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Association for Information Systems
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Research Papers ECIS 2016 Proceedings
Summer 6-15-2016
AN ACTIVITY THEORY APPROACH TO
AFFORDANCE ACTUALISATION IN
MHEALTH: THE CASE OF MOMCONNECT
Brendon Wol"-Piggo#
University of Cape Town, brendonwp@gmail.com
Ulrike Rive#
University of Cape Town, ulrike.rive?@uct.ac.za
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Recommended Citation
Wol=-Piggo?, Brendon and Rive?, Ulrike, "AN ACTIVITY THEORY APPROACH TO AFFORDANCE ACTUALISATION IN
MHEALTH: THE CASE OF MOMCONNECT" (2016). Research Papers. Paper 108.
h?p://aisel.aisnet.org/ecis2016_rp/108
Twenty-Fourth European Conference on Information Systems (ECIS), Đstanbul,Turkey, 2016
AN ACTIVITY THEORY APPROACH TO AFFORDANCE
ACTUALISATION IN MHEALTH: THE CASE OF MOM-
CONNECT
Completed Research
Wolff-Piggott, Brendon, University of Cape Town, South Africa, brendonwp@gmail.com
Rivett, Ulrike, University of Cape Town, South Africa, ulrike.rivett@uct.ac.za
Abstract
There is a substantial body of research on mHealth interventions in low-resource settings, but little
empirical understanding of use by staff in established health facilities. What evidence there is indi-
cates divergent outcomes. In order to generate insight into this phenomenon we undertake an explora-
tory study of mHealth use in several public clinics, where the staff are required to perform a simple
registration process for the MomConnect system.
We draw on the lenses of Activity Theory and affordance actualisation to assist in the analysis of the
evidence collected, and find that professional identities, local priorities and technology features all
interact in shaping the forms that mHealth use takes in practice. Based on this analysis we propose a
set of higher-level concepts in order to compare case studies of mHealth use.
This research contributes to theory by proposing a framework for understanding mHealth use in exist-
ing facilities, with specific reference to low-resources settings. In addition we contribute to the litera-
ture on conceptualising affordance actualisation, drawing on Activity Theory. Finally, we inform
practitioners by outlining important constraints that impede staff as they strive to accommodate this
additional burden in their daily routines.
Keywords: ICT4D, mHealth, Low-resource setting, Affordance Theory, Activity Theory, case study
1 Introduction
Research on the implementation of mobile applications to support health care (mHealth) has received
increasing attention in recent years (Chib, van Velthoven, & Car, 2015; Free et al., 2013). There is
limited understanding of the way that these innovations are adopted in practice in existing institutions,
and how this relates to the specific characteristics of the technical system. In addition, researchers
have questioned whether mHealth solutions are effective and scalable (Tomlinson, Rotheram-Borus,
Swartz, & Tsai, 2013). This emphasises the importance of better understanding mHealth implementa-
tions in established health facilities.
Currently it is unclear what the dynamics underlying staff use of mHealth are, and how they are influ-
enced by the technical choices of the mHealth solution. Characterising affordance actualisation in
low-resource mHealth implementation is thus a matter of pressing importance to understanding
broader issues of scalability and sustainability (Sahay, Monteiro, & Aanestad, 2009; Sahay &
Walsham, 2006), that are important for policy makers and scholars alike.
Recent research has convincingly argued that understanding routine IS use requires an attention to the
work practices in which this takes place (de Guinea & Markus, 2009; Riemer & Johnston, 2014). Ac-
tivity Theory is a practice-oriented theoretical framework with which to interpret data gathered from
intensive research dealing with information systems (IS) implementations (Kaptelinin & Nardi, 2009;
Star, 1998). Situating the concept of affordance actualisation in the framework of Activity Theory
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allows us to extend affordance analysis to better take contextual issues into account in understanding
the phenomenon.
Affordance theory has been increasingly explored in recent years as a way to come to grips with the
specific characteristics of various forms of IT applications, and their use in practice (Balci,
Rosenkranz, & Schuhen, 2014; Choy & Schlagwein, 2015; Lindberg, Gaskin, Berente, & Lyytinen,
2014; Pozzi, Pigni, & Vitari, 2014). Aspects of Information Systems (IS) that have been explored in-
clude software development (Lindberg et al., 2014), social media (Choy & Schlagwein, 2015) and
human-computer interaction (Kaptelinin & Nardi, 2012), as well as more theoretical extensions
(Gaskin, Berente, Lyytinen, & Yoo, 2014). Research on affordances in the health sector has been less
extensive (Strong et al., 2014).
