Case Paper

DOI: 10.4018/JCIT.2020100103

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


Copyright©2020,IGIGlobal.CopyingordistributinginprintorelectronicformswithoutwrittenpermissionofIGIGlobalisprohibited.



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

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

ABSTRACT

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

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

INTRoDUCTIoN To DIGITAL HeALTHCARe PRoMoTIoN PRoGRAMS

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

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

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

originalpublicationsourceareproperlycredited.

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

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

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

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

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

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

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

SeTTING THe STAGe

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

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CASe DeSCRIPTIoN

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

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

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

Figure 1. HIC’s organisation structure

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Despitethisaim,thereweredifferentopinionsamongthepanelmembersaboutcertaintopics,such
asthefibrecontentofahealthydiet,andsoon.

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

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

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

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

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

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

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

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

• Email Newsletter Campaigns:Theseemailsweretobecomeavitalcomponentoftheemail
promotioncampaignforpromotingtheNutritionCentre.

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

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

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

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

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PoST IMPLeMeNTATIoN ReVIew: LeSSoNS FRoM THe PAST

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

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

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

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

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

Asaresultofthepervasivenessofthesebroadersocialstructuresinmodernsocietybehavioural
changesaredifficulttomakeevenwiththeguidanceofapractitionerletaloneviaadigitalhealthcare
promotiontool.ThefollowingexcerptbyoneofHIC’swellnesspractitionersdescribesthechallenge:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

UponreflectingontheNutritionCenter’sabilitytoplaytheroleofadietician,ourNutrition
Expertadmittedthisasamistake.

Tryingtofigureouteverythingadieticianwouldwanttoknowfromapersonandtryingtoput
thatinsomekindoftoolwasactuallyamistakebecausewereallydidn’tintendtobecomeorreplace
theservicesofaregistereddietician,thereisabsolutelynowaythatwecouldpossiblydothatand
yetweweretryingsohardtogettothatpointofbeinganonlinedietician.

CURReNT APPRoACHeS To PRoMoTING NUTRITIoN

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

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54

yoUR CHALLeNGe AND TASKS

TheHICexecutiveisreassessingtheirdigitalstrategyfornutrition.Theyhavereachedouttoyouand
yourteamofconsultantstoadvisethefirm.Theoverarchingobjectiveistwofold:

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

2. Toproposewhethertomoveforwardandhowtomoveforwardwiththeirdigitalstrategyregarding
nutrition(recommendations).

NoTeS

Sincetheorganizationpreferredanonymity,allnameshavebeenfictionalised.

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APPeNDIX

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

Subject Measures

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

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

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

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

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

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

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59

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

Table 2. Exhibit 5: Summary of key user characteristics

Subject Measures

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

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

Source:InternalManagementReport(2004)
ThemajorityoftheusersappeartobeyoungerandaffiliatedtotheWellnessprogram.
Themeasureofactiveuseisbasedonloginspermonth