WhatsApp In Health Communication: The Case Of Eye Health In Deprived Settings In India CHANDRANI MAITRA PhD 2021 WhatsApp In Health Communication: The Case Of Eye Health In Deprived Settings In India CHANDRANI MAITRA A Thesis Submitted In Partial Fulfilment Of The Requirements Of Manchester Metropolitan University For The Degree Of Philosophy Department Of Languages, Information And Communications Manchester Metropolitan University March 2021 Supervisory Team Prof Jennifer Rowley Dr Esperanza Miyake iii Abstract The aim of this study was to explore the use of WhatsApp in developing a community based practice of eye health promotion in a deprived locality bordering a metropolitan city in India. Globally, 285 million people are visually impaired, a quarter of whom live in India, which results in lower employment and lessened productivity. The national blindness prevention strategy aims at eyecare promotion through health behaviour change achieved by raising awareness. Traditionally, health behaviour change has been achieved through conventional communication platforms like radio and television-. The recent exponential development in social media technology, ubiquitous and inexpensive, offers significant potential for two-way communication in real time with a wider audience, including those from disadvantaged groups. WhatsApp, an inexpensive social media platform which is widely used in the Indian subcontinent, may offer an important channel for eyecare related health communication. Importantly, no study has systematically evaluated WhatsApp in promoting health communication on eye care in India, specifically in its largely deprived population. This qualitative study used WhatsApp (as an interventional tool) to create an information resource link on basic eye care between a tertiary city based healthcare provider and the deprived community, resident in the fringe of the city. WhatsApp use was facilitated by specially selected local women trained in information usage to disseminate contextual audio-visual information on eye care through multiple ‘educational’ sessions. Perspectives of 10 healthcare providers, 10 community health advocates and 30 women participants from the deprived community, were qualitatively explored. Changes in health behaviour of the deprived community members were also assessed. A thematic analysis was performed to systematically interrogate data to create meaningful themes. This study confirmed the presence of a significant information gap on eye care on the face of high disease burden. The use of WhatsApp was supported unanimously iv by healthcare providers and community health advocates as an acceptable, feasible and cost-effective two-way communication tool, although concerns were raised about its hidden costs, privacy and security issues. Acceptability of WhatsApp based information dissemination amongst the study participants was high with reported benefits of increased awareness of eye diseases, their preventative management, remedial measures and the availability of affordable eyecare services. Additionally, study participants found WhatsApp technology appealing and intuitive. The resultant increase in self-confidence, consequent to heightened awareness, boosted social empowerment and enabled study participants to challenge prevalent social and cultural norms. In conclusion, this study demonstrated that WhatsApp can be effectively used as a suitable vehicle of information dissemination on eye care in mediating a behavioural change in deprived settings. Findings from this study may be considered in developing policies that develop and disseminate eye care information. The wider implications and impact of this study lies in disseminating healthcare information related to other important public health issues to the marginal population. v Table of contents Abstract ……………………………………………………………………... iv Table of contents…………………………………………………………… vi List of tables ………………………………………………………………… xii List of figures ………………………………………………………………. xiii Acknowledgements ……………………………………………………….. xiv Dedication …………………………………………………………………... xv CHAPTER 1. Introduction ………………………………………………… 1 1.1. Introduction …………………………………………………………… 1 1.2. Context of the study …………………………………………………. 1 1.3. Research question …………………………………………………… 3 1.3.1. Aims ……………………………………………………………… 4 1.3.2. Objectives ……………………………………………………….. 4 1.4. Approach……………………………………………………………… 4 1.5. Researcher’s motivation ……………………………………………. 6 1.6. Thesis structure ……………………………………………………… 6 CHAPTER 2. Research context …………………………………………. 10 2.1. Introduction …………………………………………………………… 10 2.2. Global context of eye diseases, blindness and visual impairment 10 2.2.1. Vision impairment ……………………………………………….. 10 2.2.2. Variation of eye disease by geographical region, socioeconomic parity, age, gender, area of residence and ethnicity ………………………………………………………….. 