Our core research question is what are the key drivers of affordance actualisation in mHealth use by
facility staff, in a low-resource setting? We use a field study to address this question, as the existing
literature does not provide a solid basis for advancing understanding. The MomConnect maternal
health messaging system was launched in South Africa in August 2014. An empirical study of se-
lected public health clinics implementing MomConnect is reported on in this paper, examining the
relationship between a specific system affordance and how it was actualised in practice.
Following this introduction we review the literature on affordances and activity theory, and examine
how affordance theory may be framed using Activity Theory. After this we present the study method-
ology, and the research setting. We then move on to the empirical findings. After the discussion, we
present our conclusions.
2 Theoretical Background
2.1 Activity Theory
The most fundamental concept in Activity Theory is that of activity (Engeström, 1993; Kaptelinin,
Kuutti, & Bannon, 1995; Nardi, 1996). An activity happens when a subject (a person or group of peo-
ple) attempts to achieve a specific goal (known as the object of activity) using one or more tools
(Kaptelinin & Nardi, 2009). This tool is not necessarily a physical object like a hammer, a tool may
be a concept that is used to advance ways of reasoning, or an information system that is used to enter
and manipulate information (Leonardi, 2012). The concepts of subject, object and tool are interrelated,
and together form an activity system. In Activity Theory, the nature of reality (ontology) is fundamen-
tally relational, as the subject, the object and tool derive their nature from their ongoing engagement in
goal-directed activity.
Activity Theory argues that the process of attempting to achieve the object of activity is a dynamic
one, as the actual outcome may not be satisfactory, leading to a realignment of the activity system as
the subject attempts in different ways to realise the intended object of activity (Vygotsky, 1978). An-
other important concept in Activity Theory is that of contradictions. Activity Theory holds that activ-
ity systems generally contain contradictions that place stress on the system, that may be identified
from empirical data in the form of breakdowns and recurrent problems (Kuutti, 1999).
An organization may also be understood as a series of nested activity systems. These systems may
contain contradictions both within themselves and between the different systems. The constructs of
Activity Theory have been used successfully in a small but growing stream of IS research (Karanasios,
Allen, & Finnegan, 2015; Korpela et al., 2004), including those with a focus on mobile technology use
(Allen, Brown, Karanasios, & Norman, 2013).
Engeström (1999) proposed an expanded version of the activity system that identified aspects of the
social world relevant when applying Activity Theory in an organisational context. This model has
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found acceptance in the Activity Theory community as a useful device (Kaptelinin & Nardi, 2009) and
is shown in Figure 1 below.
Figure 1 The Activity System Model (Yrjö Engeström, 1999)
We use the lens of Activity Theory in this research to analyse the dynamics of mHealth use by facility
staff. Using Activity Theory allows us to consider the influence of the mHealth solution in the context
of existing work practices, tools and the broader context of the health facility.
2.2 Affordances
The concept of affordances has been introduced into IS from ecological psychology in order to bridge
the divide between the nature of the IT artifact and social context (Leonardi, 2011; Markus & Silver,
2008; Strong et al., 2014). The concept was originally defined as an opportunity for action offered by
the environment to an organism (Gibson, 1979), that is perceived directly rather than being the result
of rational reflection. The definition of affordance adopted in this research is therefore a relational
one, in line with the ontology of Activity Theory, based on that of Markus and Silver (2008). In their
words, affordances are “the possibilities for goal-oriented action afforded to specified user groups by
technical objects” (p.622).
There has been ongoing debate about the nature of affordances (Baerentsen & Trettvik, 2002; Faraj &
Azad, 2012; Gaskin et al., 2014; Kaptelinin & Nardi, 2012), but much of the research to date has fo-
cussed on conceptual discussions (Strong et al., 2014). While there is growing support for a relational
definition of affordances as appropriate for IS research (Faraj & Azad, 2012; Kaptelinin & Nardi,
2012; Leonardi, 2011), the concept has been operationalised in slightly different ways in empirical
studies.
