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Mobile persuasive technologies for rural health

Dissertation
Author: Divya Lalitha Ramachandran
Abstract:
Mortality rates due to preventable tragedies in the developing world are devastatingly high. For example, 99% of maternal deaths due to complications in pregnancy and childbirth--which number nearly half a million each year--occur in developing regions. Enabling health information access is often seen as key to promoting preventive health measures. Yet, deep-rooted traditional values and beliefs often pose barriers to the acceptance of more modern maternal health behaviors, like delivering in clinics, or taking prenatal vitamins. This thesis looks at how technologies can leverage psychological theories of motivation and persuasion and be designed specifically to empower agents of change, in this case rural health workers, to address these barriers and promote maternal health practices in developing communities. This thesis describes three years of field research studying the maternal health care system in rural India, where gaps in training, accountability and credibility of community health workers limit their effectiveness in convincing pregnant women to utilize free medical services. It presents the iterative design and deployment of persuasive mobile videos to motivate and build the persuasive power of rural health workers. These include testimonials by influential persons in the villages, and dialogic, persuasive videos which directly target clients. The thesis includes findings from two experiments that compare the persuasive power of audio information when presented in a lecture style vs. a dialogic, interactive mode. The results show improvement in health workers' self-efficacy (an important precursor to motivation), knowledge, and ability to provide high-quality counseling about important health information to clients. The contributions of this thesis are, (1) evidence that dialogic speech-based information presentation is more persuasive than traditional lecture styles, (2) a detailed ethnography of maternal health in India, and a sketch and exploration of the persuasive technology design space in this context, (3) an architecture for designing persuasive messages that improve the quality of health worker-client consultations, and (4) reflections on achieving ICTD research goals amidst challenging, developing world realities.

ii C ontents List of Figures vi List of Tables vii Acknowledgements viii 1 Introduction 1 1.1 A Persuasive Approach..........................1 1.2 Contributions...............................2 1.3 Thesis Organization............................3 2 Persuasive Power of Human-Machine Dialogue 5 2.1 Introduction................................5 2.2 Theoretical Background.........................6 2.3 Related Work...............................6 2.3.1 Computers as Social Actors...................6 2.3.2 Tailored Information.......................7 2.4 The NASA Moon Survival Problem...................7 2.5 System Design...............................7 2.5.1 Recorded Message System....................8 2.5.2 Interactive Dialogue System...................8 2.6 Persuasion Measures...........................9 2.6.1 Expert and Confederate Rankings................9 2.6.2 Standard Rank Metrics......................9 2.6.3 A New Measure..........................10 2.7 Hypotheses................................11 2.8 Study Method...............................12 2.8.1 Participants............................12 2.8.2 Conditions.............................12 2.8.3 Measurement Instruments....................12 2.8.4 Procedure.............................13 2.9 Results...................................14

iii 2 .9.1 Comparison of Systems......................14 2.9.2 Amount of Information Heard..................15 2.9.3 Post-session Questionnaire....................15 2.10 Discussion.................................15 2.10.1 Revisiting Hypotheses......................15 2.10.2 Future Work............................16 2.11 Conclusion.................................16 3 Understanding the Role of Technology in Rural Maternal Health 17 3.1 Introduction................................17 3.2 Background................................18 3.2.1 Maternal Health in India.....................18 3.2.2 Integrated Child Care......................19 3.3 Methodology...............................20 3.3.1 Field Study 1:January......................20 3.3.2 Field Study 2:July - August...................20 3.4 Findings..................................21 3.4.1 Training..............................21 3.4.2 Acceptance............................23 3.4.3 Accountability...........................26 3.4.4 Household Influence.......................29 3.5 A Role for Technology..........................31 3.5.1 The Case for Mobile Phones...................31 3.6 Theoretical Framework..........................32 3.6.1 Persuasion.............................32 3.6.2 Motivation.............................33 3.7 A Sketch of the Design Space......................33 3.7.1 On-the-job Learning and Teaching...............34 3.7.2 Building Credibility........................34 3.7.3 Managing Expectations......................35 3.7.4 Changing Minds.........................35 3.8 Conclusion.................................36 4 Iterative Design with Rural Health Workers 38 4.1 Introduction................................38 4.2 Related Work...............................39 4.2.1 Technology for Rural Health Workers..............39 4.2.2 Persuasion,Motivation and ICTs................40 4.3 Persuasion and Motivation for Health..................40 4.4 Designing an Intervention........................41 4.4.1 Prototype Design.........................41 4.4.2 Methodology...........................42

