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CONTEXTUAL CONTRADICTIONS TO THE SCALING -UP
OF MOBILE HEALTH IN ARMED-CONFLICT SETTINGS
OF NORTH-EASTERN NIGERIA:
A CASE STUDY OF ALMANACH
Nakama David1, Muhammadou Kah2, Jennifer Tyndall3 and Olumide Longe4
American University of Nigeria, Nigeria
1+2348038013255
2+2348149228426
3+2348077092830
4+2348160900893
ABSTRACT
Developing countries are undergoing an unprecedented growth on the adoption of ICT’s. Mobile technologies,
digital platforms and services for health care are gaining acceptance and use for detection and response for disease
outbreaks, support of the healthcare value chains to facilitate improvements of public health care delivery and services.
This study through a case study examines how m-Health platforms and services produce positive results in the context
of Sub-Saharan Africa, specifically investigating the challenges of m-Health adoption and use in the Boko Haram
settings in Adamawa State, North Eastern Part of Nigeria. Our study also explores the challenges that impede the
successful scale-up of m-Health intervention in armed conflict settings of Adamawa State in the North Eastern region of
the Federal Republic of Nigeria. We examined the use of ALMANACH in five local government areas (LGAs)
namely; Yola south, Girei, Mubi-South, Mubi-North, and Maiha located in the armed-conflict (Boko Haram) settings
of Adamawa State, Nigeria. Nineteen PHCs where ALMANACH has been deployed, primarily conducted in
children clinics. A m-Health: “Algorithm for the Management of Acute Childhood Illnesses” (ALMANACH) was
introduced as a clinical decision support tool into the child health system to aid the management of common acute
illnesses in children between 2 months and 5 years. The ALMANACH is an electronic version of the integrated
management of childhood illnesses (IMCI) running on mobile tablets. The lens of activity theory has guided the study
to unearth the emergence of some developments in ALMANACH adoption and use in our study setting. Activity
theory (AT) was used as the analytical lens because it is central for understanding challenges in adoption and use
which can present in the form of contradictions. Thus, our findings suggest several challenges in the form of
contradictions that can impede the successful scale-up of ALMANACH in peculiar settings of Boko Haram. Hence,
a key contribution to the literature from our study is uncovering that contradictions are critical to achieving mHealth
scale-up in our study setting.
KEYWORDS
mHealth, Healthcare Services, Armed-Conflict, ALMANACH, Contradictions
1. INTRODUCTION
Armed-conflict zones usually present some of the most precarious health systems with poor human capacity
and significant governance challenges. There is also an acute shortage of human resources for health
care service delivery in conflict and post-conflict settings due to the migration of large numbers of qualified
health workers, as well as the destruction of educational and health facilities (Devkota & van
Teijlingen, 2010; Woodward et al., 2014) . These challenges have contributed greatly to the poor child
health outcomes as well as the high child mortality rates especially in developing countries. In 2015, about 6
million children between age 0 and 5 died of curable and preventable illnesses in conflict-affected
countries like Syria, Nigeria, and Niger (Asi & Williams, 2018). In an attempt to augment these healthcare
deficiencies, mobile health (mHealth) solutions have witnessed a high number of implementations in
many disadvantaged regions of the world including conflict and post- conflict regions (Woodward et al.,
2014). mHealth can have a resounding and
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positive effect on health care delivery in the most disadvantaged regions around the world (Chigona et al.,
2012; Motamarri et al., 2014), if it is properly implemented and effectively scaled-up. Such is especially the
case in the areas of reproductive, maternal and child health (Chigona et al., 2012). By leveraging on mobile
technologies to improve child health outcomes, mHealth has experienced unprecedented growth in recent years
with about 500 distinct pilot implementations globally, the majority of these developments have taken place in
developing countries (Tomlinson et al., 2013). This approach has been found to overcome widespread health
system barriers such as health professional shortages, reliance on untrained and/or informal providers, cost of
service and transportation, and lack of sources of reliable information (WHO,2011). Regardless of the
enthusiasm around mHealth and its great potentials in improving the health care landscape of developing
countries (Motamarri et al., 2014; Schmied et al., 2010), the majority of mHealth interventions are faced with
challenges which hampers the scale-up of such interventions (Bilandzic & Venable, 2011; Chigona et al., 2012;
Fanta & Pretorius, 2018; Mangone et al., 2016).