When the concept of affordances is applied in empirical contexts, it becomes necessary to extend it to
take account of the complexities of actual work practice involving ICTs (Bernhard, Recker, & Burton-
Jones, 2013; Leonardi, 2011; Strong et al., 2014). Some extensions that have been proposed include
distinguishing individual from group-level affordances (Leonardi, 2013), as well as identifying “bun-
dles” of affordances and teasing out the actualization of affordances (Bernhard et al., 2013; Strong et
al., 2014). Strong et al (2014) is one of the few research papers applying the concept of affordance in
a health care context.
Our interest in this research is in mHealth use in practice. We therefore focus on the process of affor-
dance actualisation, and the multiple ways that “possibilities for action” are realised by different user
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groups. In the next section we set out the argument for using affordance actualisation as a way to fo-
cus Activity Theory analysis to understand mHealth use.
2.3 Activity Theory and Affordance Actualisation
Activity Theory offers a structured framework with which to analyse IS use in practice, in organisa-
tional settings. The empirical analysis of affordances actualisation as a relational process is currently
underdeveloped. Grounded Theory (Strong et al., 2014) and Critical Realism (Bygstad, Munkvold, &
Volkoff, 2016) have recently been proposed, but both approaches lack the strong focus on goal-
oriented action that is the hallmark of Activity Theory.
Activity Theory is particularly suitable as a framework in which to analyse activity actualisation be-
cause of its strong relational ontology. While the activity system uses terms like “subject”, “object”
and “tool” that might be mistaken for static constructs, these are all in dynamic relationship and con-
stantly lead to transformation through their interaction (Allen et al., 2013). One of the key dynamics
in Activity Theory is the constant tension involved in the attempt to better realise the intended object
of activity in relation to actual outcomes, and the internal and external contradictions that need to be
managed in this process.
We propose that for Activity Theory offers a suitable framework for empirically analysing affordance
actualisation, because of the their overlapping approaches to understanding IS use. The outcome of
goal-directed activity may be considered as users’ actualisation of the aggregated “possibilities for
goal-oriented action” offered by the IS tool. At the level of an individual user, the “tool” in the Activ-
ity System may be considered as equivalent to a technical object, defined as “IT artifacts and … com-
ponent parts” (p.620, Markus and Silver, 2008). The dynamic resulting in the actualisation of affor-
dances may be reconceptualised as the operations of an Activity System, at the level of an individual
interacting with the technical features.
In this perspective, activity actualisation may be considered to be the process that takes place as spe-
cific user groups make use of the technical features of a particular mHealth system, to realise its func-
tional affordances. This framing of the concept of affordance actualisation provides a way to relate
affordances to the organisational context in a structured way. At the same time, using the concept of
nested activity systems, Activity Theory allows us to understand how affordance actualisation takes
place at different levels of an organisation, and the relationship between these levels. It can also ac-
count for broader contextual influences.
3 Research Method
We used an exploratory case study to address the research question, as routine mHealth system use by
facility staff is a relatively new phenomenon, and little understood. An inductive methodology was
used to identify key themes and concepts (Sarker, Xiao, & Beaulieu, 2013), and then our hybrid lens
of Activity Theory and affordance actualisation was used to guide further analysis. The approach was
therefore anchored in the empirical data, but full grounded theory methodology was not used
(Matavire & Brown, 2011).
Our case study investigated the implementation of the maternal messaging mHealth solution known as
MomConnect (SABC Digital News, 2014). We drew on this for our case study, as MomConnect is
one of the first large-scale mHealth rollouts in a low-resource setting (South Africa), and we were able
to obtain access to a number of sites where the rollout took place. MomConnect requires facility staff
to register pregnant women in order for them to obtain the full set of messages from the system.
The field study was carried out approximately six months after the launch of MomConnect, so that we
could study routine use of the system. After an initial round of data collection we returned to the field
some months later, to conduct additional observation sessions so that we could develop a fuller picture
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of how the use practices were playing out. Initial interviews were held with a range of stakeholders to
obtain background information on the project. More formal interviews were conducted with clinic
staff to obtain their perspective on MomConnect, as the users in the facilities. Non-participant obser-
vation sessions were also held. In addition, we collected project documentation and consulted web
sites to develop a fuller picture of the implementation. Details are provided in Table 1 below.
