Formative research for the deployment of smart phone-based applications to a community health worker program in rural Nepal

 

Abstract

The World Health Organization has identified “task shifting” as an important component of global healthcare workforce development.  Supplying non-physician providers with health information technologies may advance this endeavor.

 

Therefore, Nyaya Health, an NGO that operates a hospital in Achham, Nepal, is preparing to deploy smart phones to its network of Community Health Workers (CHW). Literature on e-health projects in developing countries suggests that success of such interventions can be predicted by organizational readiness, measured by a variety of factors including 1) comfort with the technology among staff members; 2) the extent to which the technology is tailored to the organization’s priorities and integrated into its infrastructure; 3) level of staff involvement in project development; 4) quality of financial planning; 5) technical readiness; and 6) availability of training and support for users. 

 

Here I propose a needs assessment that is guided by this literature, focusing on the first three components of readiness listed above. The assessment will consist of brief surveys and semi-structured interviews with the CHWs who will use the smart phones and with staff at the supervising hospital. The interviews will identify the most significant clinical problems that CHWs face and will gather the CHWs’ and hospital staff’s perceptions of the intervention.  The participatory nature of the assessment is intended to promote staff buy-in.  Additionally, the insights gleaned from the interviews will inform future software and program development, ensuring that the smart phones are well suited to the needs of CHWs and integrated into the existing structure of the program.

 

 

Background

Over three decades ago the Declaration of Alma Ata projected a vision of primary health care for all.  A massive deficit of human resources has thwarted efforts to fulfill the Declaration’s mission.  Recent advances in information technology have demonstrated the possibility of significantly boosting the capacity and productivity of each available health worker.  The formative research proposed here draws inspiration from specific IT solutions that can contribute to the resolution of a regional healthcare workforce crisis.

 

The district of Achham in Nepal suffers a severe shortage of skilled healthcare providers: only two allopathic physicians serve a population of over 250,000.  Nyaya Health (a local NGO) has responded by capacitating and compensating a cadre of primary health workers who work with the hospital that the NGO operates in partnership with the Nepali government. This CHW program’s strategy is in line with the WHO’s push for task shifting, which calls for delegating more responsibility to health workers who are decentralized and who hold positions that require fewer years of training.  Nyaya’s CHWs were recruited from the surrounding communities, provided training, put on pay-roll, and asked to fulfill a wide set of responsibilities, including general health surveillance, pre and antenatal health services, recruitment for the hospital’s malnutrition program, outpatient follow-up, and TB-DOTs administration.

 

In an effort to support these providers, Nyaya plans to outfit its CHWs with smart phones that contain software developed by Johns Hopkins’ eMOCHA (electronic Mobile Open-source Comprehensive Health Application) team.  eMOCHA is a free open-source application, developed by the Johns Hopkins Center for Clinical Global Health Education.  eMOCHA is designed to assist health programs in developing countries to improve provider communication and education, as well as patient care, by coordinating wireless devices with local healthcare systems.

Nyaya envisions that smart phones equipped with eMOCHA’s software will improve CHWs’ access to clinical consultants at the hospital and to peers, deliver training materials for continuing education, involve CHWs in data collection for clinical and research purposes, and provide tools for spatial mapping and triage algorithms that would support daily tasks.  In addition, the smart phones would give program administrators a tool for supervision.

 

It is anticipated that functions will be added to the smart phones in a staged process, first starting with the basic phone feature and an application with algorithms that will guide triage decisions.  Those two functions were proposed because triage and oversight were deemed to be priorities for the CHW program.  Currently, CHWs arrive at triage decisions spontaneously and independently.  The smart phone would help in two ways: 1) An application would prompt the CHWs through triage algorithms and 2) the phone would allow the CHW to seek consultation from clinicians at the hospital.  These functions could dramatically improve the quality and efficiency of the CHW’s triage.  Oversight of the program is difficult because poor access to phones has meant that CHWs have to traverse long distances over harsh terrain to communicate with their supervisors.  While the CHWs will continue to physically report to the hospital weekly, the phones will allow for communication at other times.

The needs assessment proposed herein represents the formative research that will guide the collaborative effort to adapt eMOCHA’s smart phone technology to Nyaya’s CHW program.