iv 4 .4.3 Findings..............................43 4.5 Discussion and Implications for Design.................47 4.5.1 Primary Role of Persuasive and Motive ICTs..........47 4.5.2 Engaging Influential Actors...................48 4.5.3 Motivation and Training.....................49 4.5.4 End-User Authoring and Play..................49 4.6 Conclusion.................................50 5 Mobile Persuasive Messages for Rural Health Promotion 51 5.1 Introduction................................51 5.2 Persuasion.................................52 5.3 Persuasive Message Design........................53 5.3.1 Health Outcomes.........................53 5.3.2 Existing Materials........................53 5.3.3 Culturally Relevant Arguments.................54 5.3.4 Recommending Actions......................54 5.3.5 Architecture............................54 5.3.6 Lecture vs.Dialogic Style....................55 5.4 Study Site:Kalahandi,Orissa......................55 5.4.1 Social Hierarchy..........................56 5.4.2 Maternal Health.........................56 5.4.3 Technology Infrastructure....................57 5.5 Iterative Prototype Design........................58 5.5.1 Flexible Architecture for Rapid Prototyping..........58 5.5.2 Branching.............................59 5.5.3 Dealing with Language Woes..................60 5.5.4 Culturally Appropriate Prosody.................60 5.6 Persuasion Tasks.............................61 5.7 Iterations in Study Design........................61 5.7.1 Participant Selection.......................62 5.7.2 Limited Access to Health Workers................63 5.7.3 Special Attention.........................63 5.8 Hypotheses................................64 5.8.1 Persuasive Power.........................64 5.8.2 Quality of Counseling.......................64 5.8.3 Engagement of Client.......................65 5.9 Methodology...............................65 5.10 Participants................................66 5.10.1 Health Workers..........................66 5.10.2 Clients...............................67 5.11 Results...................................67 5.11.1 Persuasion Metrics........................67

v 5 .11.2 Quality of Counseling.......................68 5.11.3 Client Engagement........................69 5.11.4 Health Worker Variability....................70 5.11.5 Quality of Control Sessions....................71 5.11.6 Preferences............................71 5.11.7 Content Relevance........................71 5.11.8 Iron Pills - A Closer Look....................72 5.11.9 Saving Money - A Closer Look..................72 5.12 Research and Reality:The Bigger Picture...............73 5.12.1 Truly Rural............................74 5.12.2 Cutting across Castes.......................74 5.12.3 Unidentified Foreign Researchers................75 5.12.4 Research Study,or Intervention?................75 5.13 Conclusion.................................76 6 Conclusion 78 6.1 Future Work................................78 6.1.1 Largescale Evaluation......................78 6.1.2 Video Exchange..........................79 6.1.3 A Community of Practice Portal................79 6.2 Contributions...............................80 6.2.1 Dialogic Information Presentation................80 6.2.2 Persuasive Technologies for Rural Maternal Health......81 6.2.3 Persuasive Message Design....................81 6.2.4 Reflections on the ICTD Research Process...........82 Bibliography 84

