Dr Marco J Haenssgen

Research Area: Global Health
Scientific Themes: Tropical Medicine & Global Health
Keywords: social sciences, mixed-methods research, behaviour, health systems, technological change, marginalisation, evaluation and antimicrobial resistance
Web Links:
Survey villages in mountainous areas of Chiang Rai, Thailand

Survey villages in mountainous areas of Chiang Rai, Thailand

Marco approaches tropical medicine from a social science perspective, focusing on interactions between patients and the health system, healthcare-seeking behaviour, social and technological change, and evaluation. He conducts mixed-methods research with a regional focus on Southeast Asia. Current research activities include a social study of C-reactive protein biomarker testing in Thailand, Myanmar, and Vietnam; the evaluation of science-themed theatre in Thailand, and surveys of rural healthcare-seeking behaviour in the context of antibiotic use in rural Thailand and Laos. Marco is also active in knowledge exchange and social research training across academics and non-academics in Southeast Asia. Marco's current social research projects on antimicrobial resistance in Southeast Asia include:

  1. Antibiotics and Activity Spaces (Thailand, Lao PDR): A survey of 4,800 villagers in Chiang Rai (Thailand) and Salavan (Lao PDR) to better understand (1) how people access healthcare and what actually counts as “problematic” antibiotic use, (2) whether antibiotic-related information from educational activities spreads or simply evaporates in village community networks, and (3) whether there are simple “early warning” indicators (e.g. specific symptoms) to detect whether people are likely to have “problematic” antibiotic use. The surveys are currently being implemented by 10-member survey teams in each country and expected to be finished in April 2018. This project is funded by the Antimicrobial Resistance Cross Council Initiative supported by the seven research councils in partnership with the Department of Health and Department for Environment Food & Rural Affairs (grant ref. ES/P00511X/1, administered by the UK Economic and Social Research Council).
  2. Antibiotic Supply and Demand (Thailand): A related qualitative study that focuses in particular on the interplay of healthcare demand and supply of economically and socially less privileged groups in Chiang Rai. The qualitative work involves interviews with members of the general population as well as private and informal healthcare providers, and aims to inform and develop the theory of supply-induced demand at the interface between the general population and health systems.
  3. The Social Context of Biomarker Testing to Reduce Antibiotic Prescriptions (Thailand, Myanmar): This social research project is integrated into a clinical study led by Prof Yoel Lubell to test the effect of C-reactive protein (CRP) biomarker tests (finger-prick blood tests) on the antibiotic prescription behaviour of nurses and doctors in primary care health centres in Chiang Rai (Thailand) and Yangon (Myanmar). Drawing on qualitative data from 131 respondents, the social research contributes to a better understanding of (a) the quantitative outcomes of the clinical trial, (b) how the introduction of a new diagnostic technology interacts with existing behaviours and conceptions among patients and healthcare workers, (c) the cross-cultural differences in behaviour in Southeast Asia, and (d) contextual factors that influence the effectiveness and usefulness of clinical interventions at the primary care level.

Name Department Institution Country
Professor Yoel Lubell Tropical Medicine Oxford University, Bangkok Thailand
Dr Proochista Ariana Tropical Medicine Oxford University, Peter Medawar Building United Kingdom
Professor Caroline Jones Tropical Medicine Oxford University, Kilifi Kenya
Professor Heiman Wertheim Tropical Medicine Oxford University, Hanoi Vietnam
Professor Paul Newton Tropical Medicine Oxford University, Vientiane Laos
Dr Mayfong Mayxay Tropical Medicine Oxford University, Vientiane Laos
Dr Giacomo Zanello University of Reading United Kingdom
Professor Felix Reed-Tsochas Said Business School University of Oxford United Kingdom
Haenssgen MJ, Charoenboon N, Do NTT, Althaus T, Khine Zaw Y, Wertheim HFL, Lubell Y. 2019. How context can impact clinical trials: a multi-country qualitative case study comparison of diagnostic biomarker test interventions. Trials, 20 (1), pp. 111. | Show Abstract | Read more

BACKGROUND: Context matters for the successful implementation of medical interventions, but its role remains surprisingly understudied. Against the backdrop of antimicrobial resistance, a global health priority, we investigated the introduction of a rapid diagnostic biomarker test (C-reactive protein, or CRP) to guide antibiotic prescriptions in outpatient settings and asked, "Which factors account for cross-country variations in the effectiveness of CRP biomarker test interventions?" METHODS: We conducted a cross-case comparison of CRP point-of-care test trials across Yangon (Myanmar), Chiang Rai (Thailand), and Hanoi (Vietnam). Cross-sectional qualitative data were originally collected as part of each clinical trial to broaden their evidence base and help explain their respective results. We synthesised these data and developed a large qualitative data set comprising 130 interview and focus group participants (healthcare workers and patients) and nearly one million words worth of transcripts and interview notes. Inductive thematic analysis was used to identify contextual factors and compare them across the three case studies. As clinical trial outcomes, we considered patients' and healthcare workers' adherence to the biomarker test results, and patient exclusion to gauge the potential "impact" of CRP point-of-care testing on the population level. RESULTS: We identified three principal domains of contextual influences on intervention effectiveness. First, perceived risks from infectious diseases influenced the adherence of the clinical users (nurses, doctors). Second, the health system context related to all three intervention outcomes (via the health policy and antibiotic policy environment, and via health system structures and the ensuing utilisation patterns). Third, the demand-side context influenced the patient adherence to CRP point-of-care tests and exclusion from the intervention through variations in local healthcare-seeking behaviours, popular conceptions of illness and medicine, and the resulting utilisation of the health system. CONCLUSIONS: Our study underscored the importance of contextual variation for the interpretation of clinical trial findings. Further research should investigate the range and magnitude of contextual effects on trial outcomes through meta-analyses of large sets of clinical trials. For this to be possible, clinical trials should collect qualitative and quantitative contextual information for instance on their disease, health system, and demand-side environment. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02758821 registered on 3 May 2016 and NCT01918579 registered on 7 August 2013.