Related studies have illuminated on mHealth scale-up with some wide range methods, outcome measures,
and scope (Dehzad et al., 2014; Sanner et al., 2012). While these studies were successful in exploring the
different measures of taking mHealth pilots to full scale-up across diverse settings, experts in the field have
acknowledged the relative absence of a rigorous scholarly approach of how mHealth scale-up can be achieved
(Tomlinson et al., 2013). There is also, the need to study the challenges of mHealth implementations in
developing countries (Kruse et al., 2019). Thus, this study aims to explore the challenges that impede the
successful scale-up of mHealth intervention in developing countries. Particularly, armed conflict settings. Such
studies are scarce in literature. Hence, knowledge from this study will contribute to extant literature on mHealth
implementations. The study may serve as a valuable tool for intervention donors and policymakers to consider
when planning or designing imminent mHealth projects. Findings from this study will also strengthen the
chances of long-term, sustainable scale-up of mHealth in armed conflict settings of developing countries. This
study was conducted within a child health care program in the armed conflict settings (Boko Haram) of
North-East (NE) Nigeria. A mHealth: “Algorithm for the Management of Acute Childhood Illnesses”
(ALMANACH) was introduced as a clinical decision support tool into the child health system to aid the
management of common acute illnesses in children between 2 months and 5 years. Activity theory (AT) was
used as the analytical lens because it is central for understanding challenges in practice which can present in
the form of contradictions (Shidende, 2014). With that understanding, the following research question is
addressed: how can the challenges faced by mHealth systems in armed conflict settings affect its scale-up?
2. THEORETICAL FOUNDATION
Activity theory is a social-psychological theory that is based on the work of the Russian psychologist Leo
Vygotsky during the first half of the 20th century (Leontiev et al., 1981). AT is a theory that seeks to understand
who is doing what, why they are doing it and how the activity is done in a social context. Engeström (2001)
describes AT as "a theory of object-driven activity". In the sense that, it provides scholars with a holistic
framework and explanation for all the meaningful things people do to produce a change in practice. The basic
unit of analysis in AT is the activity performed by humans (Kaptelinin et al., 2018; Ngoma et al., 2011). From
the perspective of AT, an activity occurs when a "subject'' uses certain tools to achieve an object. A subject
could be an individual or an organization working together as a team with the aim of achieving an object
(Kaptelinin et al., 2018). Objects are set goal (s) needed to be achieved by the subjects with the aid of certain
tools. These Tools can be tangible or intangible. Examples of tangible tools are the hammer, spanner, mobile
phone, or computer while intangible tools comprises ideas, signs or language (Ngoma et al., 2011). These
concepts are interrelated and form part of an activity system. Hence, the nature of AT holds a relational
ontology (Armstrong, 2011). The interrelationships among these concepts has the potentials of producing
dynamic and conflicting perceptions through continuous interaction between and among these components in
goal-directed activity (Wolff-Piggott & Rivett, 2016a).The dynamic perceptions can be controlled by rules and
a clear division of labor. Rules are the guiding principles that govern how and why a person acts within the
activity system while. Division of labor defines specific roles and responsibilities of an individual subject in
an activity system
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Activity Theory believes that the cultural-historical context of activity is key to understanding the dynamic
nature and characteristics of an activity (Engeström, 2001; Wolff-Piggott & Rivett, 2016b). This aspect of
activity theory is an important when studies are done in the context of developing countries where activity
systems are influenced by the societal and organizational context in which the activity exists (Karanasios
& Allen, 2013). Another fundamental concept in Activity Theory that is relevant to this study is contradiction.