vi L ist of Figures 3.1 ASHA and AWW of one village......................23 3.2 Pregnant women in village.........................29 4.1 ASHA using phone with client......................39 4.2 Summary of our design and deployment.................42 4.3 Logs of viewings of persuasive videos...................44 4.4 ASHAs using mobile phones........................45 5.1 Health worker shows video to client....................52 5.2 Persuasive message architecture......................56 5.3 Hello points.................................57 5.4 Message flow diagram...........................59 5.5 Clay money bank and poster.......................62 5.6 Health worker and village caste break down...............66 5.7 Graph of persuasive power over three conditions.............68 5.8 Graph of quality of counseling over two conditions...........69 5.9 Graph of client engagement over two conditions.............69 5.10 The study often attracted a number of onlookers............72 5.11 Reactions of selected clients towards iron pills..............73

vii L ist of Tables 2.1 Sample interactions for the two conditions................8 2.2 NASA Expert (E) and Confederate (C) rankings of 15 items......10 2.3 Difference in persuasive force across conditions.............14 2.4 Difference in amount of information heard................15 3.1 Reported Training of Health Workers..................22 3.2 Roles of AWW...............................27 3.3 Roles of ASHA...............................27 4.1 Influencers and testimonial content....................47 5.1 Results for counseling quality and engagement..............68

viii A cknowledgments The years I have spent working on this dissertation are full of memories that bring me happiness,inspiration and the drive to do so much more.I am grateful to so many people that have had a part to play in shaping my research,my values and my personal growth over the past six years of my life. My advisor,John Canny,gave me the reins to make my Ph.D.my own.He encouraged me to pursue a topic that excited and interested me,but still provided very attentive support when I needed it most.Through my years in graduate school I have learned so much about the world,about problem-solving,about forming and communicating ideas,and about people,and I thank him for giving me so many opportunities to grow. My dissertation committee is comprised of three more very inspirational profes- sors.Eric Brewer introduced me (and much of the world) to the idea of ICTs and development.I feel so fortunate that I was at the right place at the right time,looking for a research area that interested me,when he started promoting a research agenda to use technologies to address the needs of those in the developing world.I amgrateful for his guidance,encouragement and optimism.Tapan Parikh,has been a role model. His approach and attitude toward research has been a source of inspiration for me, and I amso happy that he came to Berkeley right when I was forming my dissertation committee.I really value all of the discussions we have had,not just about research, but about the goals of ICTD,about choosing a career path,and following a passion. Malcolm Potts is a pioneer in international maternal health.His accomplishments are awe-inspiring,and my interactions with him and experiences in his class opened my eyes to the importance of global health.He has provided constant support and encouragement. I owe my biggest thanks to the wonderful people I have met and worked with in the field.Thank you to all the ASHAs and Anganwadi Workers who have taken time out of their busy days to talk to me,participate in my studies and help me learn. Thanks to all the then mothers-to-be,who,amidst taking care of families,working in fields and dealing with their pregnancies,still pleasantly consented to participate in my studies,and welcomed me into their homes.They have taught me to appreciate life for what it is. I had the privilege to work with Gram Vikas,a non-governmental organization based in Orissa,India,for the majority of my dissertation research.I have met so many heroes in the field.Thanks to Chitra,Urmila and Joe for orienting me, and letting me carry out my exploratory projects at GV.Thanks to Jagdish,Sila, Rasmita,Anushikta,Mrs.Mishra,Achut,Sharat and Pushpa for making time to give me feedback on field plans,translating scripts and recording voiceovers.Thank you Ajay,artist extrordinaire,Donald and Jacob for making everything happen smoothly, and Nana for always making sure I was well fed.Thank you Sanjukta Didi for advising me on all the health content,for taking me on field visits,and for being so giggly.