 

Objectives

1) To identify significant clinical challenges faced by Nyaya CHWs.

2) To assess how smart phone-based triage algorithms and phone communication might affect how those challenges are handled.

3) To learn the perceptions of CHWs and hospital staff toward the use of smart phones.

4) To assess the needs and clinical challenges of the CHW program.

 

Methods

This study is an opportunity for Nyaya to involve CHWs and hospital staff in the development of mobile technology and to gather their input on the program.  Nyaya’s CHW program hopes to double the number of CHWs within one year and it is therefore crucial to elicit feedback from Female Community Health Volunteers (FCHV) in Achham, who are the most likely job candidates.

 

Therefore, this study is formative research composed of semi-structured interviews and a brief survey of four health worker groups: 1) clinical staff including three health assistants and two family physicians; 2) the four members of Nyaya’s administrative staff;  3) the four existing Nyaya CHWs; 4) a purposeful sampling of eight FCHVs, selected for their interest in the CHW position and their qualifications for the job.

Interviews will be conducted one at a time in a private location and will be digitally recorded.  Interviews will be conducted in the language of the participant’s choice (English or Nepali).  Interviews conducted in English will be immediately transcribed.  Interviews conducted in Nepali will be translated into English and transcribed.

 

Interviews will be semi-structured using interview guides.  Sample interview guides are located in Annex 1: CHWs and FCHVs; Annex 2: clinical staff; Annex 3: administrative staff.  Annex 4 is the survey that will be administered immediately before the interviews of all participants.  As qualitative research is an iterative process, we will continue to refine the interview guides and survey when the fieldwork begins, rephrasing questions as needed and adding finer-grained, follow-up questions as our understanding deepens.

 

Sample size is based upon a desire to purposefully sample the entire group of health workers potentially associated with this future smart phone intervention. Ongoing, iterative analysis of the interview data will be used to determine whether the interviews are generating repeated themes and patterns.

 

Translation and transcription will be an ongoing process carried out by the study team. We will analyze conceptual themes as they emerge to ensure that the themes are reflected in the transcripts. The data analysis process will begin with line-by-line coding by hand, directly onto the paper transcripts.

 

We will develop a codebook based on emerging themes. Once the codebook is complete, we will begin focused coding in computer software NVivo. We will review coded transcripts to ensure consistency with the codebook guidelines. Recurring themes will be placed back into individual narratives in order to include context and maintain the validity of the analysis.  Survey data will be presented descriptively only.

 

Timeline

Now through February:    Continue revising interview guides and survey

January 2010:                  I arrive in Achham

February and March:         Conduct interviews, translations, transcriptions.

                                         Plan around other implementation challenges, not related to study

Fall 2010:                           Pilot smartphones

 

References

Rowe AK, Savigny D, Lanata CF, Victoria CG.  How can we achieve and maintain high-quality performance of health workers in low resource settings?  Lancet Aug 9 2005.

Jennett P, Yeo M, Pauls M, Graham J.  Organizational readiness for telemedicine: implications for success and failure.  Journal of Telemedicine and Telecare 2003; 9 (Suppl. 2): S2:27-30.

Khoja S, Scott RE, Casebeer AL et al.  e-Health Readiness Assessment Tools for Healthcare Institutions in Developing Countries.  Telemedicine and e-Health.  13:4 2007.

Alma Ata in the Digital Era: Telemedicine for Community Health Workers.  Maru DSR et al. 

Community health workers: What do we know about them?  Lehmann U, Sanders D. World Health Organization, Evidence and Information for Policy, Geneva January 2007.

Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines.  World Health Organization 2008.

 

Annex 1

Interview Guide for Community Health Workers and Female Community Health Volunteers

1. Please describe the two most significant clinical problems you have had to deal with during the last five weeks while in the field.

Explain what led up to the situation.

Explain what you were able to do for the patient.

Explain what else you may have wished to do for the patient but were unable to do.

 

2. Imagine you had the ability to contact staff at Bayalpata to seek their guidance while you were in the field.

How would you feel about that?

Would this have made a difference in how you handled either of the situations you described above?