Contradictions are not simply problems or conflicts, they are "historically accumulating tensions among and
between activity systems". Contradiction is an important principle in activity theory because it can lead to
change and development (Brown, Allen et al., 2013). Contradictions are identified from empirical data in form
of breakdowns and recurrent problems. They manifest in primary, secondary, tertiary and quaternary levels
(Engeström, 2001). Primary contradictions are found within a component of an activity system. For example,
conflicting rules may occur in situations where a physician may be forced, because of the economic strength
of his patient, to prescribe cheaper and less effective drugs over the best (Riechert et al., 2016). Secondary
contradictions manifest between components of an activity system. Secondary contradiction emerges when
some elements like the division of labor or rules collide with new set of rules or roles. Tertiary contradictions
are found "between the object of the central activity system and object of a more cultural advanced activity
system". Quaternary contradictions appear in a network of activity systems between some components of the
main activity system and the components of another activity system. Thus, activity systems change and develop
by resolving their historically evolving contradictions (Engeström, Y, 1999). Furthermore, activity theory
acknowledges contradictions as inevitable in the functioning of any activity system and identifies them as
useful sources for developments in a system (Igira & Aanestad, 2009).
3. RESEARCH CONTEXT
The setting of this research comprises selected PHCs in the Boko Haram affected areas of Adamawa State,
Nigeria. Adamawa state is located in the North-Eastern (NE) region of Nigeria. The Boko Haram movement
became militant in NE Nigeria in 2009. Consequently, Nigeria has been described as home to the deadliest
armed conflict actors in Africa and was ranked as the third unsecured terrorized country in Africa
(Ekhator-Mobayode & Abebe Asfaw, 2019). Boko Haram is based on the Takfiri Islamic belief system, which
opposes western education and views it as Haram (forbidden). Although a peaceful movement at inception,
Boko Haram became violent in 2009 when the movement clashed with the Nigerian government because the
government was against the ideology of Boko Haram (Badau & Abdulrasheed, 2015). Boko Haram insurgency
has displaced about 10,000 people in Borno and Adamawa states Most of the internally displaced people(IDPs)
are from six Local Governments in Adamawa and Borno - Madagali, Gwoza, Michika, Gombi, Hong, Mubi
North and Mubi south. This forceful movement has negative social and health impacts on the people of
Adamawa state, especially children (Adamawa State Emergency Management Agency, 2014).
The research investigates the effectiveness of ALMANACH program in Adamawa State, Nigeria.
ALMANACH was piloted in Adamawa state in December 2016 through a tripartite collaboration among the
Adamawa State Primary Healthcare Development Agency (ADPHDA), the SWISS-TPH, and the International
Committee of the Red Cross (ICRC). The ALMANACH is an electronic version of the integrated management
of childhood illnesses (IMCI) running on mobile tablets. IMCI is a regulatory guideline that is in line with
WHO's policy for improving the quality of child healthcare against the commonest child killer diseases in
developing countries (malaria, measles, pneumonia, diarrhea, and malnutrition). Consequently, the
ALMANACH was deployed as a clinical decision support tool to enhance the activities of the PHC workers
during clinical consultations of children under the age of 5 by ensuring adherence to the IMCI guidelines. The
ALMANACH provides a step-by-step process that guides the PHC worker to make accurate diagnosis and to
administer correct dosage. It also suggests whether a patient needs referral to a higher care facility when
necessary. The collaboration among the ADPHCDA, ICRC, and SWISS TPH is consistent with the ICRC
Health Strategy, and complementary to the United Nations Sustainable Development Goals 3 (SDG3) (on
ensuring good health) and SDG17 (pursuing partnerships to meet the goals). The long-time vision of the
ALMANACH project is to scale up its application to all supported Primary Healthcare (PHC). This study seeks
to provide additional insights that will help ALMANACH stakeholders realize their vision of a wide-scale-up.
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4. RESEARCH METHODOLOGY
A case study design was used to examine the use of ALMANACH in five local government areas (LGAs)
namely; Yola South, Girei, Mubi-South, Mubi-North and Maiha. All the selected LGAs are located in
armed-conflict (Boko Haram) parts of Adamawa State, Nigeria. Nineteen PHCs where ALMANACH has been
deployed were studied, and the study was conducted mainly in children clinics. A conceptual understanding
was developed by drawing insights from the Activity Theory in interpreting the data. A case study data
collection procedure was used because the approach is suitable for investigating complex phenomena like
mHealth (Yin, 2003).