Interview Data Observation and Other Data
•
Interviews with Clinic Staff (Four
with facility managers, three with
ANC nurses, five with support staff)
•
Direct Observation of Registration Process (eighteen ses-
sions in total)
• General Clinic Observations (six partial and three full days)
• Field Notes (Over 192 A5 pages of handwritten notes)
• Training and Promotional Material (over fifteen documents)
Table 1. Summary of data collected and analysed
The clinics included in the research were selected on the basis of their accessibility to the research
team, through an established association with the Wits Reproductive Health Institute. All of the clin-
ics fall under the City of Johannesburg Health Department. Open-ended interviews were held with the
facility manager at each clinic, with the nurse responsible for providing antenatal services, and with
any other staff involved in MomConnect registration that were identified by the nurse. Each of these
interviews was recorded with the permission of the informant, and professionally transcribed.
Observation sessions of MomConnect registration were also negotiated with the informants, typically
for the first half of a morning. General observation of clinic routines was also performed over at least
three days, with a minimum of one full day being spent in each clinic. Field notes were made during
each observation session, and reviewed as soon as possible afterwards. Work pressure in the clinics
meant that interviews and observation sessions not infrequently had to be rescheduled, and lead to
substantially more time being spent in the clinics than is reflected in Table 1.
The interview transcripts were loaded into qualitative data analysis software (“Atlas.ti,” 2015). Ini-
tially the transcripts were coded using open coding (Saldaña, 2013). The initial codes were then
grouped according to themes identified from the literature review, and emergent concepts were identi-
fied. Hermeneutic analysis (Klein & Myers, 1999) was used to move between the coding of the tran-
scripts and the relevant literature, in order to refine the codes and themes, and develop higher-level
concepts. Information from field notes and informal conversation was also taken into account in this
process.
4 Research Setting
South Africa is one of the few countries where child mortality has increased since the baseline set for
the Millennium Development Goals in 1990 (Chopra et al., 2009). MomConnect is part of the ambi-
tious National Health Insurance initiative, that aims to improve public health by upgrading the availab-
lity and quality of services (Department of Health, 2012a, 2012b).
MomConnect is a free SMS-based mobile messaging service. It provides informative messages to
pregnant women, and to mothers with children under one year in age, in order to help them look after
their own health. In addition, it provides facilities for them to report on their satisfaction with the ser-
vices provided in the clinic, as well as to ask questions of their choice to a central team under the su-
pervision of a professional nurse at the NDoH.
Community health workers or pregnant women are able to perform registrations for MomConnect, but
a full set of messages will only be provided if the woman is registered at a clinic. The clinic staff are
thus involved only peripherally as users of the system, but they are gatekeepers of access to the ser-
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vice. Regional health managers also receive statistics of the number of women registered at the clinics
from the NDoH central database, allowing them access to these figures well before the rest of the
clinic data. Most clinic reporting is provided by the facility in the form of monthly paper reports.
The MomConnect mHealth service uses the Unstructured Supplementary Service Data (USSD) proto-
col to register users. MomConnect registration involves entering a standard code to initiate the regis-
tration process. The phone number for SMS message delivery is then required, followed by the unique
clinic code. Finally, the baby’s expected date of delivery and the woman’s passport or identity docu-
ment number need to be entered before she can start receiving biweekly messages.
5 Empirical Findings
5.1 Overview
Primary health care clinics in South Africa are run by facility managers, who are typically registered
nurses. These facility managers supervise other nurses who provide care in the different sections of
the clinic. Primary health care services include HIV testing and treatment, family planning, antenatal
and postnatal care, and chronic illness management.
In clinics that we observed, the nurses recorded the patient’s details in large registers, that took up a
large part of the surface of their desks. Nurses generally did not have access to a computer, and most
reporting was done by hand. The ANC consulting rooms typically each contained a desk and chair for
the nurse, a chair for the client (or more, depending on the size of the office), and an examination
couch. Other equipment such as weighing scales typically stood outside the consulting rooms in a
common area.
MomConnect registration typically took place as part of antenatal care services, under the manage-
ment of the nurse in charge. The nursing staff were supported by a variety of other designated staff,
including community health workers, health promoters and volunteers who received a small monthly
stipend. There were also clerks and general workers who assist in administrative and other duties. For
the sake of brevity we will refer to non-nursing staff as support staff from here on.
