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

© 2016 The Authors 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 t ime 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. 2017. The place of technology in the Capability Approach Oxford Development Studies, pp. 1-15. | 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.

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

© 2016 The Authors 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 t ime 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. 2017. The place of technology in the Capability Approach Oxford Development Studies, pp. 1-15. | 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.

3182