ix W ords are not enough to express how grateful I am to the field staff - Yashoda Didi,Sukhdev Bhaiya,Anu Didi,Usha Didi and particularly Damayanti Didi and Paramaji - for spending so much time with me in the field,recruiting participants, walking,hiking,motor-biking,and what-not so that I could get my work done.The Bahalpur water tank will always be one of my favorite places in the world.Thanks to the great friends I made at GV - Sambit,Vipin,Christine and Nimisha - for all the memories of watching little Joey,eating mangoes and enjoying those beautiful, starry,quiet nights. I have found true inspiration and a good friend in Dipti Vaghela.She opened my eyes and taught me to see rural life without an academic lens.She facilitated my introduction to Gram Vikas and Orissa.My month in Kalahandi spent with her entirely changed my perspective on research.By watching her in the field,I learned to take ownership of my field work,to work without translators or staff support,and to stop feeling and acting like an outsider.She showed me that I don’t need language to communicate an idea,that I should focus on making friends,not recruiting study participants.I thank Dipti for her incredible support and inspiration,for empowering me like she has so many people in Kalahandi,and for reminding me to care about the consequences of my work. Prabhu Dutta Das was an able research assistant,developer,student leader and translator.He was my guinea pig,and had to put up with a lot of ups and downs from me as a mentor - I am grateful for his quiet persistence.Vivek Goswami worked hard as a developer,and showed such sincere willingness to give field work a try.I learned a lot from mentoring both of them.I thank Dhiren Patra for his help and translation in the field.I hope they will all treasure those memories from the field as much as I will. I am grateful to Sandra Spence for believing in this project.She has spent count- less hours convincing me that what we are doing is impactful,and pep-talking me into being more optimistic about myself and my work.Her enthusiasm has kept me going and charged.Graduate school may be over,but the two of us are just getting started - I am excited to continue working alongside someone as bold,intelligent and energetic as Sandra.Go team! Matthew Kam has been a true mentor for me throughout my years in graduate school.In my first year,he encouraged me to get involved in his then baby project MILLEE,and introduced me to the worlds of ICTD and HCI.I thank him for trust- ing me enough to join him in field work and co-author papers when I had literally no experience,for getting me into the BiD lab,and for being my go-to person for everything HCID.I am ever grateful for the time he has dedicated to making me a better researcher. Thank you,Ana,my cubicle mate,advisor,dear friend,workpace break buddy, lunch companion,and diary to whom I reported every event in my life.Moving into your cubicle changed my Berkeley experience completely.Thank you for being there to advise me in all my decisions,get me out of ruts,help with last minute latex

x fi gures,and discuss and analyze meetings;for showing me how to be rational,and for literally having a solution for everything. Thank you,Dave for being a true friend and colleague through that slow,confus- ing,middle period of graduate school.I am so grateful for the help,guidance and resources you provided for my early persuasion study.You made the BiD lab the amusement park it was,and I’ll always treasure memories of trying (and failing) to talk to you through the glass window. Thanks to the rest of my BiD lab colleagues - Jingtao,Andy,David Sun,Ryan, Lora,Wes,Kenghao,Jeremy and Anuj - for the feedback on talks and papers,and for the hours of conversations and fun we’ve had in the lab that have shaped the way I think,research and live. I thank my inspiring colleagues in the TIER research group.Melissa is the most driven-but-mellow,capable-but-modest women I know.I’ve enjoyed talking to her about all topics ranging from chick flicks to rural clinics.When Joyojeet speaks, I’m left either either wowed by his intelligence,laughing uncontrollably,or reacting dramatically to what is an obvious lie to everyone but me.He is a source of non-stop entertainment,and it seems like everyday I discover he has another hidden talent. Rabin is as sincere as people get.I can always count on himfor anything,fromcoming to practice talks,to translating Oriya videos,to picking up the missing ingredients for my recipe to dancing.Sergiu has been a great friend and colleague,always willing to listen to my most recent dilemma,suggest a solution and then make me laugh. Thanks to Madelaine Plauche for teaching me to stand on my own two feet in the early days.Thanks to the rest of TIER - R.J.,Rowena,Bowei,Mike D.,Yahel, Omar,Jen,Kurtis,Kuang and Renee - and to the honorary members - Roycie,Ann and Rosemary - for all the good times. Kentaro Toyama has always questioned me,challenged me and encouraged me to think critically about my research.I am so grateful that he provided me with the opportunity to intern at Microsoft Research Labs,India,and for his guidance during that time.I was lucky enough to interact with Ed Cutrell,Indrani Medhi,Bill Thies, Rikin Gandhi and David Hutchful during my time at MSRI,and am grateful for all the conversations we had,the feedback they provided and experiences they shared to help me develop a broader perspective on ICTD research.Thanks to my fellow MSRI interns - Nithya,Ilda and Julie - for being my sounding boards,for inspiring me with their creativity,for feedback on talks,papers and study designs,and for being so enthusiastic about technology for rural women.I will always remember our crazy times in Bangalore and Tucson! I thank my colleagues in the Young Researchers in ICTD (once Grad Students in HCID) group,for all those early-morning stimulating conversations.In particu- lar,thanks to Jahanzeb Sherwani and Brian DeRenzi for their encouragement and excitement,and for constantly reminding me how much this work is worthwhile. Paul Aoki has always been available to help me narrow in on my research goals and provide detailed feedback on paper drafts.I hope to one day have his clarity