The data collection took place through different but overlapping fieldwork phases. Data collection was
done from March 2019 to July 2019 and from September 2019 to November, 2019. The ethnographic approach
inspired the data collection methods adopted. The data collection procedure was guided by the activity theory
principle of contradictions. Ethnography helps researchers to have a deep insight and describes how subjects
utilize tools to accomplish an object in practice (Kaptelinin & Nardi, 2018). We visited ten children clinics in
different PHC centres in the state and observed clinical consultations. We collected the requisite data we need
for the study and stored it in a database. We further reviewed clinical records (hospital cards) and the
ALMANACH mobile tablet. We also participated in two steering committee meetings where all activities
around ALMANACH were discussed with relevant stakeholders. A total of seventeen observation sessions
were made across all selected PHCs with each session lasting between 1 to 3 hours. Interview was the main
source of data collection techniques we deployed. A total of thirty-seven. Semi-structured interviews were
conducted to have an understanding of work practices around ALMANACH. In some cases, focused group
interviews were conducted for subset of health workers involved in the ALMANACH activity. This was
augmented with one-on-one interviews where necessary. The interviews were conducted in Hausa and English
languages. During observations and interviews, we interacted with three nurses, fifteen facility managers, nine
CHEWs, and two laboratory technicians. However, because this type of interaction often leads to bias in sample
selection, purposive sampling was used to select participants for the study. The participants were selected
because they have met the inclusion criteria outlined for the conduct of the research. The criteria include being
a member of ALMANACH team, experience in handling the ALMANACH system for at least six months and
the ALMANACH must be deployed in an armed conflict zone of Adamawa State, Nigeria. Participants must
also be 18 years of age and above before they eligible to participate in the study.
The data collection and analysis were guided by the Vygotsky’s principles of contradictions which have
been discussed in the previous section. Notes were taken during the focus group and interview sessions. In
total, 22-page notes of qualitative data were collected, grouped, and analyzed using (Braun and Clarke (2006)
principles of thematic analysis. This included careful and repeated readings of the data to get a summary of the
main themes discussed by the participants. Next, a set of themes and relevant quotations from interviews were
produced with relation to Vygotsky’s principles of contradictions.
5. ANALYSIS AND DISCUSSION
Vygotsky’s’ principle of contradictions was used as the framework for the case study analysis. This was
adopted in order to understand the challenges of using mHealth at PHCs in the selected study sites. These
challenges manifested in the form of contradictions. Some of these contradictions have led to changes/
developments in the original activity system. Contradictions in ALMANACH system are then discussed.
5.1 Contradictions within ALMANACH Systems (Primary Contradictions)
The ALMANACH is deployed at the PHCs with the assumption that all clinical consultations of children under
the age of 5 will be done using the ALMANACH. The present reality does not fit this assumption, as only one
ALMANACH is assigned to each PHC and as it takes a long time to complete the process of a single clinical
consultation (i.e. one child). The consequence to this is that facilities with a high turn-out of patients have
developed other means of using the ALMANCAH whenever they have many patients awaiting consultation.
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The strategy the PHCs have employed is that while one health worker is using the ALMANACH to consult,
another health worker records the vital signs of patients on a hard copy clinic card. In such scenario problem
arises as some health workers sometimes forget to transfer all the data into the ALMANACH. Also, quality of
care can be compromised thereby affecting the overall outcome of child healthcare, since some of the health
workers work based on assumptions. For example, we witnessed discrepancies associated with data quality
when we tried to compare entries made on the hard copy IMCI card and data recorded on the ALMANACH
on some specified dates.
In some PHCs ALMANACH were powered off at the time there was electricity supply at the facilities.
A health worker confessed to our team that they used the ALMANACH in their facility for only a month and
since then they have been having problems whenever they try to use it again. Another staff said he feels the
problem is that they do not understand how to use it. This highlights the lack of self-efficacy which was
supported by the comment below:
"How can we even know how to use it properly when the person that was trained on how to use the
ALMANACH is not a serious person and cannot use it herself?"