The MomConnect registration process within the clinic may be understood as three nested activity
systems oriented around three different goals: clinic management by the facility manager, ANC ser-
vice provision as the responsibility of the ANC nurse, and MomConnect registration as arranged by
the ANC nurse (Wolff-Piggott, Coleman, & Rivett, 2016). In contrast to many studies of affordances
in the IS literature, MomConnect use is characterised by high levels of professional flexibility by the
responsible user group in a front-line service bureaucratic environment, and severe resource con-
straints. Further, the affordances of MomConnect are primarily intended for the use of pregnant
women, rather than the clinic staff.
5.2 Activities and Contradictions
Interviews at facility manager, ANC nurse and support staff levels provided more details of their dif-
ferent levels of focus, and how they related to MomConnect use as a result. The facility manager was
concerned with ensuring that all units of the clinic were providing adequate care, and balancing re-
sources across the clinic to ensure that critical shortages were addressed. In several interviews and
informal conversations it became clear the clinic management involved continually making trade-offs,
as it was not possible to meet all the demands on the clinic with the available resources.
Nurses examined clients and diagnose health issues all morning, and sometimes well into the after-
noon from their designated rooms. A nurse was responsible for attending to all clients in her section,
before moving across to help out in another one, in case of an event such as another nurse being on
unexpected sick leave. The mass of clients requiring attention and the shortage of staff meant that
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nurses in particular were torn between attending to each client as rapidly as possible (“pushing the
queue”), and taking the time to ensure that no significant symptoms were missed in each consultation.
MomConnect registration practices seldom involved the nurses performing registrations themselves.
This trend, and the influential role of nurses in the clinics leant weight to the respondent who stated
directly that MomConnect registration was not seen as in line with the scope of professional work of a
nurse. Shortage of professional nursing staff and time were also mentioned as constraining the in-
volvement of nurses in MomConnect use: "Work is added ... (by) this Mom Connect, it's on top of
other things".
The work practices around MomConnect registration differed in each case, but many of the same
themes appeared across clinics. In the one case where there was a nurse present when registration was
taking place, it was in a clinic where the support staff member and nurse typically saw patients to-
gether. This meant that the nurse was able to expand on key points raised by the health promoter.
Pregnant women were then asked to enter the registration information themselves, in a group setting.
In the other clinics, the support staff member would provide an educational talk to the mothers, and
close off by introducing MomConnect as an important source of information. They would then write
down the mother’s details if they were interested in registering, and do the registration on a personal
handset later in the day in a staggered process. This had the advantage that the staff member worked
with a known (own) handset, as one of the issues raised in the other clinics was that working with the
mother’s handsets meant having to navigate a wide range of devices every day.
This description has indicated that both the facility level and ANC activity systems operate under se-
vere resource constraints, and contradictions arise as a result. In the following section we discuss the
MomConnect registration affordance as it was observed to operate in practice.
5.3 MomConnect Registration: Handset and System Affordances
The literature suggested that mobile phone use, certainly in urban areas such as Johannesburg, should
be quite unproblematic. This was not found to be the case, with informants reporting that clients not
infrequently either did not have a mobile handset, or there was a perception that they were not able to
use it effectively. Urban South Africa has a percentage penetration of cell phones, and most clinic
clients had one in their possession when they attended. Concerns cited regarding confidentiality of
information submitted at the clinic could explain this: "... some of them are HIV positive so they are
scared that we will be sending information on HIV, and some of them haven't disclosed and some-
times they share the phones".
When MomConnect registration sessions are observed, a number of issues were seen to arise. On the
one hand, when group registrations were carried out by the pregnant women, language became an is-
sue. There are eleven official languages in South Africa, and large immigrant populations from other
African countries in Johannesburg. The pregnant women were not infrequently unable to read Eng-
lish, and the registration menu was only available in English. The registration menu was intended for
use by clinic staff, who are all required to be English literate. Some women were observed to need
assistance from those sitting next to them, as a result of this issue.