Althaus T, Greer RC, Swe MMM, Cohen J, Tun NN, Heaton J, Nedsuwan S, Intralawan D, Sumpradit N, Dittrich S et al. 2019. Effect of point-of-care C-reactive protein testing on antibiotic prescription in febrile patients attending primary care in Thailand and Myanmar: an open-label, randomised, controlled trial. Lancet Glob Health, 7 (1), pp. e119-e131. | Show Abstract | Read more

BACKGROUND: In southeast Asia, antibiotic prescription in febrile patients attending primary care is common, and a probable contributor to the high burden of antimicrobial resistance. The objective of this trial was to explore whether C-reactive protein (CRP) testing at point of care could rationalise antibiotic prescription in primary care, comparing two proposed thresholds to classify CRP concentrations as low or high to guide antibiotic treatment. METHODS: We did a multicentre, open-label, randomised, controlled trial in participants aged at least 1 year with a documented fever or a chief complaint of fever (regardless of previous antibiotic intake and comorbidities other than malignancies) recruited from six public primary care units in Thailand and three primary care clinics and one outpatient department in Myanmar. Individuals were randomly assigned using a computer-based randomisation system at a ratio of 1:1:1 to either the control group or one of two CRP testing groups, which used thresholds of 20 mg/L (group A) or 40 mg/L CRP (group B) to guide antibiotic prescription. Health-care providers were masked to allocation between the two intervention groups but not to the control group. The primary outcome was the prescription of any antibiotic from day 0 to day 5 and the proportion of patients who were prescribed an antibiotic when CRP concentrations were above and below the 20 mg/L or 40 mg/L thresholds. The primary outcome was analysed in the intention-to-treat and per-protocol populations. The trial is registered with ClinicalTrials.gov, number NCT02758821, and is now completed. FINDINGS: Between June 8, 2016, and Aug 25, 2017, we recruited 2410 patients, of whom 803 patients were randomly assigned to CRP group A, 800 to CRP group B, and 807 to the control group. 598 patients in CRP group A, 593 in CRP group B, and 767 in the control group had follow-up data for both day 5 and day 14 and had been prescribed antibiotics (or not) in accordance with test results (per-protocol population). During the trial, 318 (39%) of 807 patients in the control group were prescribed an antibiotic by day 5, compared with 290 (36%) of 803 patients in CRP group A and 275 (34%) of 800 in CRP group B. The adjusted odds ratio (aOR) of 0·80 (95% CI 0·65-0·98) and risk difference of -5·0 percentage points (95% CI -9·7 to -0·3) between group B and the control group were significant, although lower than anticipated, whereas the reduction in prescribing in group A compared with the control group was not significant (aOR 0·86 [0·70-1·06]; risk difference -3·3 percentage points [-8·0 to 1·4]). Patients with high CRP concentrations in both intervention groups were more likely to be prescribed an antibiotic than in the control group (CRP ≥20 mg/L: group A vs control group, p<0·0001; CRP ≥40 mg/L: group B vs control group, p<0·0001), and those with low CRP concentrations were more likely to have an antibiotic withheld (CRP <20 mg/L: group A vs control group, p<0·0001; CRP <40 mg/L: group B vs control group, p<0·0001). 24 serious adverse events were recorded, consisting of 23 hospital admissions and one death, which occurred in CRP group A. Only one serious adverse event was thought to be possibly related to the study (a hospital admission in CRP group A). INTERPRETATION: In febrile patients attending primary care, testing for CRP at point of care with a threshold of 40 mg/L resulted in a modest but significant reduction in antibiotic prescribing, with patients with high CRP being more likely to be prescribed an antibiotic, and no evidence of a difference in clinical outcomes. This study extends the evidence base from lower-income settings supporting the use of CRP tests to rationalise antibiotic use in primary care patients with an acute febrile illness. A key limitation of this study is the individual rather than cluster randomised study design which might have resulted in contamination between the study groups, reducing the effect size of the intervention. FUNDING: Wellcome Trust Institutional Strategic Support Fund grant (105605/Z/14/Z) and Foundation for Innovative New Diagnostics (FIND) funding from the Australian Government.

Haenssgen MJ, Xayavong T, Charoenboon N, Warapikuptanun P, Khine Zaw Y. 2018. Outputs, Outcomes, and Behavioural Impacts of an Antibiotic-Related Educational Activity in Lao PDR | Show Abstract | Read more

Education and awareness raising are the primary tools of global health policy to change public behaviour. Considering the limitations of awareness agenda and the lack of social research to inform alternative approaches, our objective was to generate new empirical evidence on the consequences of antibiotic-related awareness raising in a low-income country context. We implemented an educational activity in two Lao villages to share general antibiotic-related messages, but also to learn about people&rsquo;s conceptions and health behaviours. Two rounds of census survey data enabled us to assess the activity&rsquo;s outputs, its knowledge outcomes, and its immediate behavioural impacts in a difference-in-difference design. Our panel data covered 1,130 adults over two rounds, including 58 activity participants and 208 villagers exposed indirectly via conversations in the village. We found that activity-related communication circulated among more privileged groups, which limited its indirect effects. Among participants, the activity influenced the awareness and understanding of &ldquo;drug resistance,&rdquo; while effects on attitudes were minor. Evidence on behavioural impacts was sparse and mixed, but the range of possible consequences included a disproportionate uptake of antibiotics from formal healthcare providers. Our study casts doubt on the continued dominance of awareness raising as a behavioural tool to address antibiotic resistance.

