebrefers tomultimedia-baseddocumentsthatcanbeaccessedonline,overtheInternet(Lupton,2014).This becameknownastheWeb1.0eraortheso-calledbrochurewebera.TheWeb1.0erabeganrapidly in1990sbecauseoftheavailabilityofbrowserswithuser-friendlygraphicalinterfaces.TheWorld Wide Web had become a valuable channel for accessing and seeking health information. Rapid improvementincommunication,hardwareandsoftwaretechnologiesalsoledtonewandbetterhealth serviceofferingsviatheInternet.Bytheearly2000s,therewasanoticeableshiftintheuseofthe webandthedevelopmentofweb-basedapplications.ThiswastermedWeb2.0andinvolvesusers creating,organizing,sharing,critiquingandupdatingcontent.Web2.0connectspeopleandcontent inuniqueways.Web2.0facilitatesan‘architectureofparticipation’–adesignthatencouragesuser interaction,empowermentandcommunitycontributions.PopularWeb2.0applicationsincludeFlickr, Wikipedia,Facebook,MySpace,TwitterandYouTube.Bythemid-2000s,Healthcare2.0emerged totakeadvantageofthenetworkofWeb2.0applicationsandservicesdeliveredthroughtheWeb platform. Health 2.0 uses social networking sites, blogs, email list services, online communities, podcasts,search,tagging,videos,andwikistopersonalizehealthcareandtocollaborateandpromote healtheducation(Lupton,2014).

Recent advances in processor, memory, and disk storage capacity have made digital devices relativelyinexpensiveandaccesstoonlineplatformshavebecomemoreubiquitous.Consequently, increasinglysmallerdigitaldevicesfromthepersonalcomputertothetablettosmartphonestowearable computersarebeingbeenusedinhealthcare(Lupton,2015).m-Healthormobilehealthisdefined astheuseofmobiledevices,suchasmobilephones,patientmonitoringdevices,personaldigital assistants(PDAs),andotherwirelessdevicestosupporthealthpractices(Bert,Giacometti,Gualano& Siliquini,2014).Forexample,trackingdevicescanbeusedtomonitorapatient’scalorieconsumption, exerciseandmetabolicrate.Thesedevicesarebeingintegratedwithsocialmediatoprovidesupport andmotivation.ExpertspredictthattheWebwillevolveintoWeb3.0orthe‘SemanticWeb’(Giustini, 2007).TheSemanticWebaimstoimproveuponthemeaningfulnessofinformationontheWebthereby improvingcooperationbetweendigitaldevices,healthcarepractitionersandpatients.

Apartfromthecreationofdigitalcontentbyhealthcareuserswhentheyuploadinformationto theInternet,sensorsembeddedinhealthcaredigitaldevicesandphysicalhealthcareenvironmentsare alsogeneratingmassivedatasets(NevesStachyra,Rodrigues2008;Panesar,2019).Thesemassive datasetsarereferredtoas‘bigdata’.Cloudcomputingtechnologiesarebeingusedtofacilitatethe production,storageandsharingofthesebigdatasetstoprovidedigitalhealthcaresolutions(Darwish, Hassanien,Elhoseny,Sangaiah&Muhammad,2019).Artificialintelligenceandmachinelearning are being used to uncover hidden connections and patterns in these massive data sets to provide evidence-baseddigitalhealthcaresolutions(Panesar,2019).Today’shealthcareICTecosystemis much more complex and involves network providers, network operators, digital device suppliers, platform,contentandapplicationsproviders,healthcarecompanies,healthagencies,governments andpatients(Fransman,2007).Theterm‘digital’isnowbeingemployedtodescribepaper-based elementsthathavebeentransformedintodigitalformats,andthedevices,communicationnetworks andsoftwareapplicationsthatusetheseformats.

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

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

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

SeTTING THe STAGe

Introducing the e-Health Case Study Terry Rossi burst into his office, walked directly to his desk and slumped into his chair. He had just arrived from another tough Exco meeting. The committee was concerned that the “wellness innovations”deliveredontheWebhadsofarappealedtoonlyaminorityofcustomersandnotthe highnumbersthathadbeenpromisedbye-Health.Atbest,thehealthcarepromotionprogram,the onlinenutritioncenter,wasservingasacomplementarychannelforasmallcaptiveaudience.Terry wonderedhowhewasgoingtoimprovetheperformanceoftheonlinenutritioncenter.Terryknew that if he were to convince the Exco that this healthcare promotion program was a success, this programwouldhavetoattainacriticalmassofusers.Hewasconsideringthestepshecouldtaketo ensurethate-Healthbuiltacriticalmassofusers.

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CASe DeSCRIPTIoN

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

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

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

Figure 1. HIC’s organisation structure

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Despitethisaim,thereweredifferentopinionsamongthepanelmembersaboutcertaintopics,such asthefibrecontentofahealthydiet,andsoon.

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

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

WhiletheNutritionCenterdidattractusers,itwasnotaspopularastheapplicationsthatwere concernedwiththemembers’healthplans.Themonthlymanagementreportindicatedthatapplications related to health plan issues, such as the online claims tracker application, were used as much as threetimesforeverysingleuseofthenutritioncentre.Pageimpressionswereonaveragefewerthan 3000perweek.