xi o f thinking.I thank Ndola Prata,for her inspiring work and thoughtful feedback.I learned so much in her classes,and am very grateful for the ways in which she helped me understand the social,cultural and political aspects of global health. Thanks to Manjiree,Anu,Jessica and Gireeja,my housemates at various stages of graduate school.They were there to celebrate all the good times,and put up with me during the frustrating times.Thanks to Roshni,for motivating me to be disciplined,work hard,and still have fun.Our lunch breaks spent talking about research,advisors,Karma Kitchen and life always recharged me.Thanks to Viral, Pavi,Neerav,Trushna and Sannihita for all the comic relief,and to the bay area carnatic fanatics for the music relief. Bharathi - Dr.B.Knowing how much you love your research drove me to search for a problem that truly moved and excited me for my Ph.D.Thank you for always listening,and for always making me laugh till my sides hurt. Adryon - graduate school has been full of ups and downs for both of us,and now we have more memories to talk about when we are old and shriveled up.It was talks with you,early on in graduate school,that gave me the confidence to follow my heart and work on something I cared about.Emily and Evan - you will never stop inspiring me with your incredible achievements.I’m so happy that we all still laugh,cry and talk about everything in the world,the way we did when we were giggly teenagers. Our yearly reunions have been a wonderful source of joy and relaxation over these past few years. Gopala and Chitthu,during our days at the U,you gave me a glimpse into graduate life and made me want it.I am so grateful that you have been there for me,cheered me on,and teased me to death. Thanks,Hemakka,Athimbar and Jikku - for spoiling me with hot showers and good food after weeks of field work in Lucknow and Orissa.Thank you Anand, Chandramouli Sir and Hari Akka - for being my local guardians during my Chennai field trip,and Ramani Mama and Shantha Mami for the twice-daily missed calls. Thank you,Mom and Papa.We came into each other’s lives just as I entered the last and most eventful mile of my Ph.D.Thank you for encouraging me so much,for taking care of me completely while I worked toward a very stressful paper deadline, for calling to check up on me while I was doing field work,and for being there to celebrate the successes.Thank you,Nanosa,for believing in me.I wish I could have shared this with you. Thank you,Ammappa and Ammamma,for your blessings,and for encouraging me to follow my dreams. Thank you,Appa and Amma,for everything - for instilling in me the importance of education,for praying for my success,for comforting me when I’ve been down,and for being so proud of my every achievement.I am so fortunate to have been raised by such honest,loving,dedicated and good parents. Thanks,Akka,for being the best role model a big sister can ever be,for all the phone conversations as I hiked to and from campus,for listening to me talk about