Khine Zaw Y, Charoenboon N, Haenssgen MJ, Lubell Y. 2018. A Comparison of Patients' Local Conceptions of Illness and Medicines in the Context of C-Reactive Protein Biomarker Testing in Chiang Rai and Yangon. Am J Trop Med Hyg, 98 (6), pp. 1661-1670. | Show Abstract | Read more

Antibiotic resistance is not solely a medical but also a social problem, influenced partly by patients' treatment-seeking behavior and their conceptions of illness and medicines. Situated within the context of a clinical trial of C-reactive protein (CRP) biomarker testing to reduce antibiotic over-prescription at the primary care level, our study explores and compares the narratives of 58 fever patients in Chiang Rai (Thailand) and Yangon (Myanmar). Our objectives are to 1) compare local conceptions of illness and medicines in relation to health-care seeking and antibiotic demand; and to 2) understand how these conceptions could influence CRP point-of-care testing (POCT) at the primary care level in low- and middle-income country settings. We thereby go beyond the current knowledge about antimicrobial resistance and CRP POCT, which consists primarily of clinical research and quantitative data. We find that CRP POCT in Chiang Rai and Yangon interacted with fever patients' preexisting conceptions of illness and medicines, their treatment-seeking behavior, and their health-care experiences, which has led to new interpretations of the test, potentially unforeseen exclusion patterns, implications for patients' self-assessed illness severity, and an increase in the status of the formal health-care facilities that provide the test. Although we expected that local conceptions of illness diverge from inbuilt assumptions of clinical interventions, we conclude that this mismatch can undermine the intervention and potentially reproduce problematic equity patterns among CRP POCT users and nonusers. As a partial solution, implementers may consider applying the test after clinical examination to validate rather than direct prescription processes.

Haenssgen MJ, Charoenboon N, Zanello G, Mayxay M, Reed-Tsochas F, Jones COH, Kosaikanont R, Praphattong P, Manohan P, Lubell Y et al. 2018. Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation and knowledge diffusion. BMJ Glob Health, 3 (2), pp. e000621. | Show Abstract | Read more

Background: Antimicrobial resistance (AMR) is a global health priority. Leading UK and global strategy papers to fight AMR recognise its social and behavioural dimensions, but current policy responses to improve the popular use of antimicrobials (eg, antibiotics) are limited to education and awareness-raising campaigns. In response to conceptual, methodological and empirical weaknesses of this approach, we study people's antibiotic-related health behaviour through three research questions.RQ1: What are the manifestations and determinants of problematic antibiotic use in patients' healthcare-seeking pathways?RQ2: Will people's exposure to antibiotic awareness activities entail changed behaviours that diffuse or dissipate within a network of competing healthcare practices?RQ3: Which proxy indicators facilitate the detection of problematic antibiotic behaviours across and within communities? Methods: We apply an interdisciplinary analytical framework that draws on the public health, medical anthropology, sociology and development economics literature. Our research involves social surveys of treatment-seeking behaviour among rural dwellers in northern Thailand (Chiang Rai) and southern Lao PDR (Salavan). We sample approximately 4800 adults to produce district-level representative and social network data. Additional 60 cognitive interviews facilitate survey instrument development and data interpretation. Our survey data analysis techniques include event sequence analysis (RQ1), multilevel regression (RQ1-3), social network analysis (RQ2) and latent class analysis (RQ3). Discussion: Social research in AMR is nascent, but our unprecedentedly detailed data on microlevel treatment-seeking behaviour can contribute an understanding of behaviour beyond awareness and free choice, highlighting, for example, decision-making constraints, problems of marginalisation and lacking access to healthcare and competing ideas about desirable behaviour. Trial registration number: NCT03241316; Pre-results.

Haenssgen MJ. 2019. Manifestations, Drivers, and Frictions of Mobile Phone Use in Low- and Middle-Income Settings: A Mixed Methods Analysis of Rural India and China The Journal of Development Studies, 55 (8), pp. 1834-1858. | Show Abstract | Read more

© 2018 Informa UK Limited, trading as Taylor & Francis Group Against the backdrop of alleged mobile phone ubiquity and the enthusiasm about the developmental value of mobile technology, this paper examines the manifestations, drivers, and frictions of mobile phone use in two low- and middle-income settings where mobile technology has diffused rapidly. Qualitative data from 231 participants and survey data from 800 adults in rural Rajasthan and Gansu provide consistent and strong support for the claim that the notion of ‘ubiquity’ can mislead development practice because it obscures persistent non-use, under-utilisation, and heterogeneous engagement with mobile technology despite its apparently wide accessibility in rural field sites. The paper suggests avenues for further work on the indicators of technology adoption, and it cautions that phone-based development interventions (and their benefits) may diffuse unevenly if the assumption of ubiquitous technology use is violated.

Haenssgen MJ, Charoenboon N, Althaus T, Greer RC, Intralawan D, Lubell Y. 2018. The social role of C-reactive protein point-of-care testing to guide antibiotic prescription in Northern Thailand. Soc Sci Med, 202 pp. 1-12. | Show Abstract | Read more

New and affordable point-of-care testing (POCT) solutions are hoped to guide antibiotic prescription and to help limit antimicrobial resistance (AMR)-especially in low- and middle-income countries where resource constraints often prevent extensive diagnostic testing. Anthropological and sociological research has illuminated the role and impact of rapid point-of-care malaria testing. This paper expands our knowledge about the social implications of non-malarial POCT, using the case study of a C-reactive-protein point-of-care testing (CRP POCT) clinical trial with febrile patients at primary-care-level health centres in Chiang Rai province, northern Thailand. We investigate the social role of CRP POCT through its interactions with (a) the healthcare workers who use it, (b) the patients whose routine care is affected by the test, and (c) the existing patient-health system linkages that might resonate or interfere with CRP POCT. We conduct a thematic analysis of data from 58 purposively sampled pre- and post-intervention patients and healthcare workers in August 2016 and May 2017. We find widespread positive attitudes towards the test among patients and healthcare workers. Patients' views are influenced by an understanding of CRP POCT as a comprehensive blood test that provides specific diagnosis and that corresponds to notions of good care. Healthcare workers use the test to support their negotiations with patients but also to legitimise ethical decisions in an increasingly restrictive antibiotic policy environment. We hypothesise that CRP POCT could entail greater patient adherence to recommended antibiotic treatment, but it could also encourage riskier health behaviour and entail potentially adverse equity implications for patients across generations and socioeconomic strata. Our empirical findings inform the clinical literature on increasingly propagated point-of-care biomarker tests to guide antibiotic prescriptions, and we contribute to the anthropological and sociological literature through a novel conceptualisation of the patient-health system interface as an activity space into which biomarker testing is introduced.

