Introduction
Sierra Leone is consistently ranked among the countries with the highest maternal mortality ratio (970 per 100,000) and women in Sierra Leone have a 1 in 21 lifetime risk of dying as a result of pregnancy. Despite some progress, Sierra Leone still ranks 5th in the world for countries with the highest under-five mortality rates (140 per 1000), and 1 in every 7 children die before reaching their fifth birthday. The inequitable distribution of health facilities, a severe lack of health equipment, and a shortage of skilled health staff are some of the identified factors underlying the poor performance of health systems to deliver effective maternal and child health care services.
The Ministry of Health and Sanitation (MOHS) introduced free health care for pregnant women, breastfeeding mothers, and children under-five in April 2010. Early reports show that the uptake of these services has improved significantly but that health centers are struggling to keep up with increasing demand for health care. In response to this, the government of Sierra Leone is in the process of finalizing a revised policy on the integration of community health workers (CHWs) into the formal health system. This form of task shifting, or “the rational redistribution of tasks among health workforce teams [whereby] specific tasks are moved from highly qualified health workers to heath workers with shorter training and fewer qualifications”, recognizes CHWs as a key alternative cadre in the delivery of maternal and child health services in Sierra Leone.
Results from systematic reviews of CHW programmes confirm that CHWs provide critical links between rural communities and the formal health system and have been shown to reduce child morbidity and mortality when compared to usual healthcare services. With appropriate support and sufficient training, CHWs can potentially play a pivotal role in strengthening health systems in areas with poor human resources for health. More specifically, they are an important resource for implementing interventions targeting reductions in neonatal mortality and tracking women throughout their pregnancy while simultaneously promoting appropriate maternal and newborn care practices. Their potential however, is hampered by inadequate supervision, lack of locally relevant incentive systems, loss of motivation, insufficient recognition and community support, poor connectivity to health facilities, and knowledge retention problems. Moreover, higher attrition rates are often observed in programmes where CHWs are asked to volunteer. The motivation of CHWs and the risk of high attrition rates therefore have important implications for the effectiveness, success, cost, credibility and continuity of CHW-based programmes.
The current enthusiasm around information communication technology for development (ICT4D) has sparked international interest and large investments in mobile telecommunication and multimedia technologies across the globe. Mobile health, or mHealth, is a sub-segment of the broader field of electronic health (eHealth) that uses mobile phones to enhance the efficiency of service delivery and improve the quality of health care. mHealth tools have shown important promise in providing better access to care in low income countries, especially in rural and underserved populations. Low and middle income countries (LMICs) are seeing massive growth in the mobile technology sector with over 3.8 billion subscriptions, comprising 73% of worldwide subscriptions . The growing availability of mobile phones in LMICs has the potential to address a number of current healthcare challenges including: addressing the shortage of skilled health workers, strengthening health information systems; improving timely data collection, diagnosis and disease surveillance; increasing treatment adherence and compliance; better administration of drug inventories and drug supply chain management; and improving case-management among health workers.
Rationale
Despite growing enthusiasm, the evidence demonstrating the impact of mobile phones as a human resource management tool for CHWs however, remains scarce. Globally, a high interest in mHealth, or mobile health, has led to an abundance of pilot project, the vast majority of which have failed to deliver sustained impact at scale. Moreover, mHealth projects can potentially place a high burden on already overextended health resources and health centre staff as they are forced to reconsider and reconfigure their current workflows and protocols. Lastly, there is a lack of evidence demonstrating how the use of mobile phones can mediate CHW attrition rates through impacting CHW motivation, supervision, and organizational commitment of CHWs.
Background
The Centre for Global Health, Trinity College Dublin is partnering with the MOHS, World Vision Ireland, and World Vision UK to increase access to maternal, newborn and child health (MNCH) in Bonthe District. As part of this initiative, CHWs will be trained in the delivery of the 7-11 timed and targeted counseling (7-11/ttC) strategy for pregnant women and their newborn children. The 7-11/ttC strategy trains CHWs to promote 7 key health interventions for pregnant women and 11 key health interventions for children under the age of 2. The key health interventions are summarised in Table 1:
These core interventions are delivered over the course of 10 timely household visits made by the CHW at specific times during a woman’s pregnancy and during childhood as per the schedule in Figure 1:
The ttC mobile application is an innovative component of 7-11/ttC that will allow CHWs to receive reminders about household visits, to register pregnant women for 7-11/ttC, to make referrals to their affiliated peripheral health unit (PHU), to track their own progress, and to collect household data for transmission to the health facility to support clinical and managerial decision-making.
