The design and evaluation of a mobile learning intervention for the training and supervision of community health workers

Lead Research Organisation: University of Oxford
Department Name: Education

Abstract

This project relates to the Information and Communications Technology and Development theme of the call.

Through this innovative 2-year mobile learning project, the Institute of Education, University of London (IoE) and the African Medical and Research Foundation (AMREF) aim to advance the training and supervision of community health workers (CHWs) in Kenya, resulting in improved access to primary health care for the marginalised communities of Makueni County and the Kibera informal settlement. This is important because supporting poor communities gain access to health care by training CHWs and connecting them to the local health system can help reduce poverty.

CHWs are community members who provide basic medical services. Research consistently evidences CHWs pivotal role in providing equitable health access in support of poverty alleviation by preventing and diagnosing diseases like malaria and HIV, treating minor ailments, referring patients and providing support and care for pregnant women and babies.

This project will work closely with CHWs and their supervisors to collaboratively design, develop implement and evaluate a mobile learning intervention that better connects CHWs and supervisors. The innovative nature of this intervention will mean that for the first time CHWs will have a mobile portfolio of their practice, easily accessible reference material on their phone and the ability to share practice related questions and resources with their colleagues through activities which promote peer learning and reflection. Supervisors will be better informed of CHWs' training needs and AMREF will gain a better insight into the nature and frequency of their two-way interaction and into the specifics of on-the-ground support structures needed for intervention implementation. Kenyan policymakers will benefit from policy briefings demonstrating how our mobile intervention supports affordable, equitable and effective access to health care.

The improved mobile-based supervision and training will link CHWs more closely to the local primary healthcare system so as they can be more effective in reducing poverty through improving the access of local communities to health care.

Planned Impact

Who will benefit from this activity?
The project's research questions address five groups of beneficiaries. The three direct beneficiaries will be: (i) the 64 CHWs and (ii) 8 supervisors directly involved in the project and (iii) AMREF in Kenya. The two indirect beneficiaries will be (iv) the Kenyan Ministry of Public Health and Sanitation (MOPHS) and (v) the communities the CHWs serve in Makueni County and the Kibera informal settlement in Southern Nairobi.

How will they benefit from this activity?
(i) CHWs will benefit from increased communication with their supervisors thus improving their integration with the local primary healthcare system.
(ii) Supervisors will also benefit from the improved communication links and will be able to better tailor their support to CHWs as they will have asynchronous access to CHWs' personal practice data (including the points where they requested help) for the first time.
(iii) For AMREF the main benefits will be (a) access to a grounded dataset to better understand and analyse CHWs learning needs (b) an evidence-base of how CHW service delivery is improved by the intervention and (c) specifics of the on-the-ground support structures needed for intervention implementation.
(iv) The Kenyan MOPHS will benefit from iterative policy briefings on the role of mobile learning in CHW supervision and training, inputting into specific implementation strategies at community level.
(v) The communities in Makueni County and Kibera will benefit from improved access to health care.

What will be done to ensure that they have the opportunity to benefit from this activity?
(i) In order to build capacity at the NGO level, the project researchers will share their research methods expertise and AMREF staff will be encourage to take part in data analysis according to their skills and interests.
(ii) In support of this training, two members of AMREF staff will undertake a two capacity-building trips to the IoE.
(iii) The participatory action research (PAR) approach ensures that CHWs and their supervisors will be participants in the entire research process, with the priorities of CHWs and their supervisors addressed through genuine collaboration and the co-construction of knowledge.
(iv) The stakeholder inception workshop, held at month 1, will ensure that the project is fully grounded in the local context and focuses on the poverty-relevant practices of CHWs.
(v) The mobile application wil be made freely available under a creative commons licence.
(vi) Findings will be reported back to all participants in appropriate formats (e.g. story narratives and case studies) using venues arranged through the support of local community organisations.

The legacy of the research will be managed building on the expertise of AMREF in developing their nurse training eLearning programme in a public-private partnership with Accenture, the Nursing Council of Kenya and the MOPHS and then passing it over to the Nursing Council to scale-up and run independently. We will learn from and build on this strategy for seeking wider use and uptake of our mobile learning intervention as opportunities arise.

