Recognising & supporting informal mhealth in Africa through grassroots interventions (REIMAGINE)
Lead Research Organisation:
Durham University
Department Name: Anthropology
Abstract
The potential for mobile devices to expand access to healthcare (mHealth) has been widely lauded, especially in rural areas of Low- and Middle-Income Countries (LMICs). However, the practice has not yet lived up to the hype: heavy reliance on donor funding and poor integration into national health systems means that projects often fizzle out when the funding dries up. Meanwhile, Community Health Workers (CHWs) are taking matters into their own hands, using personal devices on their own initiative in their work: a phenomenon we call "informal mhealth." Of 3000 CHWs we surveyed in Ghana, Ethiopia and Malawi, over 97% reported using a personal mobile device for work-related purposes on a daily basis, calling/messaging patients, organising logistics, calculating medicine dosages, and even using the torch function to deliver babies (compared with only 15% using "formal" mhealth phones or applications).
These developments were viewed positively by CHWs and service users, facilitating communication, logistics and patient care, and even saving lives. However, they also brought costs and challenges, especially for CHWs working in more remote communities, including financial hardship in managing phone costs, increased stress and burn-out from 24/7 availability, risks to patient confidentiality, and lack of digital literacy in assessing online information. These give cause for concern: informal mhealth is happening at scale but the costs are borne by the lowest-paid cadre of health-workers, most of whom are women.
In discussions with CHWs and policy-makers, we identified three possible low-cost interventions to recognise and support CHWs' existing practices: (1) providing basic training on digital literacy, online safety and use of relevant open-access applications; (2) developing and implementing locally-appropriate guidelines on use of personal mobile devices in healthcare; and (3) compensating CHWs for work-related phone expenditure.
We now seek to develop and trial a participatory intervention incorporating all three elements (training, guideline development and financial compensation) in 6 contrasting rural ("hard-to-reach") sites across Ghana, Ethiopia and Malawi (2 sites per country). In each site, we will engage a cluster of c.106 CHWs to receive the intervention, alongside service users (community members) and local managers/supervisors. Crucially, while the framework is common to all sites, the content and delivery of the training and guidelines will be co-designed with CHWs and community representatives and will be specific to each location, building on and supporting existing good practice.
In order to assess feasibility and acceptability of the intervention, and to assess possible impacts on CHWs, service users and managers, we will collect relevant data at baseline and post-intervention. All participating CHWs (minimum 212 per country) will complete questionnaires to measure changes in working practices and work-related wellbeing (including burn-out and retention intentions). Follow-up focus group discussions will be conducted with CHWs, service users and local supervisors/managers in each site (minimum 16 groups per country), to obtain a more detailed understanding of the concerns and priorities of these different groups, and to help elucidate potential causal pathways and mechanisms for changes observed.
Ongoing engagement of national and local stake-holders is core to the project. Building on strong working relationships developed during our previous study, we will convene a National Stakeholder Group (NSG) in each country to help oversee the project, provide input and plan for subsequent scale-up. In each study location, we will form a Local Steering Group (LSG), comprising CHW and community representatives, and local managers. LSGs will meet regularly to coordinate each stage of the project, and deliver the intervention to Community User Groups (CUGs) at each participating health post
These developments were viewed positively by CHWs and service users, facilitating communication, logistics and patient care, and even saving lives. However, they also brought costs and challenges, especially for CHWs working in more remote communities, including financial hardship in managing phone costs, increased stress and burn-out from 24/7 availability, risks to patient confidentiality, and lack of digital literacy in assessing online information. These give cause for concern: informal mhealth is happening at scale but the costs are borne by the lowest-paid cadre of health-workers, most of whom are women.
In discussions with CHWs and policy-makers, we identified three possible low-cost interventions to recognise and support CHWs' existing practices: (1) providing basic training on digital literacy, online safety and use of relevant open-access applications; (2) developing and implementing locally-appropriate guidelines on use of personal mobile devices in healthcare; and (3) compensating CHWs for work-related phone expenditure.
We now seek to develop and trial a participatory intervention incorporating all three elements (training, guideline development and financial compensation) in 6 contrasting rural ("hard-to-reach") sites across Ghana, Ethiopia and Malawi (2 sites per country). In each site, we will engage a cluster of c.106 CHWs to receive the intervention, alongside service users (community members) and local managers/supervisors. Crucially, while the framework is common to all sites, the content and delivery of the training and guidelines will be co-designed with CHWs and community representatives and will be specific to each location, building on and supporting existing good practice.