Research Objectives
The main objective of the proposed research is to examine changes in CHW motivation, triggered by the introduction of the 7-11/ttC mobile application, and assess how this mediates health worker performance over time. The hypothesis to be formally tested is whether there are statistically significant changes in the motivation levels of participating CHWs over a minimum period of 18 months of 7-11/ttC deployment across three different various intervention groups and whether these changes are associated with changes in CHW performance indicators. Motivation levels will be assessed in conjunction with other factors including: supervision, organisational commitment, and job satisfaction. This is the first study that we are aware of, which assesses the effects of both mobile phones and the ttC mobile application on health worker motivation and health care service delivery structures.
As a secondary research objective, we will explore how the mobile component of 7-11/ttC changes MNCH health care delivery practices as well as identify the potential challenges and obstacles to scale-up of the 7-11/ttC intervention. A better understanding of how the mobile component of 7-11/ttC contributes to health worker performance, changes existing system workflows, and influences communication pathways between community health structures and peripheral health units has important implications for how the programme will be scaled-up across the 20 countries where it is currently being implemented.
Methodology
We will employ a longitudinal cohort design to monitor individual and group changes in motivation, organizational commitment, supervision and job-satisfaction across three intervention groups over a period of 18 months. Participants will initially be contacted from a list of active CHWs in the area, provided by the Bonthe District Health Management Team (DHMT). All 333 community health workers on the mainland in addition to one in-charge member of staff from all 26 health care centres in the area will be asked if they would be willing to participate in the study. Within this sample size, both males and females will be represented equally as part of the selection criteria for CHWs within each PHU. In order to ensure that all CHWs have the same basic level of 7-11/ttC training, CHWs must have completed the 7-11/ttC training jointly conducted by the DHMT and World Vision. The inclusion and exclusion criteria as part of this research project is therefore as follows:
Exclusion Criteria
- CHWs or PHU workers in either Jong, Imperi, Sogbeni or Kpanda Kemoh chiefdoms who were not trained as part of the 7-11 ttC programme, or who have not completed ttC training.
- CHWs or PHU workers under the age of 18.
Inclusion Criteria
- CHWs or PHU workers over the age of 18 in either Jong, Imperi, Sogbeni or Kpanda Kemoh chiefdoms who have been trained in ttC as part of the 7-11 ttC programme.
An initial prototype to test the 7-11/ttC will be tested in January 2013. Once the proof of concept has been completed, and adjustments have been made, the 26 health centers and their associated CHWs will be randomly assigned to one of three intervention groups:
The first intervention group will be comprised of CHWs having only received ttC training from the MOHS appointed Bonthe District Health Management Team (DHMT) in collaboration with World Vision Sierra Leone. CHWs assigned to this intervention group will use the existing paper forms for referrals, registrations, and for reporting to their affiliated PHU. Likewise, any counter-referrals made from the PHU for follow-up by a CHW would also be paper-based. In other words, this first intervention group will be receiving all of the benefits of 7-11/ttC without the mobile component and acts as our control group for the implementation of a mobile component.
The second intervention group will receive ttC training in addition to being given a mobile phone without the mobile ttC application. The CHWs assigned to this second group will be set up on a closed-user-group, permitting them to make unlimited calls to one another and to their affiliated PHU. They will not however, have access to the mobile ttC application. This second group will allow us to see how CHWs communicate amongst each other and with their supervisor and affiliated community health committee. Moreover, it will allow us to differentiate any impact attributable by sole virtue of access to a mobile phone as part of 7-11/ttC from the mobile ttC application itself.
The third and final intervention group will receive ttC training and a mobile phone equipped with the aforementioned mobile ttC application. All referrals, registration, and reporting forms will therefore be available to CHWs electronically and delivered in real-time to their supervisor at the PHU. As the closed-user group will also be available to this group, this third intervention group will allow us to evaluate the added value of the mobile ttC application in terms of mediating both CHW motivation, supervision, organisational commitment, and job satisfaction and allow us to see how the added technology influences the change in workflows over time.
Assessment
Follow-up questionnaires will take place every 5-6 months to assess the impact of the 7-11/ttC mobile phone application on maternal and child referral rates as well as on the motivation, organisational commitment, and supervision amongst CHWs. CHW motivation will be assessed using the Volunteer Motivation Inventory (VMI) . The VMI is a validated psychometric measure containing 44 statements with 4-5 statements associated with each of the 10 identified motivational factors, scored with a Likert scale. The 10 sub-scales are as follows: values, reciprocity, recognition, understanding, self-esteem, reactivity, social, protective, social interaction, and career development. Motivations to volunteer identified by the VMI are not assumed to be independent of one another. CHW’s perception of supportive supervision will be assessed using a series of 20 statements, scored with a 5-point Likert scale. The supportive supervision scale that will be used is based on the findings of research conducted by Mathauer et al. Organisational commitment will be assessed using a series of 20 statements, scored with a 5-point Likert scale based on the Allen & Meyers scale . Job satisfaction will be assessed using the Minnesota Satisfaction Questionnaire (MSQ) short form . This is a validated measure using a series of 20 statements scored with a 5-point Likert scale. Work and Wellbeing will be assessed using the UWES scale, with 3 sub-scales: vigour, dedication, and absorption in work engagement .