Haenssgen MJ, Charoenboon N, Khine Zaw Y. 2018. It is time to give social research a voice to tackle antimicrobial resistance? J Antimicrob Chemother, 73 (4), pp. 1112-1113. | Read more

Haenssgen MJ. 2018. The struggle for digital inclusion: Phones, healthcare, and marginalisation in rural India WORLD DEVELOPMENT, 104 pp. 358-374. | Show Abstract | Read more

© 2017 Elsevier Ltd The gains from digital technology diffusion are deemed essential for international development, but they are also distributed unevenly. Does the uneven distribution mean that not everyone benefits from new technologies to the same extent, or do some people experience an absolute disadvantage during this process? I explore this question through the case study of curative healthcare access in the context of rapid mobile phone uptake in rural India, contributing thus to an important yet surprisingly under-researched aspect of the social implications of (mobile) technology diffusion. Inspired by a previous analysis of cross-sectional data from rural India, I hypothesise that health systems increasingly adapt to mobile phone users where phones have diffused widely. This adaptation will leave poor non-adopters worse off than before and increases healthcare inequities. I use a panel of 12,003 rural households with an illness in 2005 and 2012 from the Indian Human Development Survey to test this hypothesis. Based on village-cluster robust fixed-effects linear probability models, I find that (a) mobile phone diffusion is significantly and negatively linked to various forms of rural healthcare access, suggesting that health systems increasingly adapt to phone use and discriminate against non-users; that (b) poor rural households without mobile phones experience more adverse effects compared to more affluent households, which indicates a struggle and competition for healthcare access among marginalised groups; and that (c) no effects emerge for access to public doctors, which implies that some healthcare providers are less responsive to mobile phone use than others. Overall, my findings indicate that the rural Indian healthcare system gradually adapts to increasing mobile phone use at the expense of non-users. I conclude that rapid mobile phone diffusion creates an opportunity to improve people's access to healthcare in rural India, but it also creates new forms of marginalisation among poor rural households.

Haenssgen MJ, Ariana P. 2017. Healthcare access: A sequence-sensitive approach. SSM Popul Health, 3 pp. 37-47. | Show Abstract | Read more

It is widely accepted that healthcare-seeking behaviour is neither limited to nor terminated by access to one single healthcare provider. Yet the sequential conceptualisation of healthcare-seeking processes has not diffused into quantitative research, which continues to analyse healthcare access as a "one-off" event. The ensuing lack of understanding healthcare behaviour is problematic in light of the immense burden of premature death especially in low- and middle-income countries. This paper presents an alternative approach. Based on a novel survey instrument, we analyse original survey data from rural India and China that contain 119 unique healthcare pathways among 637 respondents. We offer three applications of how such sequential data can be analysed to enhance our understanding of people's health behaviour. First, descriptive analysis of sequential data enables more a comprehensive representation of people's health behaviours, for example the time spent in various healthcare activities, common healthcare pathways across different groups, or shifts in healthcare provider access during a typical illness. Second, by analysing the effect of mobile technology on healthcare-seeking process characteristics, we demonstrate that conventional, sequence-insensitive indicators are potentially inconsistent and misleading approximations when compared to a more precise, sequence-sensitive measure. Third, we describe how sequential data enable transparent and flexible evaluations of people's healthcare behaviour. The example of a sequence-insensitive evaluation suggests that household wealth has no statistical link to an illustrative "ideal" form of public healthcare utilisation. In contrast, sequence-sensitive evaluations demonstrate that household wealth is associated with an increased likelihood of bypassing referral processes and approaching unregulated and costly informal and private practitioners before accessing a public clinic. Sequential data therefore do not only reveal otherwise neglected locational idiosyncrasies, but they also yield deeper insights into the drivers of people's health behaviours compared to a conventional approach to "access to healthcare."

Haenssgen MJ, Ariana P. 2017. The Social Implications of Technology Diffusion: Uncovering the Unintended Consequences of People's Health-Related Mobile Phone Use in Rural India and China WORLD DEVELOPMENT, 94 pp. 286-304. | Show Abstract | Read more

© 2017 The Authors After three decades of mobile phone diffusion, thousands of mobile-phone-based health projects worldwide (“mHealth”), and hundreds of thousands of smartphone health applications, fundamental questions about the effect of phone diffusion on people's healthcare behavior continue to remain unanswered. This study investigated whether, in the absence of specific mHealth interventions, people make different healthcare decisions if they use mobile phones during an illness. Following mainstream narratives, we hypothesized that phone use during an illness (a) increases and (b) accelerates healthcare access. Our study was based on original survey data from 800 respondents in rural Rajasthan (India) and Gansu (China), sampled from the general adult population in 2014 in a three-stage stratified cluster random sampling design. We analyzed single- and multi-level logistic, Poisson, and negative binomial regression models with cluster-robust standard errors. Contrary to other research at the intersection of mobile phones and healthcare, we captured actual health-related mobile phone use during people's illnesses irrespective of whether they own a phone. Our analysis produced the first quantitative micro-evidence that patients’ personal mobile phone use is correlated with their healthcare decisions. Despite a positive association between phone use and healthcare access, health-related phone use was also linked to delayed access to public doctors and nurses. We considered theoretical explanations for the observed patterns by augmenting transaction cost and information deficit arguments with the prevailing health system configuration and with notions of heuristic decision-making during the healthcare-seeking process. Our study was a first step toward understanding the implications of mobile technology diffusion on health behavior in low- and middle-income countries in the absence of specific mHealth interventions. Future research will have to explore the causal relationships underlying these statistical associations. Such a link could potentially mean that development interventions aimed at improving access to healthcare continue to require conventional solutions to sustain healthcare equity.

