Mobile Health (mHealth) in Sierra Leone: A Critical Realist Study

The number of mobile health (mHealth) implementations around the world, particularly in developing countries, has been increasing dramatically. However, the design, implementation and adoption of mHealth in such environments is beset with wide-ranging challenges and many such projects have been unable to sustain or demonstrate any significant impact at scale. This is because any mHealth implementation in a developing country environment is bound to be shaped by a variety of ethical, social, cultural, political, environmental, ideological, and technological factors. This PhD research examines an ongoing mHealth initiative in Bonthe District, Sierra Leone. The research questions ask why the mHealth project evolved the way it did, and what were the mechanisms that determined the outcome. A research framework that relies on critical realism and Margaret Archer s morphogenetic approach is leveraged to hypothesize generative mechanisms which provide an answer to the research question. Critical realism is used as the philosophical approach as it addresses many of the concerns associated with the interpretivist and positivist approaches that have dominated the ICT4D field for many years. A further research question examines how such a critical realist-based research framework can be applied to this case in practice. Such a critical realist-based philosophical approach has the potential to inform how this particular mHealth case has evolved in a variety of different social, cultural, and political contexts. This approach can also bring many other advantages to the research including its ontological realism combined with epistemological relativism; its iterative, pluralist, and reflexive methodology; and its emancipatory values. In addition, critical realism brings with it a variety of generic values including exposure of context, a contingent causality that reflects real-world experiences, support for use of theoretical frames, legitimisation of different stakeholder views, and reduction of research bias. A total of 5 generative mechanisms are hypothesized. These include the communications and technological infrastructure built around the mHealth project - in particular the technology, people and monitoring and reporting structures; the motivation and attitude of the CHWs including the altruistic nature of the CHWs and the manner in which they use the mHealth technology to complete their work; the actions of two separate mHealth project champions who are part of the mHealth management team in Sierra Leone; the mHealth infrastructure in its entirety; and the financial and non-financial incentives given to the CHWs and part of the recently introduced CHW national policy. It is proposed that these generative mechanisms have dictated why this mHealth project evolved in the way that it did. Although these mechanisms are always contingent on conditions and causal structures, they are particularly relevant in this case. This is despite the assertion that it cannot be claimed any of the hypothesized mechanisms identified are the best ones to explain this case, or indeed, that the hypothesized mechanisms even exist. Despite this however, the research framework developed for this research has the potential to be able to identify the best possible explanation of a situation that is consistent with the data provided in the same situation. All of this means that there is potential to contribute to improving this particular mHealth case, and by extension the entire public health system in Sierra Leone. There are many benefits to be gained from being able to provide explanation of this type for why mHealth implementations have evolved in a certain way. This knowledge has the potential to stop problems before they start and also to do more of what is needed to make mHealth projects work successfully. This gives researchers and mHealth implementers the potential to have great impact, which may mean that many of the world s poorest and most disadvantaged people can benefit from improved mHealth and public health systems