Related Projects

Project Reference Relationship Related To Start End Award Value
ES/J018619/1 01/11/2012 31/10/2014 £417,353
ES/J018619/2 Transfer ES/J018619/1 01/11/2014 30/09/2015 £114,819
 
Description This project set out to advance the training and supervision of community health workers (CHWs) in Kenya. It addressed this by developing an accessible mobile learning intervention that encouraged more supportive supervision and helped to link this more closely to CHW practice. This consisted of three inter-related parts: Mobile webapps, face-to-face training and community support. The project generated significant new knowledge in the following areas: 1. How to use a participatory action research approach to develop mHealth applications for CHWs and their supervisors (known as community health extension workers, or CHEWs) working in low-resource settings; 2. How a protocol for the assessment of child development stages can be used for decision support by CHWs as part of a mobile app. Aligned to this, the project showed how mobile messaging apps (i.e. Whatsapp) can be used for mentorship and improved social support; 3. How to develop mobile apps that support the professional development of CHWs, moving beyond a simple information acquisition model of learning to one focused on successful social participation; 4. How mobile-based supervision and training can be successfully embedded within the existing structures of community-based care; 5. How a 'theory of change' approach to evaluation can be used to detail the ways in which CHW and supervisor actions are changed by the addition of a mobile app to their practice. Two mobile webapps were developed in consultation with paediatricians in Kenya and in the UK: the REFER app and the ALPHA app. • The REFER app built capacity by teaching 100 community health workers the skills of how to assess the motor, cognitive and social development of children under five. The app enabled supervisors to provide feedback on the CHWs' assessments and practices, so as to enhance their skills and improve their performance. This was the first time that these CHWs were trained in skills around the developmental assessment of children. • The second app, ALPHA, allowed supervisors and Public Health Officers to design their own mobile training apps, without the need to code. For the marginalised communities of Makueni County and the Kibera informal settlement in Nairobi, the project resulted in: • Improved access to primary and community-based health care for children with disabilities and their families; • Training of CHWs and CHEWs in assessing child development in under-5s, resulting in the identification of over 40 families with a disabled child. Neither CHWs nor CHEWs had received any training on the development of children under five prior to the project. In addition, both CHWs and CHEWs received training in the use of smartphones; • CHW, CHEW and household knowledge of the development milestones of children under five has increased substantially; • Through workshops on child development and disability, the supervision and mentorship skills of CHEWs have been improved; • Improved referral decision-making by CHWs, resulting in more efficient use of medical time and resources. Project partnership supported capacity building, through community exchange visits, and training for Amref researchers in the UK. This enabled the research in mHealth to inform practice in the Kenyan context.
Exploitation Route The next step to take forward this work is to understand how mobile interventions in health care training can be better linked to broader conceptualisations of poverty alleviation. While most measures of poverty alleviation focus on income, research in development studies has consistently shown that trying to understand poverty alleviation by focusing on economic measures alone ignores the bigger picture. Work remains to be done on using this broader conceptualisation to inform the evaluation of mHealth interventions as tools for poverty alleviation. The role of mHealth interventions in addressing the "treatment gap", where health services only reach a very small minority of those in low-income settings, remains an under-explored area. There is great potential in partnering with health workers and hospitals to explore how this can be addressed by investigating the take-up of mHealth interventions at scale in real-word settings. With respect to policy, and in response to the call from the Ministry of Health in Kenya, a welcome next step would be support for more co-ordination between mHealth research projects so they can pool their findings, resources and expertise. In particular, expertise on transferring combined research findings from funded projects into high-level policy discussions would be welcome. This could be done with NGOs and the private sector.
Sectors Digital/Communication/Information Technologies (including Software),Education,Healthcare,Other

URL http://www.mchw.org/?page_id=14
 
Description For dissemination by the University of Oxford, see: http://www.ox.ac.uk/research/research-impact/using-mobile-learning-technology-improve-access-healthcare-east-africa As an ESRC Impact Case Study: http://www.esrc.ac.uk/news-events-and-publications/impact-case-studies/the-mobile-app-supporting-kenyan-healthcare/
First Year Of Impact 2016
Sector Education,Healthcare
Impact Types Societal

 
Description Oxford University Fell Fund Pump Priming Award
Amount £60,000 (GBP)
Organisation University of Oxford 
Sector Academic/University
Country United Kingdom
Start 09/2015 
End 08/2016
 
Description Amref 
Organisation Amref Health Africa
Country Kenya 
Sector Charity/Non Profit 
PI Contribution Kenyan collaborator - in charge of liasing on the ground with community health workers and the Kenyan Ministry of Health
Collaborator Contribution Set up the fieldwork, with our involvement, and kept the relationships on the ground in Kenya going while we were not in the country.
Impact see relevant sections of the form
Start Year 2013
 
Title ALPHA App 
Description We've developed over the course of the project also a generic smartphone application tool kit that enables community health extension workers (supervisors of community health workers) and public health officers to develop their own mobile webapps without the need for tech skills. This toolkit is currently still in Beta. 
Type Of Technology Webtool/Application 
Year Produced 2015 
Impact Please see narrative impact section 
 
