Agile Development of an Affordable mHealth Technology for Point-of-Use Water Quality Testing and Education in Guatemala Open Access

Abstract

BACKGROUND: Uptake of point-of-use water filters manufactured by the local, Guatemalan social enterprise EcoFiltro in rural indigenous regions is suboptimal, as previous studies have identified a gap in awareness about water contamination that is undetectable by sight. Edutainment and mobile health technologies have been shown to promote water, sanitation, and hygiene (WaSH) recommendations, and microscopy along with non-mobile image recognition analyses have been used to detect enteric pathogens. However, the intersection between handheld technologies and microscopy-based point-of-use water quality testing has not been explored.

STUDY OBJECTIVES: To 1) explore a possible innovative method for point-of-use water quality testing using the Foldscope and an AI-based algorithm for real-time E. coli detection, 2) co-design an application with this water testing capability and WaSH edutainment by interviewing relevant stakeholders in the EcoFiltro company, and 3) from their perspectives assess how the application can promote their filter’s uptake and consistent use.

METHODS: In partnership with the Universidad del Valle de Guatemala (UVG) Microbiology Department, UVG computer science students, and image recognition experts at the Department of Biomedical Informatics in the Emory University School of Medicine, the application described above has started taking shape. Furthermore, the agile co-design and evaluation of the application development was carried out starting in October 2020 through two rounds of semi-structured interviews (n = 17) with EcoFiltro leadership and employees, including field staff. The qualitative data was transcribed and coded using a grounded-theory approach.

FINDINGS: The co-designed EcoFiltro application has high compatibility and acceptability within the company. The edutainment content coincides with field workers’ routine tasks, and there was a high level of agile engagement. Interviewees recognize that the content and in-development water testing capability can address the lack of community awareness on water contamination, and EcoFiltro’s poor customer service and community engagement. This can result in increased confidence in EcoFiltro and increased filter uptake. Therefore, the wider use of and adherence to the EcoFiltro (which already has a nationwide distribution chain) has the potential to reduce the burden of diarrheal disease in the country. The novel method of water quality testing has other potential implications for global WaSH.

Table of Contents

Table of Contents

I. INTRODUCTION.......................................................................................................... 1

II. BACKGROUND............................................................................................................ 3

2.1 The Two Guatemalas............................................................................................... 3

2.1.1 Historical Background..................................................................................... 4

2.1.2 Resulting Human Development Indicators........................................................ 7

2.1.3 The Guatemalan Healthcare Landscape............................................................ 10

2.2 Water Quality and Sanitation Systems in Guatemala................................................. 13

2.2.1 Water Supply.................................................................................................. 13

2.2.2 Sanitation Coverage and Handwashing............................................................. 15

2.2.3 Diarrheal Disease........................................................................................... 17

2.2.4 Water Quality Testing Methods........................................................................ 19

2.2.5 Water Purification Scalability.......................................................................... 21

2.3 EcoFiltro: A Social Enterprise for Water.................................................................... 23

2.3.1 The Filter and the Company............................................................................ 23

2.3.2 Issues with Community Outreach.................................................................... 24

2.4 Mobile Health (mHealth) Interventions in WaSH....................................................... 26

2.4.1 mHealth Overview.......................................................................................... 26

2.4.2 Edutainment.................................................................................................. 28

2.4.3 Smartphone Applications................................................................................ 29

III. METHODS................................................................................................................. 31

3.1 Ethics.................................................................................................................... 32

3.2 Technology Development........................................................................................ 33

3.2.1 Application Development................................................................................ 34

3.2.2 Microbiology.................................................................................................. 38

3.2.3 Image Recognition.......................................................................................... 40

3.3 Agile Design-Thinking Research Process................................................................... 41

3.3.1 Alpha- and Beta-tester Sample Characteristics................................................. 42

3.3.2 Data Collection.............................................................................................. 43

3.3.3 Data Storage and Analysis............................................................................... 43

IV. ALPHA-TESTER INTERVIEW RESULTS......................................................................... 44

4.1 Application Revisions and Edits............................................................................... 44

4.1.1 Language Norming......................................................................................... 44

4.1.2 Additional Content and Tools.......................................................................... 46

4.1.3 Modifications to Existing Content and Tools..................................................... 49

4.1.4 Structural Changes......................................................................................... 51

4.2 Long-Term Potential Functions of the App................................................................ 52

4.2.1 Future Additions............................................................................................ 52

4.2.2 Increased Sales and Community Reach............................................................. 53

4.2.3 The Water Testing Capability........................................................................... 55

4.3 Culturally Appropriate Design for End-User Engagement........................................... 56

4.3.1 Simplicity...................................................................................................... 56