Haenssgen MJ, Ariana P. 2018. The place of technology in the Capability Approach Oxford Development Studies, 46 (1), pp. 98-112. | Show Abstract | Read more

© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Increasing scholarly attention has focussed on how to integrate technology within the Capability Approach (CA), yet without a consistent solution. Some describe technology as a special kind of capability input, but others consider the concept of technology to be fundamentally different from that of an ordinary input. We aim to contribute to the theoretical development of the CA by offering a consistent justification for the explicit inclusion of technology in this framework. We propose that technical objects have a ‘generative’ and a ‘transformative’ dimension through which they enable capabilities directly and affect other inputs in the attainment of valued capabilities. The objects acquire the transformative dimension from the broader technological context, which we propose as a new class of conversion factors. Using the example of mobile phones and their role in healthcare access, we demonstrate that our proposal helps to frame the analysis of the development impact of technology.

Haenssgen MJ. 2017. Impact of high-intensity polio eradication activities on children's routine immunization status in Northern India. Health Policy Plan, 32 (6), pp. 800-808. | Show Abstract | Read more

The objective of this article is to analyse and quantify the side effects of the Polio Eradication Initiative on routine immunization performance in India. Past studies have faced methodological challenges in assessing these side effects. This article offers a methodological alternative for health policy analysts. The research uses secondary household survey data from the Indian District-Level Household and Facility Survey (DLHS), focusing on children aged 10-30 months in the Northern Indian states of Uttar Pradesh (n = 34 327) and Bihar (n = 20 525). Covering the years 2002-08, this is the latest large-scale data from India that enables the matching technique used in this article. District-level programme intensity data of the Polio Eradication Initiative in India were reconstructed using publicly available resources. The methodological innovation compared with previous studies consists of matching each child in the DLHS data set with a child-specific value of programme exposure depending on its district of residence, its birth date, and the date of the survey interview. Average and age-specific associations between polio programme exposure and children's full immunization status were assessed using logistic regression, controlling for other determinants of immunization. The regression results show that the link is negative in Uttar Pradesh and positive in Bihar. Age-specific analysis shows that the positive association diminishes for older children in Bihar and that a negative association emerges and becomes increasingly pronounced for older children in Uttar Pradesh. This indicates that heterogeneous results emerge across two neighbouring states with similar programme intensity and suggests that the catch-up of unvaccinated older children may be a channel through which negative effects accrue. The method described in this article, based on an analytical focus on individual-level programme exposure, can therefore help health policy implementers and evaluators to illuminate positive or negative interactions between a health intervention and a health system.

Haenssgen MJ. 2017. After Access: Inclusion, Development, and a More Mobile Internet JOURNAL OF HUMAN DEVELOPMENT AND CAPABILITIES, 18 (1), pp. 137-139. | Read more

Haenssgen MJ, IEEE. 2015. Exploring the Mismatch Between Mobile Phone Adoption and Use Through Survey Data from Rural India and China 2015 IEEE INTERNATIONAL SYMPOSIUM ON TECHNOLOGY AND SOCIETY (ISTAS), 2016-March | Show Abstract | Read more

© 2015 IEEE. Persistent disciplinary and methodological divides between technology diffusion and adoption studies and the study of use and engagement with technology raise obstacles to understanding the development implications of mobile technology diffusion, for example in the area of healthcare access. As quantitative assessments in the area of health and technology almost exclusively rely on binary indicators of mobile phone adoption, it is not clear whether this is indeed a reasonable proxy that does not obscure the distributional implications of mobile phone use. This paper therefore compares patterns of mobile phone adoption and utilisation using original survey data from rural India and China. "Utilisation" here is assessed through a simple yet novel multidimensional index. The paper further assesses the role of these concepts as determinants of locally emerging forms of mobile-phone-aided healthcare-seeking behavior ("health action"). The investigation uses descriptive statistical analysis and multilevel logistic regression analysis, which provide evidence in support of the claims that (a) patterns of mobile phone diffusion and utilisation are related yet incongruent, that (b) mobile phones facilitate health action in both field sites to a notable extent, and that (c) the mobile phone utilisation index is a better predictor for phone-aided health action than mobile phone adoption. In light of the superiority of the utilisation index vis-à-vis binary measures of mobile phone adoption, other researchers can apply the survey instrument and technology utilisation concept developed in this paper to support the analysis of the social implications of technology diffusion.

Haenssgen MJ. 2015. Satellite-aided survey sampling and implementation in low- and middle-income contexts: a low-cost/low-tech alternative. Emerg Themes Epidemiol, 12 (1), pp. 20. | Show Abstract | Read more

BACKGROUND: The increasing availability of online maps, satellite imagery, and digital technology can ease common constraints of survey sampling in low- and middle-income countries. However, existing approaches require specialised software and user skills, professional GPS equipment, and/or commercial data sources; they tend to neglect spatial sampling considerations when using satellite maps; and they continue to face implementation challenges analogous to conventional survey implementation methods. This paper presents an alternative way of utilising satellite maps and digital aides that aims to address these challenges. RESULTS: The case studies of two rural household surveys in Rajasthan (India) and Gansu (China) compare conventional survey sampling and implementation techniques with the use of online map services such as Google, Bing, and HERE maps. Modern yet basic digital technology can be integrated into the processes of preparing, implementing, and monitoring a rural household survey. Satellite-aided systematic random sampling enhanced the spatial representativeness of the village samples and entailed savings of approximately £4000 compared to conventional household listing, while reducing the duration of the main survey by at least 25 %. CONCLUSION: This low-cost/low-tech satellite-aided survey sampling approach can be useful for student researchers and resource-constrained research projects operating in low- and middle-income contexts with high survey implementation costs. While achieving transparent and efficient survey implementation at low costs, researchers aiming to adopt a similar process should be aware of the locational, technical, and logistical requirements as well as the methodological challenges of this strategy.

