The critical role of community health volunteers (CHVs) in promoting good health practices in Sub-Saharan Africa is well known. Systematic reviews have shown that CHV performance and their integration with the primary healthcare system are improved when sufficient priority is given to on-going supervision and feedback.
However, providing this on-going support is challenging. First, supervisory need is greatest in remote areas, where health services are most overstretched and face-to-face supervision is not always equitable, or even possible, due to geographical constraints. Second, the training needs of supervisors are often under-resourced, resulting in their supervisory activities being poorly defined and limited to occasional supervisory outreach visits. Third, there are often significant pressures on a supervisor’s time and the cost of travel can mean CHVs have difficulties in accessing training centres. Finally, CHVs often have to rely on the dissemination of guidelines, which a Cochrane Review has demonstrated has little or no effect on practice . A mobile intervention can overcome geographical constraints and provide innovative practice-based tools that help facilitate increased communication and support between CHVs and their supervisor.
The key question is: how can we work with CHVs and their supervisors to design and implement a mobile training intervention that addresses these issues? This is the challenge being address by the mCHW project, a collaboration between the London Knowledge Lab at the Institute of Education, University of London and the African Medical and Research Foundation (AMREF), funded for two years (2013-2015) by ESRC-DFID under their poverty alleviation programme. The sites of work are the Kibera informal settlement in Nairobi and Makueni County, a rural area approximately half way between Nairobi and Mombasa. The project is working with 90 CHVs and their supervisors, known as community health extension workers (CHEWs) in Kenya.
The first challenge was to understand the context and work practices of community health volunteers and their supervisors. This empirical work was undertaken over a three month period in early 2013 and gave us a strong insight into the complexities of the issues they have to deal with. By using a participatory action research approach, we co-determined two core areas of training need, where mobile learning apps could be useful: 1) child health, specifically surveillance of child development stages and 2) counselling for community members living with HIV. In this phase of our project, we are focusing on child health, with the counselling element beginning in early 2014.
The Malawi Development Assessment Tool (MDAT) which was specifically developed to assess child development in African settings forms the basis of our mobile application. The CHVs will use this in their assessment of the children they look after. The app then recommends whether the child needs to be referred or not. Based on their experience, a CHV indicates their level of agreement with this recommendation – using it as the basis for discussion with fellow CHVs and their CHEW. Their referral decision and the MDAT data on which it is based are then sent by the app to the CHEW, who provides detailed feedback to the CHV on their assessment practices.
Alongside strong content development and innovative pedagogical design, we are working closely with the Division of Child and Adolescent Health at the Ministry of Health to ensure that our training programme is aligned to their strategic priorities and can be embedded within their existing structures.
There are two reasons that supported our choice of web apps. First, from an educational perspective smartphones provide opportunities to develop tools that are underpinned by effective learning theories and support activities including collaboration and peer learning. They also allow CHVs to evidence their practice and make this practice data transparently available to their CHEW, who in turn can use it to improve their feedback to CHVs and tailor it in more relevant ways than are currently possible. Second, the price of smartphones in Kenya continues to fall and entry level models retail currently for approximately €55. As prices continue to fall, we believe this will make them an affordable resource for CHV training programmes because of 1) the significantly increased functionality they provide over low end phones and 2) the ease of development and implementation they provide over feature phone applications.
This week we are training CHVs and CHEWs to use our mobile application. They will now use it in their everyday work for the next three months. We will gather data on any changes in their practice, in particular focusing on how the mobile app supports increased support and feedback between CHEWs and CHVs. We are interested in the scope of any new actions that occur due to the mobile intervention and any new kinds of conversations that support CHVs’ child development assessment practices in their provision for quality healthcare for their communities.