If so, please describe how it would have made a difference.

If not, please explain why you don’t think it would have made a difference.

 

3. Imagine you had access to triage algorithms (show mock-up of triage algorithm to explain).

How would you feel about that?

Would this have made a difference in how you handled any of the situations you described above?

If so, please describe how it would have made a difference.

If not, please explain why you don’t think it would have made a difference.

4. Imagine you were required to record your progress (immunizations, antenatal visits, outpatient follow-up, etc) in a smart phone (show sample and explain functions) or handheld computer.

How would you feel about that?

How would this affect your work?

5. Imagine hospital staff had the ability to contact you in the field.

How would you feel about that?

How would this affect your work?

6. What problems do you anticipate with the deployment of smart phones to CHWs?

7.  Is there anything else you think Nyaya Health should consider regarding the use of smart phones for the CHW program?

 

Annex 2

Interview Guide for Nyaya Clinical Staff

1. Please describe the two most significant clinical problems you have seen CHWs deal with during the last five weeks while in the field.

Explain what led up to the situation.

Explain what was done for the patient.

Explain how the problem might have been approached differently.

2. Imagine CHWs had the ability to contact you from the field.

How would you feel about that?

Would this have made a difference in how either of the situations you described above would have been handled?

If so, please describe how it would have made a difference.

If not, please explain why you don’t think it would have made a difference.

How would you have advised the CHW?

 

3. Imagine CHWs had access to triage algorithms (show mock-up of triage algorithm to explain).

How would you feel about that?

Would this have made a difference in how the CHW handled either of the situations you described above?

If so, please describe how it would have made a difference.

If not, please explain why you don’t think it would have made a difference.

4. Imagine CHWs were required to record their progress (immunizations, antenatal visits, outpatient follow-up, etc) in a smart phone (show sample and explain functions) or handheld computer.

How would you feel about that?

How would this affect supervision of their work?

 

5. Imagine hospital staff had the ability to contact CHWs in the field.

How would you feel about that?

How would this affect supervision of their work?

6. What problems do you anticipate with the deployment of smart phones to CHWs?

7.  Is there anything else you think Nyaya Health should consider regarding the use of smart phones for the CHW program?

 

Annex 3

Interview Guide for Nyaya Administrative Staff

1. Please describe the two most significant problems that the CHW program has faced in the last 3 months.

Explain what led to the problem.

Explain what was done to respond to the problem.

Explain how the problem might have been approached differently.

 

2. Imagine CHWs and clinic staff could reach each other by phone.

How would you feel about that?

Would this have made a difference in how either situation you described above would have been managed?

If so, please describe how it would have made a difference.

If not, please explain why you don’t think it would have made a difference.

 

3. Imagine CHWs had access to triage algorithms (show mock-up of triage algorithm to explain)?

How would you feel about that?

Would this have made a difference in how the CHW handled either of the situations you described above?

If so, please describe how it would have made a difference.

If not, please explain why you don’t think it would have made a difference.

4. Imagine CHWs were required to record their progress (immunizations, antenatal visits, outpatient follow-up, etc) in a smart phone (show sample and explain functions) or handheld computer.

How would you feel about that?

How would this affect supervision of their work?

5. Imagine hospital staff had the ability to contact CHWs in the field.

How would you feel about that?

How would this affect supervision of their work?

6. What problems do you anticipate with the deployment of smart phones to CHWs?

7.  Is there anything else you think Nyaya Health should consider regarding the use of smart phones for the CHW program?

 

 

Annex 4

Survey

1. Age

2. Gender

3. Total years of school completed

4. Do you have access to internet?

If “yes”, how far (minutes) do you have to travel to get access?

5. Do you have access to a mobile phone?

If “yes”, how far (minutes) do you have to walk to get coverage?

If “yes”, have you used it to contact a colleague?

6. Do you have electricity at home?

If “yes”, approximately how many days of the week do you have electricity?

Answer the following questions according to this scale:   

1 disagree    2 somewhat disagree    3 neutral    4 somewhat agree    5 agree

7. Smart phones will be an effective tool for the community health worker program.

8. Smart phones will improve triage.

9. Smart phones will improve oversight.