Another contradiction observed among the subjects (health workers) is related techno-phobia.
Techno-phobia among health workers was confirmed at some facilities where some health workers stated that
they no longer attend to children under the age of 5 since ALMANACH was deployed at their facility. This is
because they would have to use the mobile tablet (ALMANACH) which they do not like. Therefore, they only
consult adults and children above the age of 5 since they do not need any form of technology to attend to the
medical needs of these populations. They said their decision not to consult children under the age of 5 was in
agreement with all other staff of the facility.
The next sub-section presents contradictions that arise from the interaction of the ALMANACH activity
system with other components within the activity systems.
5.2 Secondary Contradictions
Interactions among the sub-components of the ALMANACH produced some contradictions in the
ALMANACH activity system, which could serve as potential threats to its scalability. The identified
contradictions are elaborated in this sub-section.
There is no Internet network connectivity in some communities where the ALMANACH was deployed.
This is especially the case at the Boko Haram host communities. As a result, facilities affected by this challenge
devised a means through which they can overcome the problem. The facilities temporarily save all their
information entered into the ALMANACH system and then travel to the nearest community with Internet
connectivity to upload the data. This is done once in a week across all PHCs with similar problems. However,
this development is further challenged by finance even though the sum of one thousand naira is included in
their monthly budget. The money is to cover the purchase data bundle per month. A committed health worker
narrated how their facility is trying hard to overcome this challenge in the following comment:
"This facility does not provide us with either money to buy a data bundle or the data bundle subscription.
I have been using my money to buy data of about 200 naira weekly, and I have to also fuel my motor cycle to
enable me to travel for about 2 kilometers to where I can be connected to internet service that will allow me to
send our report. To be honest with you, I cannot promise you that I will continue to do this".
Delays in uploading of generated data at PHCs level could further have an impact on the disease
surveillance system or other real-time analysis.
Other forms of secondary contradiction emanated from the rule and the division of labor components of the
ALMANACH activity system. The rule guiding the use of ALMANACH states that only health worker is
allowed to use the ALMANACH for medical consultations of children under the age of 5. But we found out
that some laboratory technicians use the ALMANACH during clinical consultations of children. Such scenarios
were seen at the Boko Haram host communities due to shortage of manpower. This contradiction led to a form
of informal change in the division of labor in the facility. We have also observed that it has established a
relationship between healthcare facilities. The laboratory technician had this to say:
"if not because of my presence here, this facility would have been under lock and key and the people here
will have to travel some distance to receive any health care emergency needs''.
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Also observed was the contradiction between tool and subject. This was made manifest during our interview
sessions with the health workers where they mentioned that malaria was the most common disease in their
communities and that it is one of the most dangerous killers of children under the age of 5. They also said that
in their context, there are more than one different species of malaria and that, some malaria species cannot be
seen when a blood sample is subjected to a particular type of malaria investigation. They have expressed their
dissatisfaction with the ALMANACH arguing that ALMANACH recommends only a rapid diagnostic test
(RDT) laboratory investigation to query malaria in a patient. A health worker at a different facility narrated his
ordeal:
"A woman walked into this office crying and looking disappointed. She said to me that I had killed her
daughter for her! She further said to me that, you should have told me that you don't know your job! My
daughter died of severe malaria after you told me that there was nothing wrong with her".
There was also evidence of a contradiction between the clients and the subject. Some clients are of the view
that subject (health workers) use the ALMANACH only because they are incompetent. Some health workers
told us that some of their clients were bold to tell them the only reason they come to the clinics is that they
have no other options. The facility had to organize orientation and sensitization sessions during antenatal,
postnatal and immunization days to make the clients understand the reasons why the ALMANACH is used
during clinical consultations of their children. These sessions somewhat changed the perceptions of many of
the clients towards the use of ALMANACH. The clients also understood why they would have to go through
all the processes involved before a prescription is made. This activity produced some visible positive outcomes.