4.3.2 Cultural Accessibility...................................................................................... 57

4.4 Approval of Educational Content............................................................................. 59

4.5 Agile Design Engagement........................................................................................ 60

V. BETA-TESTER INTERVIEW RESULTS............................................................................. 60

5.1 Broader Considerations for the Water Testing Capability............................................ 61

5.1.1 Straightforwardness of the Procedures............................................................. 61

5.1.2 Accounting for Resource-Constrained Environments and Communities.............. 62

5.1.3 Field Staff Training......................................................................................... 65

5.2 Application Edits and Suggestions........................................................................... 65

5.2.1 Language Norming......................................................................................... 66

5.2.2 Additional Content and Tools.......................................................................... 67

5.2.3 Modifications to Existing Content and Tools..................................................... 68

5.3 Long-Term Goals and Potential Functions of the App................................................ 69

5.3.1 Sales Objective............................................................................................... 69

5.3.2 Corporate Compatibility and Workload Relief................................................... 71

5.3.3 Community Engagement................................................................................. 72

5.4 Appropriate End-User Design.................................................................................. 74

5.4.1 Simplicity and Clarity of Functionalities........................................................... 75

5.4.2 Cultural Appropriateness................................................................................ 76

5.4.3 EcoFiltro Branding.......................................................................................... 77

VI. DISCUSSION.............................................................................................................. 78

6.1 Individual End-Users............................................................................................... 78

6.1.1 EcoFiltro Staff Members.................................................................................. 78

6.1.2 Community Members...................................................................................... 80

6.2 Ramifications for the EcoFiltro Social Enterprise....................................................... 81

6.2.1 High Compatibility and Acceptance.................................................................. 81

6.2.2 Building on the EcoFiltro Model...................................................................... 82

6.3 Contribution to Global WaSH................................................................................... 83

6.3.1 Novel Approach to Water Quality Testing......................................................... 83

6.3.2 Potential for Scaling Up Water Purification....................................................... 84

VII. LIMITATIONS........................................................................................................... 84

VIII. FUTURE DIRECTIONS.............................................................................................. 87

IX. CONCLUSION............................................................................................................ 88

References...................................................................................................................... 90

Appendix........................................................................................................................ 100

Preliminary Water Sampling and Analysis Protocols....................................................... 100

Figures and Tables

Figure 1: Topographical map of Guatemala……………………………………….……………........... 4

Figure 2: Agile co-design phase chart………………………………………………...………............. 34

Figure 3: Original Home Page of the EcoFiltro application………………………………….......... 37

Figure 4: The altering of the testimonial video subsection title………………………..……….... 45

Figure 5: Addition of EcoFiltro product catalog and voice messaging option………………… ...47

Figure 6: “Bacteria in the water” infographic………….………….………….………………............51

Figure 7: Unedited first step and “Positive Result” graphic of testing protocols………………..67

Figure 8: Edited first step and “Positive Result” graphic of testing protocols…………………... 78

Table 1: Interview participant demographics per sample………………………………………....... 42

About this Honors Thesis

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School	Emory College
Department	Human Health
Degree	B.A.
Submission	Honors Thesis
Language	English
Research Field	Biology, Bioinformatics Health Sciences, Public Health Education Water Resource Management
Keyword	E. coli Water quality test Image recognition Guatemala Artificial intelligence Foldscope WaSH Edutainment Social enterprise Microscopy Agile design-thinking Global health mHealth
Committee Chair / Thesis Advisor	Hall-Clifford, Rachel, Emory University
Committee Members	L. Moe, Christine, Emory University Lampl, Michelle, Emory University

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