Khine Zaw Y, Charoenboon N, Haenssgen MJ, Lubell Y. 2018. A Comparison of Patients' Local Conceptions of Illness and Medicines in the Context of C-Reactive Protein Biomarker Testing in Chiang Rai and Yangon. Am J Trop Med Hyg, 98 (6), pp. 1661-1670. | Show Abstract | Read more

Antibiotic resistance is not solely a medical but also a social problem, influenced partly by patients' treatment-seeking behavior and their conceptions of illness and medicines. Situated within the context of a clinical trial of C-reactive protein (CRP) biomarker testing to reduce antibiotic over-prescription at the primary care level, our study explores and compares the narratives of 58 fever patients in Chiang Rai (Thailand) and Yangon (Myanmar). Our objectives are to 1) compare local conceptions of illness and medicines in relation to health-care seeking and antibiotic demand; and to 2) understand how these conceptions could influence CRP point-of-care testing (POCT) at the primary care level in low- and middle-income country settings. We thereby go beyond the current knowledge about antimicrobial resistance and CRP POCT, which consists primarily of clinical research and quantitative data. We find that CRP POCT in Chiang Rai and Yangon interacted with fever patients' preexisting conceptions of illness and medicines, their treatment-seeking behavior, and their health-care experiences, which has led to new interpretations of the test, potentially unforeseen exclusion patterns, implications for patients' self-assessed illness severity, and an increase in the status of the formal health-care facilities that provide the test. Although we expected that local conceptions of illness diverge from inbuilt assumptions of clinical interventions, we conclude that this mismatch can undermine the intervention and potentially reproduce problematic equity patterns among CRP POCT users and nonusers. As a partial solution, implementers may consider applying the test after clinical examination to validate rather than direct prescription processes.

Haenssgen MJ, Charoenboon N, Zanello G, Mayxay M, Reed-Tsochas F, Jones COH, Kosaikanont R, Praphattong P, Manohan P, Lubell Y et al. 2018. Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation and knowledge diffusion. BMJ Glob Health, 3 (2), pp. e000621. | Show Abstract | Read more

Background: Antimicrobial resistance (AMR) is a global health priority. Leading UK and global strategy papers to fight AMR recognise its social and behavioural dimensions, but current policy responses to improve the popular use of antimicrobials (eg, antibiotics) are limited to education and awareness-raising campaigns. In response to conceptual, methodological and empirical weaknesses of this approach, we study people's antibiotic-related health behaviour through three research questions.RQ1: What are the manifestations and determinants of problematic antibiotic use in patients' healthcare-seeking pathways?RQ2: Will people's exposure to antibiotic awareness activities entail changed behaviours that diffuse or dissipate within a network of competing healthcare practices?RQ3: Which proxy indicators facilitate the detection of problematic antibiotic behaviours across and within communities? Methods: We apply an interdisciplinary analytical framework that draws on the public health, medical anthropology, sociology and development economics literature. Our research involves social surveys of treatment-seeking behaviour among rural dwellers in northern Thailand (Chiang Rai) and southern Lao PDR (Salavan). We sample approximately 4800 adults to produce district-level representative and social network data. Additional 60 cognitive interviews facilitate survey instrument development and data interpretation. Our survey data analysis techniques include event sequence analysis (RQ1), multilevel regression (RQ1-3), social network analysis (RQ2) and latent class analysis (RQ3). Discussion: Social research in AMR is nascent, but our unprecedentedly detailed data on microlevel treatment-seeking behaviour can contribute an understanding of behaviour beyond awareness and free choice, highlighting, for example, decision-making constraints, problems of marginalisation and lacking access to healthcare and competing ideas about desirable behaviour. Trial registration number: NCT03241316; Pre-results.

Haenssgen MJ. 2019. Manifestations, Drivers, and Frictions of Mobile Phone Use in Low- and Middle-Income Settings: A Mixed Methods Analysis of Rural India and China The Journal of Development Studies, 55 (8), pp. 1834-1858. | Show Abstract | Read more

© 2018 Informa UK Limited, trading as Taylor & Francis Group Against the backdrop of alleged mobile phone ubiquity and the enthusiasm about the developmental value of mobile technology, this paper examines the manifestations, drivers, and frictions of mobile phone use in two low- and middle-income settings where mobile technology has diffused rapidly. Qualitative data from 231 participants and survey data from 800 adults in rural Rajasthan and Gansu provide consistent and strong support for the claim that the notion of ‘ubiquity’ can mislead development practice because it obscures persistent non-use, under-utilisation, and heterogeneous engagement with mobile technology despite its apparently wide accessibility in rural field sites. The paper suggests avenues for further work on the indicators of technology adoption, and it cautions that phone-based development interventions (and their benefits) may diffuse unevenly if the assumption of ubiquitous technology use is violated.