The staggered registration process, carried out by support staff after the individual consultations had
been held between the mothers and the ANC nurse, also encountered difficulties. The USSD mecha-
nism for the registration process was familiar to the clinic staff however USSD is the lowest priority
protocol handled by GSM cell phone towers, and this service suffers first if there is congestion. Reg-
istration sessions were often dropped, which made it necessary to restart the registration process. This
was not only time consuming, but also lead to some discouragement of the support staff who were
charged with doing the registrations. The more enthusiastic staff resorted to performing registration
after hours at home, but this raises a question as to whether this is sustainable.
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6 Discussion
6.1 MomConnect Registration as Affordance Actualisation
We took the perspectives and practices of facility staff as our point of departure in our research, in or-
der to develop our approach to affordance actualisation. We drew on Activity Theory as a framework
because it provides a structured set of concepts with which to analyse goal-oriented action, while be-
ing flexible enough to use in interpreting data collected using open-ended interviews and observation
(Kaptelinin & Nardi, 2009; Star, 1998). Prior research on the affordances of mobile information sys-
tems has emphasised their relevance for promoting the development of individual routines (Boillat,
Lienhard, & Legner, 2015). Our research builds on this by setting affordance actualisation in a socio-
technical context, and taking explicit account of the low-resource setting.
Using Activity Theory, we described MomConnect use in the facility in terms of a series of nested
activity systems with different goals. At the facility level, the relevant goal of the manager is to ensure
the effective operation of the clinic by allocating resources in a way that meets the most urgent needs.
The low-resource environment and high demand for services ensure that all the needs of clients cannot
be met at the same time, and trade-offs are an integral part of this activity. This issue arises in front-
line public service delivery both in developed and low-resource contexts (Lipsky, 2010).
When we considered MomConnect registration in ANC care, we clarified that it is peripheral to the
duties of the ANC nurse and her professional identity. In the same way as the facility manager, the
ANC nurse has to make decisions as to where to allocate resources and where to delegate less impor-
tant work, in order to try and offer a high level of service to each woman and still see all those who
arrive for service. Pregnant women in South Africa not infrequently struggle to obtain access to pub-
lic health services (Solarin & Black, 2013), and struggle with multiple health conditions and other
poverty-related issues (Scorgie et al., 2015).
This activity system analysis helps explain why MomConnect registration is commonly delegated,
either to support staff or to the pregnant women themselves, rather than being carried out by the nurs-
ing staff as suggested in the training material. This is in line with related research on the implementa-
tion of HIT, where doctors often delegate data entry tasks to nurses. It suggests that the professional
aura previously associated with IS, or in this case mHealth (Prasad, 1993; Scheepers, Scheepers, &
Ngwenyama, 2006), is no longer evident in this low-resource setting.
We have described the general work practices in the clinic, as well as the specific ways in which regis-
tration was carried out. Affordance actualisation at the individual level also gave rise to breakdowns
and recurrent obstacles. In the case of the pregnant women, it was most commonly observed as their
difficulty in using the English-only registration menu. The quotes regarding difficulties experienced
with the absence of handsets suggests that there was possibly passive resistance also happening, as a
results with confidentiality concerns.
We present a schematic diagram of the actualisation of the MomConnect registration affordance in
Figure 2 below. It indicates how multiple influences interact to result in multiple forms of actualisa-
tion. We have simplified the different activity systems within the clinic into one, and omitted the in-
teractions of the pregnant women with the process for the sake of clarity. The actualisations are
shown as both being a result of and an influence on the main activity system. A hypothetical example
of an influence from the affordance actualisations to the main activity system would be if inefficient
registration lead to complaints from pregnant women to the clinics.
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Figure 2 MomConnect Registration as Affordance Actualisation
6.2 Other Frameworks for Affordance Actualisation
Researchers have proposed affordances as a building block within other frameworks, for example mid-
range theories of EHR implementation (Strong et al., 2014), Critical Realism (Bygstad et al., 2016)
and sociomaterial routine analysis (Gaskin et al., 2014). Sociomaterial routine analysis proposes a
computational approach, and the use of affordances in terms of categories of functionality that are in-
corporated into routines. Gaskin et al (2014) note that this approach may draw on idiographic analy-
ses, but is not directly compatible. Our framework illustrated above is a mid-range formalisation, and
we believe that it may be generalised, thereby contributing to narrowing the gap between ethnographic
and computational approaches.