In order to assess feasibility and acceptability of the intervention, and to assess possible impacts on CHWs, service users and managers, we will collect relevant data at baseline and post-intervention. All participating CHWs (minimum 212 per country) will complete questionnaires to measure changes in working practices and work-related wellbeing (including burn-out and retention intentions). Follow-up focus group discussions will be conducted with CHWs, service users and local supervisors/managers in each site (minimum 16 groups per country), to obtain a more detailed understanding of the concerns and priorities of these different groups, and to help elucidate potential causal pathways and mechanisms for changes observed.
Ongoing engagement of national and local stake-holders is core to the project. Building on strong working relationships developed during our previous study, we will convene a National Stakeholder Group (NSG) in each country to help oversee the project, provide input and plan for subsequent scale-up. In each study location, we will form a Local Steering Group (LSG), comprising CHW and community representatives, and local managers. LSGs will meet regularly to coordinate each stage of the project, and deliver the intervention to Community User Groups (CUGs) at each participating health post
Technical Summary
We propose to develop and trial a participatory intervention, to build on and support community health workers' (CHWs') "informal" use of personal mobile devices in their work in Ethiopia, Ghana and Malawi. A pre/post study design is used to assess acceptability, feasibility, costs and impacts of the intervention.
The intervention comprises 3 core elements: (1) basic training on digital literacy, online safety, etc.; (2) participatory development of practical guidelines around responsible/effective phone use; and (3) small financial compensation to CHWs for work-related phone costs. The broad framework will be common across all sites, but the precise content and delivery will be determined locally.
The intervention will be delivered to 2 clusters CHWs per country, working in "hard to reach" rural locations, to achieve a minimum of 212 CHWs per country. Sampling will follow a 3-stage process: purposive selection of 2 contrasting regions per country; then random sampling of one District per Region that meets "hard-to-reach" criteria; then sampling of adjacent health posts within that District and recruitment of all CHWs until a total of 106 CHWs per District is reached. Based on detecting a small effect size of 0.25 (CHW emotional exhaustion pre-/post-intervention) and adjusting for design effect due to clustered sampling and 10% loss-to-follow-up, 212 CHWs per country provides 80% power at alpha=0.05 significance level.
Pre-and post-intervention questionnaires will be administered to all participating CHWs to measure: (a) changes in CHWs' working practices, and financial costs incurred; (b) changes in CHW wellbeing, burn-out and retention intentions; and (c) acceptability, appropriateness and feasibility. Follow-up focus group discussions will be conducted with CHWs, service users and local supervisors/managers (min. 16 groups per country), to obtain more detailed understandings of user experiences, and help elucidate potential causal pathways & mechanisms.
The intervention comprises 3 core elements: (1) basic training on digital literacy, online safety, etc.; (2) participatory development of practical guidelines around responsible/effective phone use; and (3) small financial compensation to CHWs for work-related phone costs. The broad framework will be common across all sites, but the precise content and delivery will be determined locally.
The intervention will be delivered to 2 clusters CHWs per country, working in "hard to reach" rural locations, to achieve a minimum of 212 CHWs per country. Sampling will follow a 3-stage process: purposive selection of 2 contrasting regions per country; then random sampling of one District per Region that meets "hard-to-reach" criteria; then sampling of adjacent health posts within that District and recruitment of all CHWs until a total of 106 CHWs per District is reached. Based on detecting a small effect size of 0.25 (CHW emotional exhaustion pre-/post-intervention) and adjusting for design effect due to clustered sampling and 10% loss-to-follow-up, 212 CHWs per country provides 80% power at alpha=0.05 significance level.
Pre-and post-intervention questionnaires will be administered to all participating CHWs to measure: (a) changes in CHWs' working practices, and financial costs incurred; (b) changes in CHW wellbeing, burn-out and retention intentions; and (c) acceptability, appropriateness and feasibility. Follow-up focus group discussions will be conducted with CHWs, service users and local supervisors/managers (min. 16 groups per country), to obtain more detailed understandings of user experiences, and help elucidate potential causal pathways & mechanisms.