xii e very single,nitty,gritty detail of my day at school like a 5-year-old.I have followed in your footsteps since I was born,worn your old clothes and tried hard to keep up with your successes.I used to complain,but now looking back,I wouldn’t have had it any other way.Thanks,Athimbar,for all the advice about graduate school,advisors, and research,and for starting the Ph.D.trend among us “kids.” Annapurna.You came into this world right after my last conference talk,after my last round of field work,when the end was in sight.It was pictures and thoughts of you that kept me smiling while I wrote this thesis! Sonesh,you were the only person I recognized when I walked into my first TIER meeting.When I said hi,you ignored me.We’ve come a long way.I remember the day we took a walk to that park across from ICSI and I told you I had decided to pursue “mobile persuasive technologies for rural health” as a Ph.D.topic.Since then,you have been an advisor,contructively criticizing my thoughts and ideas,reading all my paper drafts and watching my practice talks.You have been a manager,introducing me to a number of contacts who have played a major role in the shaping of this work, and helping me plan my field work.You have been my best friend,teaching me to tackle frustrating problems one step at a time,and celebrating with gusto even the smallest of my achievements.I could not have gotten this Ph.D.without you,nor could I have gotten you without this Ph.D.Therefore,I am eternally grateful for both.

1 C hapter 1 Introduction Globally,half a million women die each year due to complications in pregnancy and childbirth [66].The greater tragedy is that most of these deaths are due to preventable causes that have been almost completely eradicated in the industrial- ized world.Access to appropriate health information is often seen as the answer to prevention [49],and the use of information and communication technologies (ICTs) for delivering information in resource-scarce,developing regions settings is becoming increasingly prevalent [59,21,39,31].The interdisciplinary field of ICTs and devel- opment (ICTD) broadly examines the potential of ICTs to improve the conditions of those living in poverty [11]. With the advent of ubiquitous computing,where ICTs are becoming fundamen- tally integrated with routine practices in the industrialized world,it is difficult to recognize the ways in which they have changed how we interact with the world.How- ever,observing a community in which electricity itself is a recently acquired amenity, such patterns become more apparent.The research presented in this thesis lies at the intersection of human-computer interaction (HCI) and ICTD;broadly,it examines various social phenomena that occur as a consequence of the introduction of ICTs in rural settings,as well as examines how these phenomena can be leveraged to design ICTs that can foster positive socioeconomic change in the poorest parts of the world. 1.1 A Persuasive Approach A straightforward approach to conducting HCI research in the developing world is to practice well-known early stage iterative design practices of understanding users, assessing needs and involving local stakeholders in hope that technologies can be designed that will fit in with local cultural practices,needs and values.The underlying belief is that technology that is an appropriate match to the local culture will be widely adopted and therefore sustainable.Yet,research examining these interventions through a political lens has found that such interventions succeed or fail often for