Description "Mobiles, Development & Global Health Training: A way forward" 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Over the course of 2 days, around 20 national and international delegates attended our Symposium "Mobiles, Development & Global Health Training: A way forward" at the University of Oxford. The Symposium generated wide interest with regard to our initiative but also regarding the role of technology in health care in developing countries and led to very fruitful debates and collaborations.
Year(s) Of Engagement Activity 2015
URL http://www.mchw.org/?p=723
 
Description Crossing Boundaries Conference Presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Our research was presented at the Crossing Boundaries medical conference to around 75 doctors, nurses and academics working in low and middle income countries. The presentation got very good feedback and sparked interesting debates. It has led to a collaborative grant proposal.
Year(s) Of Engagement Activity 2015
 
Description Crossing boundaries poster presentation & flash talk 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The poster presented an evidence gap map around disability issues of children, which was a direct result of our project. The poster was accompanied by a flash talk and got very good and useful feedback.
Year(s) Of Engagement Activity 2015
 
Description Evaluation Knowledge-Exchange Workshop in the UK for our Amref Collaborators 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact The aim of this 2 week knowledge exchange visit was to take part, as a group, in a workshop on evaluation methodology. Our collaborators very much enjoyed this event and said they benefitted greatly from it.
Year(s) Of Engagement Activity 2015
 
Description Findings Dissemination Leaflet for Communities 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Study participants or study members
Results and Impact To disseminate our findings to the participants of our study in the two communities, we produced a leaflet in the local language in lay terms, to explain to the participants and community members, what valuable impact their contributions had on our project. The leaflet was handed out to them, together with a certificate of participation, issued by our collaborator organisation Amref Health Africa, and a project T-shirt, at the final hand-over ceremony, where we handed over our project to the two communities. The participants very much appreciated that and said the hope we will be continue our collaboration with them in future projects.
Year(s) Of Engagement Activity 2015
 
Description GET Health summit expert panel 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The panel organised by our team had experts from the field of mHealth and was very well received by the 45 people strong audience. It sparked a very interesting debate about technology used for mHealth in the context of low resource settings and let to a number of useful contacts.
Year(s) Of Engagement Activity 2015
 
Description GET Health summit presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Around 90 people attended the presentation on our project at the GET Health Summit. The presentation was very well received and won a summit award.
Year(s) Of Engagement Activity 2015
 
Description Global Media Player Symposium 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Findings from the projects use of whatsapp were presented by a team member at the Global Media Player Symposium in Qatar. The presentation led to wider exposure of the project to an audience of Qatari policy-makers, students and other audience members interested in the topic.
Year(s) Of Engagement Activity 2015
 
Description Humanitarian Innovation Conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Presentation of project findings at the Humanitarian Innovation Conference at the University of Oxford. The presentation sparked wide interest and we received positive feedback.
Year(s) Of Engagement Activity 2015
 
Description Impact Investment Workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Industry/Business
Results and Impact On 21 April 2015 around 100 business people attended an impact investment workshop at Said Business School. Our team was asked to present findings from the project to this group to demonstrate how relatively little investment can achieve big changes to the daily lives of people living in low resource settings.
Year(s) Of Engagement Activity 2015
 
Description Presentation at KEMRI, Nairobi 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The presentation at the KEMRI-Wellcome Trust offices in Nairobi was very well received and sparked interesting debates around policy implications of our reserach in Kenya.
Year(s) Of Engagement Activity 2015
 
Description Public OxCAHT Seminar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact The public seminar at Kellogg College summarized some of the findings of the project and drew wide interest from the academic community in Oxford.
Year(s) Of Engagement Activity 2015
 
Description Public Seminar OUDE 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact The public was very interested in the talk and asked a number of engaging and highly relevant questions, particularly with regard to applying a 'preferential option for the poor' approach in mHealth.
Year(s) Of Engagement Activity 2015
 
Description Stakeholder forum 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact The project held a highly successful stakeholder's forum on March 18, 2015 at Amref Health Africa HQ. The meeting drew 30 stakeholders from the Ministry of Health both national officials, county officials and various partners such as UNICEF, medic mobile, World Vision and Special Education Professionals. The agenda of the meeting was to disseminate project findings and discuss a way forward for the project ahead of the research project coming to an end in June 2015. The forum sparked very interesting debates and discussions.
Year(s) Of Engagement Activity 2015
URL http://www.mchw.org/?p=682
 
Description UCL mHealth conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The presentation, which was live-streamed in addition to a live audience, summarized findings from our research for an mHealth practitioner audience. It received good feedback.
Year(s) Of Engagement Activity 2015
 
Description UNESCO mobile learning week conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Third sector organisations
Results and Impact The presentation at the UNESCO HQ in Paris led to an interesting debate and a number of useful contacts to follow up afterwards.
Year(s) Of Engagement Activity 2015