Bygstad et al (2016) suggest the use of affordance actualisation as the mechanism by which IS arti-
facts influence observed outcomes, enabling them to propose a framework for carrying out systematic
analysis of empirical phenomena within Critical Realism. This is primarily a methodological contri-
bution, but it is worth noting that their model of “affordance structure” involves interaction between
agents, affordances and the environment to produce specific outcomes, quite similar to the model de-
picted in Figure 2. Activity Theory is broadly complementary to Critical Realist analysis (Allen et al.,
2013).
Strong et al (2014) provide an account that also addresses IS implementation in the health sector.
Their study dealt with the implementation of an Electronic Health Record (EHR) system, and they
identified multiple affordances that they examined in a longitudinal study. Their mid-range theory of
EHR affordance actualisation identified goals at different levels in the organisation, and also drew on a
relational definition of affordances. We complement their grounded theory-based approach with an
Activity Theory framed analysis specifically aimed at mHealth use.
Our use of Activity Theory to analyse affordance actualisation has enabled us to integrate considera-
tion of organisational, technological and individual influences on the dynamic driving the forms that
they were seen to take. In this way it builds on the strength of inductive approaches to affordance ac-
tualisation (Strong et al., 2014), but can also provide guidance in abstracting to higher-level concepts
in a way that preserves the agency of organisations, individuals and the tools that they draw on.
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6.3 Derived High Level Concepts
In this section we describe several high-level concepts that we developed inductively in the process
described of the analysis described in the previous section. While they are drawn from an Activity
Theory based understanding of mHealth, we believe that they are general enough to be useful to most
analytical approaches that are based on a sociotechnical approach to the topic. These concepts are not
intended as static constructs, but as dynamic and inter-related elements to draw on when framing stud-
ies of mHealth use by facility staff, particularly in low-resource settings.
A previous analysis of MomConnect (Wolff-Piggott et al., 2016) indicated that the national implemen-
tation of MomConnect could be represented as a larger activity system, with the goal of improving the
health of pregnant women at a national level. Facility level registration occurs at multiple local sites
that are integrated with the rest of the Health Department via management structures, and the technical
infrastructure provided by the cellular networks and the recording of registrations on a central Mom-
Connect database.
Previous research on distributed systems has suggested that this requires a focus that extends beyond
the specific sites being studied (Monteiro, Pollock, Hanseth, & Williams, 2012; Williams & Pollock,
2012). Our empirical focus has been on affordance actualisation at facility level. In order to be able
to extend our analysis to other low-resource mHealth services we need to distinguish between the
types of user targeted in relation to different types of functionality.
Accordingly, we propose the concept of affordance focus, to be able to distinguish between situations
where the affordances of the system are primarily intended for the use of the facility staff, or for other
users (in the case of MomConnect, pregnant women). This is particularly important for mobile service
delivery, where there may be diverse user groups who engage with the system. Affordance focus en-
compasses the designed affordances intended for use at facility level, and the user groups and work
practices that are targeted.
Another group of users who are important in HIT implementation, and especially in mHealth, are
managers who are enabled by the near real-time data collection activities of the front-line staff
(Asangansi & Braa, 2010; Wears & Berg, 2005). This data gives them visibility into the operational
activities of staff that is far greater than the largely paper-based reporting systems (Leclercq-
Vandelannoitte, Isaac, & Kalika, 2014) in low resource settings allows. Traditionally, health profes-
sionals have exercised a substantial degree of discretion in providing their services, and in public
health facilities this has been accompanied by a bureaucratic style of organisation. Recent research
has suggested that mHealth potentially disrupts these organisational relationships (Asangansi, 2016),
by enabling centralised monitoring of progress and reducing the role of middle-managers in informa-
tion management. We therefore suggest that another important aspect of mHealth use in existing fa-
cilities is the level and type of management control exercised on the basis of mHealth use. We term
this external motivation from the perspective of the local facility.
When we undertook our field study, the level of management feedback was low, and the processes
internal to the facility were dominant in driving affordance actualisation. In our empirical work we
distinguished different levels of goal-oriented activity, organisational phenomena such as professional
identity at work within the facility as well as individual responses that influenced MomConnect regis-
tration in practice. We use the term internal motivation to refer to this array of influences on affor-
dance actualisation.