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

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

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Promoting the Adoption of Healthcare Promotion Programs Terry’sstrategytomarkettheNutritionCentreresultedinenticingmanyuserstoregistertotrial thetechnology.Thecampaignspromotedthecompany’svisionof“improvingpeople’shealth and enhancing their lifestyles” in an online environment. The Nutrition Centre was promoted invariousmediums:

• Healthcare Insurance Fact File:TheNutritionCentrewaspromotedinthefirm’sfactfile. The fact file was a booklet that principal members received annually to explain how their healthplanworks.

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

• Email Newsletter Campaigns:Theseemailsweretobecomeavitalcomponentoftheemail promotioncampaignforpromotingtheNutritionCentre.

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

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

Figure4showsthatasaresultofthesepromotions,asmanyas60%oftheregistered userbaseregisteredtousetheNutritionCentre.DespiteeffortsatpromotingtheNutrition Centre, However, Figure 5 shows that over a short period of time as many as 90% of registrantsneverreturnedtousetheNutritionCentre.Thisisinstarkcontrasttothehealth insured member base churn or lapse rate of 3 to 4%. Despite Ter ry’s efforts to attain a criticalmassofusers,theNutritionCentrewaseventuallydisbandedbecauseofthehigh userdiscontinuance.

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

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PoST IMPLeMeNTATIoN ReVIew: LeSSoNS FRoM THe PAST

The following problems contributed to the slow uptake and negatively impacted diffusion of the NutritionZone.

Lesson 1: The Constraining Role of Broader Socio-economic Structures TheInternethighwayasastopforonlinewellnesstoolsisnowcompetingwiththemoreresilient structureofourroadnetworks.Eversincethegrowthofcarsalesandthesubsequentgrowthofsuburbs, growth which road networks had encouraged, fast food organisations have grown into sprawling multinationals by exploiting prime locations within these highway networks. Even in developing countries like South Africa and in fact many other countries around the globe, corporations like

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

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

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

Asaresultofthepervasivenessofthesebroadersocialstructuresinmodernsocietybehavioural changesaredifficulttomakeevenwiththeguidanceofapractitionerletaloneviaadigitalhealthcare promotiontool.ThefollowingexcerptbyoneofHIC’swellnesspractitionersdescribesthechallenge:

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

Lesson 2: Intense Competition for the Customer’s Attention There are other market mechanisms outside of the health insurance firm that are vying for the consumer’sattention.Thecontentdeliveredbythemediaplaysacentralroleinhowconsumers constructtheirvaluesandrulesofbehaviour.Inaneconomicsystemthatfocusesonthenarrow dictatesofprofitability,obesityhasbecomebigbusinessfortheverysystemthatinfluencedit. Indeed,consumersareoverwhelmedbythevarietyofdietschemesandweight-lossadviceand products that are available in the market place. Furthermore, food is an important factor in our day-to-daysocialpractices.

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

There were a lot of challenges I mean within any panel you are going to have differing opinions. Although they are all excellent academics in their own right there was of course a certain degree of not necessarily conflict but differences of opinions in certain aspects. You couldcertainlypickupthedifferentslantsintheirparticularfieldofinterestsandorpassion. Soforexampleonewouldconstantlybeharpingaboutfibreorlentilsandtheotheronewould beharpingonaboutyouknowvariousdifferentangles.Sotakingthescienceandtranslatingit intoaninteractivetoolwasquiteachallenge.

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

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

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

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

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

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

Forexample,theconceptionsofanonlinenutritiontoolinscribedwithaSouthAfricanperspective requiredmodificationstosuittheUKcontext.Bringingatechnologytoanewlocalcontextinvolves someexplicitandimplicitelementsofculturaltransferandmutuallearning.Thefollowingcomment by our Nutrition Expert highlights how the UK requirements were at odds with the local South Africanrequirements:

TheUKsystemusestheimperialsystemwhileweusethemetricsystem.Thisaffectedrecipes, portionsizesandbodymeasurements.ThedieticianintheUKhelpeduswithtranslatingtherecipe measurementsandportionsizesfrommetrictotheimperial,whichinvolvedcalculatingtheequivalent ounces where the recipes stated grams, millimetres or litres and converting kilograms to pounds. Someofthemeasurementslookedridiculousanddidn’tseemtomakesense,sowehadtotryand converttohouseholdmeasurementswherepossible.Forexample–1teaspoon,Icupetc.Regarding thebodymeasurements,oneofthetoolsinthenutritionprogrammeinvolvescalculatingyourbody massindex(BMI).Thisrequiresyoutoenteryourheightinmetresandyourweightinkilograms. NaturallywehadtomodifythistooltoallowfortheUKmarkettoentermetricfriendlydatasuchas feetandpounds.Thiswasn’tdifficultasitwassimplyacaseofapplyingconversionfactors.