Haenssgen MJ, Charoenboon N, Althaus T, Greer RC, Intralawan D, Lubell Y. 2018. The social role of C-reactive protein point-of-care testing to guide antibiotic prescription in Northern Thailand. Soc Sci Med, 202 pp. 1-12. | Show Abstract | Read more

New and affordable point-of-care testing (POCT) solutions are hoped to guide antibiotic prescription and to help limit antimicrobial resistance (AMR)-especially in low- and middle-income countries where resource constraints often prevent extensive diagnostic testing. Anthropological and sociological research has illuminated the role and impact of rapid point-of-care malaria testing. This paper expands our knowledge about the social implications of non-malarial POCT, using the case study of a C-reactive-protein point-of-care testing (CRP POCT) clinical trial with febrile patients at primary-care-level health centres in Chiang Rai province, northern Thailand. We investigate the social role of CRP POCT through its interactions with (a) the healthcare workers who use it, (b) the patients whose routine care is affected by the test, and (c) the existing patient-health system linkages that might resonate or interfere with CRP POCT. We conduct a thematic analysis of data from 58 purposively sampled pre- and post-intervention patients and healthcare workers in August 2016 and May 2017. We find widespread positive attitudes towards the test among patients and healthcare workers. Patients' views are influenced by an understanding of CRP POCT as a comprehensive blood test that provides specific diagnosis and that corresponds to notions of good care. Healthcare workers use the test to support their negotiations with patients but also to legitimise ethical decisions in an increasingly restrictive antibiotic policy environment. We hypothesise that CRP POCT could entail greater patient adherence to recommended antibiotic treatment, but it could also encourage riskier health behaviour and entail potentially adverse equity implications for patients across generations and socioeconomic strata. Our empirical findings inform the clinical literature on increasingly propagated point-of-care biomarker tests to guide antibiotic prescriptions, and we contribute to the anthropological and sociological literature through a novel conceptualisation of the patient-health system interface as an activity space into which biomarker testing is introduced.

Haenssgen MJ, Charoenboon N, Khine Zaw Y. 2018. It is time to give social research a voice to tackle antimicrobial resistance? J Antimicrob Chemother, 73 (4), pp. 1112-1113. | Read more

Haenssgen MJ. 2018. The struggle for digital inclusion: Phones, healthcare, and marginalisation in rural India WORLD DEVELOPMENT, 104 pp. 358-374. | Show Abstract | Read more

© 2017 Elsevier Ltd The gains from digital technology diffusion are deemed essential for international development, but they are also distributed unevenly. Does the uneven distribution mean that not everyone benefits from new technologies to the same extent, or do some people experience an absolute disadvantage during this process? I explore this question through the case study of curative healthcare access in the context of rapid mobile phone uptake in rural India, contributing thus to an important yet surprisingly under-researched aspect of the social implications of (mobile) technology diffusion. Inspired by a previous analysis of cross-sectional data from rural India, I hypothesise that health systems increasingly adapt to mobile phone users where phones have diffused widely. This adaptation will leave poor non-adopters worse off than before and increases healthcare inequities. I use a panel of 12,003 rural households with an illness in 2005 and 2012 from the Indian Human Development Survey to test this hypothesis. Based on village-cluster robust fixed-effects linear probability models, I find that (a) mobile phone diffusion is significantly and negatively linked to various forms of rural healthcare access, suggesting that health systems increasingly adapt to phone use and discriminate against non-users; that (b) poor rural households without mobile phones experience more adverse effects compared to more affluent households, which indicates a struggle and competition for healthcare access among marginalised groups; and that (c) no effects emerge for access to public doctors, which implies that some healthcare providers are less responsive to mobile phone use than others. Overall, my findings indicate that the rural Indian healthcare system gradually adapts to increasing mobile phone use at the expense of non-users. I conclude that rapid mobile phone diffusion creates an opportunity to improve people's access to healthcare in rural India, but it also creates new forms of marginalisation among poor rural households.

Haenssgen MJ, Ariana P. 2017. Healthcare access: A sequence-sensitive approach. SSM Popul Health, 3 pp. 37-47. | Show Abstract | Read more

It is widely accepted that healthcare-seeking behaviour is neither limited to nor terminated by access to one single healthcare provider. Yet the sequential conceptualisation of healthcare-seeking processes has not diffused into quantitative research, which continues to analyse healthcare access as a "one-off" event. The ensuing lack of understanding healthcare behaviour is problematic in light of the immense burden of premature death especially in low- and middle-income countries. This paper presents an alternative approach. Based on a novel survey instrument, we analyse original survey data from rural India and China that contain 119 unique healthcare pathways among 637 respondents. We offer three applications of how such sequential data can be analysed to enhance our understanding of people's health behaviour. First, descriptive analysis of sequential data enables more a comprehensive representation of people's health behaviours, for example the time spent in various healthcare activities, common healthcare pathways across different groups, or shifts in healthcare provider access during a typical illness. Second, by analysing the effect of mobile technology on healthcare-seeking process characteristics, we demonstrate that conventional, sequence-insensitive indicators are potentially inconsistent and misleading approximations when compared to a more precise, sequence-sensitive measure. Third, we describe how sequential data enable transparent and flexible evaluations of people's healthcare behaviour. The example of a sequence-insensitive evaluation suggests that household wealth has no statistical link to an illustrative "ideal" form of public healthcare utilisation. In contrast, sequence-sensitive evaluations demonstrate that household wealth is associated with an increased likelihood of bypassing referral processes and approaching unregulated and costly informal and private practitioners before accessing a public clinic. Sequential data therefore do not only reveal otherwise neglected locational idiosyncrasies, but they also yield deeper insights into the drivers of people's health behaviours compared to a conventional approach to "access to healthcare."