Finally, the specific technological features of the affordance (and supporting infrastructure) need to be
considered in context, as a sociotechnical complex. In this case study, mobile handset and USSD
communication use were familiar to the clinic staff and clients because of their widespread availabil-
ity. Despite this, some issues arose because of client confidentiality concerns on the one hand, and the
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Twenty-Fourth European Conference on Information Systems (ECIS), Đstanbul,Turkey, 2016
11
challenges to time-constrained staff because of dropped USSD sessions on the other. We term this-
contextual technology fit.
We present the four high level concepts with examples drawn from the literature in Table 2 below.
Concept Description Examples
Affordance Focus
(of mHealth sys-
tem)
The degree to which the system affor-
dances are directed to supporting or
transforming current staff activities,
the type of practices involved, and the
target user group.
Wolff-Piggott et al (2016): (MomConnect)
Low degree of focus, additional rather than
supportive/transformative, impacts on ANC
work practices, aimed primarily at ANC
nurses.
External Motiva-
tion (of facility
staff)
Influence exerted from outside the fa-
cility to ensure system use e.g. Man-
agement measures, alignment with
other directives or policy initiatives.
Mukherjee (2015): National budget transfers
to states and individual remuneration are
linked to number of registrations of preg-
nant women and small children.
Internal Motivation
(of facility staff) The extent to which system usage
aligns with motivating factors, profes-
sional hierarchies and divisions of la-
bour etc within the facility. At differ-
ent levels of staff.
Wolff-Piggott et al (2016): (MomConnect)
Alignment with professional identity low in
the case of nurses. Task-shifting to support
staff and pregnant women occurs in line
with existing practices in the clinic regard-
ing non-professional tasks.
Contextual Tech-
nology Fit
(of affordances
with the facility
activity system)
How well the technical features of the
mHealth system fit with perceived
needs, available technological re-
sources and skills (activity system) of
the facility staff. Consequent require-
ments to improve this e.g. training,
technical support.
Purkayastha, Manda, & Sanner (2013):
DHIS2 offers internet-based submission of
standard reports. Promises to save out-of-
pocket expenses involved in transporting
paper reports. Requires provision of inter-
net connectivity and training.
Table 2. Summary of High-Level Concepts
7 Conclusion
The research presented here has summarised our empirical findings and analysis of affordance actuali-
sation, in a clinic-level investigation of the MomConnect project in South Africa. Drawing on this
field study we have illustrated how Activity Theory may be used to provide improved analytic insight
on key drivers behind the observed work practices, and contributed to the limited empirical literature
on the mechanisms underlying routine mHealth use (Chib et al., 2015). We have also tentatively sug-
gested high-level concepts for framing research on mHealth use in existing facilities, providing a basis
for comparing case studies more systematically.
We proposed the concept of affordance focus to distinguish between situation where user groups and
work practices in facilities are centrally or peripherally targeted by the designers. We also argued for
external motivation as the various means of influence exercised on the facility by higher management.
Internal motivation describes the motivating and controlling processes occurring within the facilities,
such as professional identities, formal hierarchies and personal motivations. Finally, we suggested
contextual technology fit as the way in which a proposed mHealth solution satisfies actual user group
needs, meshes with work practices, and available technical resources.
We contributed to theory more broadly by developing an Activity Theory-framed approach to affor-
dance actualisation that we illustrated in our analysis of the case study. In our belief, this framework
provides a sound basis for generalising this approach to other cases of IS affordance actualisation.
We also compared this approach to other frameworks which have proposed the use of affordances to
investigate empirical phenomena, such as Critical Realism (Bygstad et al., 2016) and sociomaterial
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Twenty-Fourth European Conference on Information Systems (ECIS), Đstanbul,Turkey, 2016
12
routine analysis (Gaskin et al., 2014). In this way we built on existing research on theorising affor-
dance actualisation, as well as empirical analysis of this process (Strong et al., 2014).
Future research could fruitfully explore how the proposed model of affordance emergence may sup-
port future theoretical development, as it is general in nature. In particular, by extending it to cater for
more complex affordance actualisation than the one explored here. We are planning to embark on
comparative empirical studies of mHealth use, and would welcome collaboration with other research-
ers interested in this area.
We would like to thank the staff of the clinics under study in Johannesburg for making time available
in their busy schedules for interviews and focussed observation sessions. In addition we would like to
express appreciation to the reviewers of this track for the time and work that they put in to making
comments.
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