2 r easons that have nothing to do with the fitness of the technology in its intended role [35,37].ICTs in developing countries are introduced into environments that have highly-stratified power structures,informal economies of exchange,favors and bribes,highly-regimented traditional roles for various groups of people,centuries of traditional practices with relatively little change,and suspicion of outsiders in general, and government in particular.Into these contexts,ICTs bring radically new practices that challenge much of the existing structure and there is considerable resistance to such change.This calls for a very in-depth understanding of the social,cultural and political dynamics of a community,as well careful observation of how ICT adoption is influenced by these dynamics. We do not claim that this resistance is unique to ICT interventions;rather,any interventions which introduce modern thought or practices inevitably clash with age- old traditions.A prime example,introduced earlier,is maternal health.Deep-rooted traditional values and beliefs pose barriers to the acceptance of more modern health behaviors,like delivering in clinics,or taking prenatal vitamins.We believe that the perception of ICTs only as enablers of information access is too limited;rather,we argue that ICTs can be specifically designed to persuade targets of an intervention in favor of change,and motivate key community members to act as agents of change. For this,we draw from psychological theories of persuasion and motivation,i.e., [33,15,6,38],and contribute to the growing field of persuasive technologies,or technologies designed to promote behavioral change in the user [26]. In this thesis,we focus on maternal health in India,and the National Rural Health Mission [45] which encourages the utilization of modern medical practices during pregnancy and childbirth.The program mandates that one woman from each village should serve as an Accredited Social Health Activist (ASHA) who encourages pregnant women to utilize health services.It provides performance-based compensation for the ASHA and subsidies for poor pregnant women.Pregnant women need to be persuaded by the ASHAs to adopt the new health practices and services which the government offers.However,there are many barriers to the success of this program,namely village and household power dynamics,and compliance with traditional practices.Limited by their education,training and status within the community,ASHAs’ effectiveness, judged by maternal health indicators,is limited.They are committed to change but need help with motivation,because of significant challenges they face in trying to bring change about.We present an ethnography of this context,and an exploration and evaluation of persuasive technologies in this space. 1.2 Contributions The thesis travels through the technology design-cycle,from needs assessment to iterative design to evaluation,highlighting practices and values of rural communities, and how ICTs can or cannot change them.It also touches on a number of aspects

3 o f the design process,with reflections on practicing design research in the developing world. Chapter 2 introduces persuasive technologies,describing how modifying interac- tion techniques can impact the persuasive power of information.Chapter 3 introduces the rural maternal health context,demonstrating the necessity of understanding the complex social dynamics of a community of stakeholders before designing appropri- ate ICT interventions.Chapters 4 and 5 then examine aspects of the potentially powerful role of ICTs to bring about health behavioral change through persuasion. The contributions of this thesis are specifically: 1.Evidence that dialogic,speech-based information presentation is more persua- sive than traditional lecture styles (Chapter 2), 2.A detailed ethnography of maternal health in India,and a sketch and explo- ration of the persuasive technology design space in this context (Chapters 3 and 4), 3.An architecture for designing persuasive messages that improve the quality of health worker-client consultations (Chapter 5),and 4.Reflections on achieving ICTD research goals amidst challenging,developing world realities (Chapter 5). 1.3 Thesis Organization Chapter 2 shows that speech-based interfaces offer a compelling mode of interac- tion for engaging users and therefore explores how to best present persuasive informa- tion using speech interaction.We present a study comparing the persuasive power of two speech-based information systems,one which uses a recorded message-based lec- ture presentation and another which uses an interactive dialogic presentation which requires spoken input by the user.The results of the study show that speech inter- faces which present information in a dialogic method are more persuasive than interfaces which utilize a more standard,lecture-style approach. Chapter 3 sets the stage for the remaining chapters.We describe the context of maternal health in rural India and identify the potential of mobile technologies to deliver health information effectively.We detail two rounds of in-depth qualitative field work,in which we study the efficacy of community health workers in motivating behavioral changes among pregnant women.Many factors beyond the health worker’s control contribute to issues in training,acceptance,accountability and influence of the health worker.We end with a sketch of a rich design space for addressing these issues and building health worker capacity through the provision of innovative reference materials,and tools for establishing credibility,man- aging community expectations,and strengthening her persuasive ability.