13 2.2.3. The impact of visual impairment on individual, family and the society…………………………………………………………….. 15 2.2.4. Barriers to accessing eye care services ……………………… 17 2.2.5. Addressing and improving eye care globally ………………… 19 2.3. Visual impairment and blindness in the context in the Indian subcontinent …………………………………………………………. 20 2.3.1. Eye diseases, blindness and visual impairment in the socioeconomically disadvantaged population in India………. 21 2.3.2. Addressing eye care needs in India …………………………… 21 vi 2.4. Chapter overview..…………………………………………………... 23 CHAPTER 3. Literature review ………………………………………….. 24 3.1. Introduction …………………………………………………………… 24 3.2. Social media …………………………………………………………. 24 3.2.1. Overview of social media ………………………………………. 24 3.2.2. Popular types of social media …………………………………. 25 3.2.3. Social media usage in the global context …………………….. 28 3.2.4. Social media usage in the Indian context …………………….. 29 3.3. Health communication ………………………………………………. 30 3.3.1. Defining health communication ………………………………... 30 3.3.2. Domains of health communication ……………………………. 31 3.3.3. The health communication focus in this study ………………. 35 3.4. Social media in health communication …………………………….. 36 3.4.1. Themes in social media usage in healthcare ………………… 37 3.4.1.1. Social media usage by health providers ………………….. 39 3.4.1.2. End user use / attitude / beliefs and expectations of social media in health care communication …………………….. 48 3.4.2. Social media usage in eye health communication…………… 54 3.4.3. Determinants influencing end user engagement with social media in healthcare communication ………………………….. 56 3.4.3.1. Health provider or host factors ……………………………. 56 3.4.3.1.1. Healthcare provider’s engagement, usage and perception of social media ………………………………. 56 3.4.3.1.2. Content of health communication disseminated through social media ………………………………………………. 57 3.4.3.2. End user characteristics …………………………………… 60 3.4.3.2.1. Patient’s motives, barriers and preferences……………. 60 3.4.3.2.2. Age, gender, place of residence, sociocultural and ethnic factors ……………………………………………… 61 3.4.3.2.3. Health literacy, source trustworthiness and perception towards healthcare provider …………………………….. 65 3.4.3.3. Conclusions ………………………………………………… 66 3.5. Chapter overview ..…………………………………………………. 66 vii CHAPTER 4. Research Methodology ………………………………….. 68 4.1. Introduction …………………………………………………………… 68 4.2. Research philosophy (paradigms) ………………………………… 68 4.2.1. The ‘positivist’ paradigm ……………………………………….. 69 4.2.2. The ‘interpretive’ paradigm …………………………………. … 70 4.3. Research approaches – deductive and inductive ………………. 72 4.4. Approaches to research in information science – quantitative, qualitative and the mixed methodology …………………………… 72 4.5. Case studies in social science research ………………………….. 74 4.6. Interviews for data collection in qualitative research …………….. 74 4.7. Study Methodology ………………………………………………….. 75 4.7.1. Rationale for adopting a qualitative methods approach for this study …………………………………………………………. 75 4.7.2. Research strategy - The ‘case study’ approach ……………… 76 4.7.3. Context of the study …………………………………………….. 76 4.7.4. Selection of participants………………………... ……………… 80 4.7.5. Neo-literate women facilitators ………………………………… 84 4.7.6. The case for face to face semi-structured interviews ……….. 84 4.7.7. Pilot interviews …………………………………………………... 86 4.7.8. Conducting interviews ………………………………………….. 86 4.7.9. Recording of interviews ………………………………………… 87 4.7.10. The rationale for choosing WhatsApp as the platform for disseminating eyecare information ……………………………. 88 4.7.11. Educational sessions for dissemination of eye health information through WhatsApp ………………………………… 89 4.7.12. Assessment session ……………………………………………. 92 4.8. Data analysis …………………………………………………………. 93 4.8.1. Thematic analysis - Theoretical basis and the rationale for choice in this study ……………………………………………… 94 4.8.2. Conducting the analysis ………………………………………... 96 4.8.3. Familiarising with data ………………………………………….. 97 4.8.4. Generating initial codes ………………………………………… 99 4.8.5. Searching for themes …………………………………………… 100 viii 4.8.6. Reviewing themes ………………………………………………. 101 4.8.7. Defining and naming themes…………………………………… 102 4.8.8. Producing the report ……………………………………………. 103 4.9. Research quality ……………………………………………………... 104 4.9.1. Validity of research ……………………………………………… 104 4.9.2. Research reliability ……………………………………………… 110 4.10. Ensuring research quality in this study ……………………………. 110 4.11. Ethical considerations ………………………………………………. 112 4.12. Chapter overview.. ...………………………………………………… 113 CHAPTER 5. Findings and analyses …………………………………… 115 5.1. Introduction …………………………………………………………… 115 5.2. Descriptive analyses …………………………………………………