5.3 Quaternary Contradictions
There were other protocols and programs for the management of children under the age of 5 across all the
facilities visited. Other program protocols such as the standing order, IMCI chard, and save one million lives
were deployed in the PHCs. A health worker said to us during an interview session with him that other protocols
like the standing order covers many other illnesses which illnesses, which are not included on the
ALMANACH. Again, even though, the ALMANACH is an electronic version of the IMCI, the IMCI chart is
more detailed. As a result, some external evaluators and assessors score us high on other protocols in
comparison to the ALMANACH system. The assessors often complain that the records we have on
ALMANACH do not provide relevant information such as the client's address and phone number. They said
they need this information to track the clients and to get feedback from them. For these reasons, we now ask
for phone numbers of our clients and their addresses. Though we know there is no provision for it on the
ALMANACH, we record it on the hard copy cards that we use. In this regard, a health worker said:
"In this clinic alone, we have been trained on the management of under 5 children by different intervention
donors and each sponsor has a different approach to the management of children under the age of 5. The
sponsors encourage us to use their program because as far as they are concerned, it is the best and so their
supervision team always come around and we are always caught in-between one or more protocols".
6. DISCUSSION AND CONCLUSION
This study examined the challenges of mHealth in practice in the Boko Haram settings Adamawa State, NE of
Nigeria. Findings from the study have uncovered several challenges in the form of contradictions that can
impede the successful scale-up of ALMANACH in peculiar settings of Boko Haram. Hence, the findings of
the study respond to concerns in the literature that uncovering contradictions are critical to achieving mHealth
scale-up (Brown, Allen et al., 2013; Igira & Aanestad, 2009).
The contradictions identified in the study were categorized into primary, secondary and quaternary
contradictions. Following the Engeström (2009) principle of contradictions. The primary contradictions that
were identified in the study are similar to others that were previously reported (e.g Ngoma, Faraja T. Igira,
2014; Kenny, Heavin, et al., 2017; Kenny, O'Connor, et al., 2017; Kruse et al., 2019) where mHealth is
challenged by poorly trained health workers and poor data quality. Contrary to the findings of Kenny,
O'Connor, et al (2017), a negative attitude towards mHealth was discovered in this study. Primary
contradictions that were also discovered at the PHC level in this study include insufficient availability of mobile
tablets (ALMANACH) and increased consulting time. Secondary contradictions were discovered from
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interactions between components of the ALMANACH activity system. The secondary contradictions are poor
internet connection. This is mostly the case in the areas that have either been attacked by the Boko Haram or
areas that are still experiencing attacks by Boko Haram. Poor funding policy at the PHC level, restrictions on
certain laboratory investigations, shortage of healthcare workers especially in Boko Haram host communities,
poor clients' knowledge and perception on mHealth were all secondary contradictions that were uncovered in
the study. A quaternary contradiction was discovered from interactions among the ALMANACH system with
other external systems. For instance, there were overlapping protocols for the management of children under
the age of 5 from other intervention donors like UNICEF and the save one million lives intervention.
Insights from activity theory has guided the study to unearth the existence of some developments in
ALMANACH practice (Igira & Aanestad, 2009). Examples of such include: a form of a new division of labor,
uploading of data to the main database has been rescheduled, an alternate source of funding has been created,
rules limiting consultations at PHCs to only CHEWs have been changed to include laboratory technicians in
the process of consultations using ALMANACH. Also, other malaria tests were done concurrently with RDT
to satisfy contextual needs and CHEWs engaged some clients in conversations that changed their perception
of ALMANACH.
Finally, in suggesting areas for future studies, the limitations of this study are acknowledged. The study
was limited to a single case study. However, the study overcomes these limitations by the strength of qualitative
data in providing deep insights (Abubakar & Dasuki, 2018), into the experiences of health workers as it relates
to the challenges of ALMANACH in practice. In conclusion, the study has made both practical and theoretical
contributions. Activity theory helped in conceptualizing challenges as contradictions thereby exposing
potential threats to achieving scale-up of ALMANACH to provide more insight into the pathways towards
achieving scale-up of mHealth in armed conflict settings, our future study will examine the processes and
outcomes of implementing ALMANACH.
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