4 I n Chapter 4 we focus on the context of supporting India’s rural maternal health workers described in Chapter 3.Many factors reduce the motivation of health workers and impair their performance.We argue that familiar uses of ICTs for information services in these contexts are less potent than their use for persuasion of pregnant women and motivation of health workers in order to facilitate change.We present a two month deployment of short videos on mobile phones designed to persuade village women and motivate health workers,as well as an exercise in which health workers record their own videos.This chapters ends with a discussion of results,and an analysis in light of theories of persuasion and motivation.We show evidence that the creation and use of videos did help (1) engage village women in dialogue,(2) show positive effects toward health worker motivation and learning,and (3) motivate key community influencers to participate in promoting the health workers. In Chapter 5,the technologies described in Chapter 4 are improved to incorpo- rate the findings from the study presented in Chapter 2;the mobile,video-based tools are modified to incorporate a dialogic style of information presentation.We present a study which compares three presentations of persuasive health messages:a phone-based lecture-style message,a phone-based dialogic message that elicits user responses,and a discussion with the health worker (without the phone).We find that dialogic messages significantly improve the quality of counseling ses- sions and increase discussion between health workers and clients;however, we do not statistically measure an effect of either phone-based message on health behavioral outcomes.The results are analyzed within a discussion of the social, cultural and environmental factors in the field and their interactions with the process of technology design and evaluation.

5 C hapter 2 Persuasive Power of Human-Machine Dialogue 2.1 Introduction Live,face-to-face interaction is an undeniably powerful medium for persuasion. But for human-machine interaction,especially using new technologies such as cell phones and Interactive Voice Response systems,can we recreate some of the impor- tant persuasive aspects of live communication?We study the value of spoken voice presentation and contrast a dialogic presentation with a lecture presentation.In the dialogic presentation,the persuading systemmakes short utterances in response to the user’s prompts.In the lecture presentation,all the information needed to persuade the user on one point is included in a message containing multiple short utterances. The presentation of information for persuasion is a growing area of interest in all sorts of domains,such as physical health,environmental consciousness,finance man- agement etc.The wide range of applications for persuasive information presentation serves as motivation to examine the effects of interaction mode on persuasive power. In this chapter,we present a study in which we measured the persuasive power of two speech-based interaction modes with 52 subjects.We compared two systems,one which used speech by playing recorded messages (output only),and the other which simulated dialogue with the user (with input also using the Wizard of Oz technique). Both systems contained the same set of sentences recorded by the same actress;they differed only in the way these sentences were grouped and presented to the user,and in the need for user prompting in the dialogue case.We used the NASA Moon Survival Task [32] as a method to measure persuasion and used four different methods for analysis.Using all four methods of analysis (three standard and one novel) we found that the dialogic system is significantly more persuasive with (p < 0.05) than the lecture-style system.We also found that the dialogic system presented significantly less information (almost four times less) than the lecture system.

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Abstract: Mortality rates due to preventable tragedies in the developing world are devastatingly high. For example, 99% of maternal deaths due to complications in pregnancy and childbirth--which number nearly half a million each year--occur in developing regions. Enabling health information access is often seen as key to promoting preventive health measures. Yet, deep-rooted traditional values and beliefs often pose barriers to the acceptance of more modern maternal health behaviors, like delivering in clinics, or taking prenatal vitamins. This thesis looks at how technologies can leverage psychological theories of motivation and persuasion and be designed specifically to empower agents of change, in this case rural health workers, to address these barriers and promote maternal health practices in developing communities. This thesis describes three years of field research studying the maternal health care system in rural India, where gaps in training, accountability and credibility of community health workers limit their effectiveness in convincing pregnant women to utilize free medical services. It presents the iterative design and deployment of persuasive mobile videos to motivate and build the persuasive power of rural health workers. These include testimonials by influential persons in the villages, and dialogic, persuasive videos which directly target clients. The thesis includes findings from two experiments that compare the persuasive power of audio information when presented in a lecture style vs. a dialogic, interactive mode. The results show improvement in health workers' self-efficacy (an important precursor to motivation), knowledge, and ability to provide high-quality counseling about important health information to clients. The contributions of this thesis are, (1) evidence that dialogic speech-based information presentation is more persuasive than traditional lecture styles, (2) a detailed ethnography of maternal health in India, and a sketch and exploration of the persuasive technology design space in this context, (3) an architecture for designing persuasive messages that improve the quality of health worker-client consultations, and (4) reflections on achieving ICTD research goals amidst challenging, developing world realities.