Haenssgen MJ, Ariana P. 2017. The Social Implications of Technology Diffusion: Uncovering the Unintended Consequences of People's Health-Related Mobile Phone Use in Rural India and China WORLD DEVELOPMENT, 94 pp. 286-304. | Show Abstract | Read more

© 2017 The Authors After three decades of mobile phone diffusion, thousands of mobile-phone-based health projects worldwide (“mHealth”), and hundreds of thousands of smartphone health applications, fundamental questions about the effect of phone diffusion on people's healthcare behavior continue to remain unanswered. This study investigated whether, in the absence of specific mHealth interventions, people make different healthcare decisions if they use mobile phones during an illness. Following mainstream narratives, we hypothesized that phone use during an illness (a) increases and (b) accelerates healthcare access. Our study was based on original survey data from 800 respondents in rural Rajasthan (India) and Gansu (China), sampled from the general adult population in 2014 in a three-stage stratified cluster random sampling design. We analyzed single- and multi-level logistic, Poisson, and negative binomial regression models with cluster-robust standard errors. Contrary to other research at the intersection of mobile phones and healthcare, we captured actual health-related mobile phone use during people's illnesses irrespective of whether they own a phone. Our analysis produced the first quantitative micro-evidence that patients’ personal mobile phone use is correlated with their healthcare decisions. Despite a positive association between phone use and healthcare access, health-related phone use was also linked to delayed access to public doctors and nurses. We considered theoretical explanations for the observed patterns by augmenting transaction cost and information deficit arguments with the prevailing health system configuration and with notions of heuristic decision-making during the healthcare-seeking process. Our study was a first step toward understanding the implications of mobile technology diffusion on health behavior in low- and middle-income countries in the absence of specific mHealth interventions. Future research will have to explore the causal relationships underlying these statistical associations. Such a link could potentially mean that development interventions aimed at improving access to healthcare continue to require conventional solutions to sustain healthcare equity.

Haenssgen MJ, Ariana P. 2018. The place of technology in the Capability Approach Oxford Development Studies, 46 (1), pp. 98-112. | Show Abstract | Read more

© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Increasing scholarly attention has focussed on how to integrate technology within the Capability Approach (CA), yet without a consistent solution. Some describe technology as a special kind of capability input, but others consider the concept of technology to be fundamentally different from that of an ordinary input. We aim to contribute to the theoretical development of the CA by offering a consistent justification for the explicit inclusion of technology in this framework. We propose that technical objects have a ‘generative’ and a ‘transformative’ dimension through which they enable capabilities directly and affect other inputs in the attainment of valued capabilities. The objects acquire the transformative dimension from the broader technological context, which we propose as a new class of conversion factors. Using the example of mobile phones and their role in healthcare access, we demonstrate that our proposal helps to frame the analysis of the development impact of technology.

Haenssgen MJ. 2017. Impact of high-intensity polio eradication activities on children's routine immunization status in Northern India. Health Policy Plan, 32 (6), pp. 800-808. | Show Abstract | Read more

The objective of this article is to analyse and quantify the side effects of the Polio Eradication Initiative on routine immunization performance in India. Past studies have faced methodological challenges in assessing these side effects. This article offers a methodological alternative for health policy analysts. The research uses secondary household survey data from the Indian District-Level Household and Facility Survey (DLHS), focusing on children aged 10-30 months in the Northern Indian states of Uttar Pradesh (n = 34 327) and Bihar (n = 20 525). Covering the years 2002-08, this is the latest large-scale data from India that enables the matching technique used in this article. District-level programme intensity data of the Polio Eradication Initiative in India were reconstructed using publicly available resources. The methodological innovation compared with previous studies consists of matching each child in the DLHS data set with a child-specific value of programme exposure depending on its district of residence, its birth date, and the date of the survey interview. Average and age-specific associations between polio programme exposure and children's full immunization status were assessed using logistic regression, controlling for other determinants of immunization. The regression results show that the link is negative in Uttar Pradesh and positive in Bihar. Age-specific analysis shows that the positive association diminishes for older children in Bihar and that a negative association emerges and becomes increasingly pronounced for older children in Uttar Pradesh. This indicates that heterogeneous results emerge across two neighbouring states with similar programme intensity and suggests that the catch-up of unvaccinated older children may be a channel through which negative effects accrue. The method described in this article, based on an analytical focus on individual-level programme exposure, can therefore help health policy implementers and evaluators to illuminate positive or negative interactions between a health intervention and a health system.

Haenssgen MJ. 2017. After Access: Inclusion, Development, and a More Mobile Internet JOURNAL OF HUMAN DEVELOPMENT AND CAPABILITIES, 18 (1), pp. 137-139. | Read more

Haenssgen MJ, IEEE. 2015. Exploring the Mismatch Between Mobile Phone Adoption and Use Through Survey Data from Rural India and China 2015 IEEE INTERNATIONAL SYMPOSIUM ON TECHNOLOGY AND SOCIETY (ISTAS), 2016-March | Show Abstract | Read more

© 2015 IEEE. Persistent disciplinary and methodological divides between technology diffusion and adoption studies and the study of use and engagement with technology raise obstacles to understanding the development implications of mobile technology diffusion, for example in the area of healthcare access. As quantitative assessments in the area of health and technology almost exclusively rely on binary indicators of mobile phone adoption, it is not clear whether this is indeed a reasonable proxy that does not obscure the distributional implications of mobile phone use. This paper therefore compares patterns of mobile phone adoption and utilisation using original survey data from rural India and China. "Utilisation" here is assessed through a simple yet novel multidimensional index. The paper further assesses the role of these concepts as determinants of locally emerging forms of mobile-phone-aided healthcare-seeking behavior ("health action"). The investigation uses descriptive statistical analysis and multilevel logistic regression analysis, which provide evidence in support of the claims that (a) patterns of mobile phone diffusion and utilisation are related yet incongruent, that (b) mobile phones facilitate health action in both field sites to a notable extent, and that (c) the mobile phone utilisation index is a better predictor for phone-aided health action than mobile phone adoption. In light of the superiority of the utilisation index vis-à-vis binary measures of mobile phone adoption, other researchers can apply the survey instrument and technology utilisation concept developed in this paper to support the analysis of the social implications of technology diffusion.

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