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

At first we thought it would simply involve removing the South African foods, for example biltong3fromtherecipesandmenusonthemealplansandreplacethemwithfoodsfamiliartopeople intheUK.SoweneededtofindoutwhatequivalentfoodswouldbeavailableintheUKtouseas substitutes.Thenwerealisedwealsohadtochangethenamesofcertainfoodsthatwerecommonin bothcountries,butthatwerecalledsomethingdifferentintheUK,likeeggplantinsteadofbrinjal, whichaffectedrecipesandmenusthatcontainedthesefoods.Wealsohadtochangethenamesof recipes,suchas‘potjie’tosomethingmoreUKfriendlylikecasserole.Toensurethatallfoodswould berecognisabletoUKconsumers,weenlistedthehelpofaregistereddieticianintheUK.

AmajornutritionalissueintheUKisintoleranceorallergytowheatandtherearemanymore vegansthaninSouthAfrica.Wehadnotcateredforwheat-free andveganmealplansontheSA NutritionCentreandtheUKofficerequestedthatwedesignsuchoptionstosuittheirmarket.This involvedtheUKdieticiansupplyinguswiththenamesofproductsavailableintheUKthatcouldbe usedassubstitutesforwheatandanimalproteinfoods

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

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

UponreflectingontheNutritionCenter’sabilitytoplaytheroleofadietician,ourNutrition Expertadmittedthisasamistake.

Tryingtofigureouteverythingadieticianwouldwanttoknowfromapersonandtryingtoput thatinsomekindoftoolwasactuallyamistakebecausewereallydidn’tintendtobecomeorreplace theservicesofaregistereddietician,thereisabsolutelynowaythatwecouldpossiblydothatand yetweweretryingsohardtogettothatpointofbeinganonlinedietician.

CURReNT APPRoACHeS To PRoMoTING NUTRITIoN

Overmorethanadecadeorsoago,therewouldbeadecliningemphasisontheonlinepromotion ofnutrition.TheonlineNutritionCenterwouldalsoberemovedfrome-Health.Therewasa radicalshiftinnutritionfromtheonlinetothe‘physical’world–inotherwords,towardsthe organization’s‘realworld’networkofpartners.Today,e-Health’sroleislimitedtoproviding genericcontentonhealthyeating,food,nutrition,aswellashealthyrecipesandtipsfromthe organization’s leading nutrition experts. The nutrition program continues to encourage and rewardmembersforhealthybehaviour.However,cashrewardshavereplacedtheredeemable points based system and is awarded for purchasing healthy food and making healthier meal choiceswhendining.Customersarerewardedwithcashbackforpurchasinghealthyfooditems atselectedretailpartners.Customersarealsorewardedwithcashbackformakinghealthier mealchoiceswhendiningoutatselectedrestaurantpartners.Thisincludesapartnershipwith UberEats.Meanwhile,thefirmhasalsobegunopeninghealthyfoodstudiosinmajorurban centres to teach basic cooking skills and encourage both adults and children to cook using unprocessedandseasonalingredientstosupporthealthyeatinghabits.Nutritionassessmentsare nolongerdoneonline.DieticiansinHIC’swellnessnetworknowdothenutritionandweight assessments.Whileredeemablepointsfornutritionassessmentsarenolongerofferedonline, pointscanbeareearnedfordoingtheseassessmentsataccreditedwellnessnetworks.HIC’s nutritionexpertusestheYoutubevideo-sharingcommunitytoprovidedietlessons,eventhough theviewsareverylow.Thefirmalsooffersincentivesforphysicalactivity.Asmartwatchis offered to qualifying customers. The smartwatch measures the wearer’s activity levels and setspersonalisedweeklyfitnessgoalsbyconnectingtothefirm’sfitnessapp.Thecompany claimsthattheyhaveobservedincreasedactivitylevelsamongmanyoftheparticipantsusing the smartwatch reward programme. Today, HIC operates in more than 15 countries and has over10millioncustomers.Thecompanyfocusesonusingsmartphones,wearabledevicesand gamingelementstopromotehealthcare.Successinthediffusionofthesedigitalhealthcare promotionprogramscontinuestobemixed.

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yoUR CHALLeNGe AND TASKS

TheHICexecutiveisreassessingtheirdigitalstrategyfornutrition.Theyhavereachedouttoyouand yourteamofconsultantstoadvisethefirm.Theoverarchingobjectiveistwofold:

1. To assess how well digital technologies have progressed to date and to what extent they canaddresssomeofthesocialchallengesexperiencedinthepastiterationsofthenutrition center(assessment);

2. Toproposewhethertomoveforwardandhowtomoveforwardwiththeirdigitalstrategyregarding nutrition(recommendations).

NoTeS

Sincetheorganizationpreferredanonymity,allnameshavebeenfictionalised.

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ReFeReNCeS

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APPeNDIX

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

Subject Measures

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

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

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

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

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

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

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

Table 2. Exhibit 5: Summary of key user characteristics

Subject Measures

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

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

Source:InternalManagementReport(2004) ThemajorityoftheusersappeartobeyoungerandaffiliatedtotheWellnessprogram. Themeasureofactiveuseisbasedonloginspermonth