CHW performance will be measured using a number of MNCH and performance-based indicators such as the number of completed emergency referrals made to their affiliated PHU, the number of registered households for the 7-11 ttC programme, the number of tardy or missed scheduled household visits, the number of completed counter-referral follow-ups made, the number of mothers and children accessing health services at appropriate times (ante and post natal clinics, immunisations, etc.), the percentage of pregnant women delivering in health centres, and the number of pregnant women and children under five sleeping under insecticide treated nets (ITNs), for example. These indicators will be monitored and compared across the three different intervention groups. The attrition rate of CHWs will also be monitored over time and any decision to withdraw from 7-11 ttC will be followed-up with a key informant interview to further explore the reasons behind this decision.
The second research objective will observe changes in community uptake and demand of MNCH care services, MNCH behaviour practices, referral cases, case management, and existing health system workflows. By examining how the technology shapes and reshapes professional, social, and organizational structures we can track how the mobile component of 7-11/ttC may or may not be contributing to reconfigurations in health care practices in the programme areas. Such an analysis would additionally focus on the exploration of the emergence of new and innovative ways of health service delivery and the collection of health information, and what role mobile systems have played in this process. By adopting this focus, we hope to identify the organisational, institutional, political, and socio-technical challenges and opportunities that are relevant to the effective scale-up of 7-11/ttC.
In order to achieve this, existing workflows and MNCH health care delivery procedures will be mapped out prior to the introduction of the mobile component. This will be achieved through a number of key informant interviews and focus group discussions with existing formal and informal structures within the health care system. This includes interviews with traditional birth attendants, community health workers, community health committees, PHU workers, district health management team members, and those in charge of the PHU and hospitals. Moreover, interviews will also be conducted with pregnant women and women with small children, documenting their own experiences with the health care system to date.
The paper-based workflow system present in the first intervention group will subsequently be compared to the other two intervention groups through regular follow-up interviews with these stakeholders. Any reported anecdotal changes will be compared to the paper-based referrals, registration, and reporting forms, the closed user group phone records, and the back-end of the ttC mobile application for the purposes of triangulation.
Data Analysis
Inferential statistics will be used to test for significant differences across the three different intervention groups. The aforementioned Likert scale questionnaires with sub-scales will be analysed to yield sub-scale scores for the purpose of analysis. A coefficient of reliability such as Cronbach’s alpha will be used to assess internal consistency scores for each of these scores. The data will subsequently be subjected to factor analysis. Among the hypotheses to be tested are that volunteer motivation is positively correlated with organisational commitment, supportive supervision, job satisfaction and CHW performance over time. More specifically, we hypothesise that the link between motivation and these constructs would be mediated by autonomous motivation. Demographic variables such as age, education level, marital status, number of dependent children, income, and gender will be used to test for possible interaction effects with the main variables included in this study. A formal qualitative assessment will also be performed after 12 months of the intervention and will be designed to complement the quantitative assessment to allow us to better triangulate our findings.
The second objective of our proposed research will be met through an extensive collection and analysis of qualitative data. This will be triangulated with data gathered from the mobile use, which will allow us to see who CHWs call or contact in the case of an emergency referral, how often they contact their supervisor at the PHU, and how often they communicate with one another.
Research Timeline
The first phase is taking place during November 2012-January 2013 and is comprised of the following activities: An early version of the ttC mobile application will be piloted and tested in a local chiefdom not included in the study area. This first phase will also be characterised by the finalisation of research tools and interviews through initial piloting of the proposed questionnaires and interviews. Once this is completed, we will begin the informed consent process whereby CHWs participating in 7-11/ttC across the four chiefdoms will be contacted to participate in the research component. Once participants have been recruited, the informed consent procedure has been completed, and written consent has been obtained for their participation in the research, the first set of questionnaires will be administered prior to the introduction of the mobile component as a baseline exercise. Focus group discussions and key informant interviews will also be conducted with key stakeholders as a preliminary investigation of existing workflows and relations between informal (traditional birth attendants, CHWs, community health coalitions), and the formal health system (PHU workers, district health management teams).
The second phase is marked by the introduction of the mobile phone and the assignment of CHWs and health care centres to the three intervention groups. We anticipate this will commence following the baseline exercise around January 2013. This second phase is primarily a data collection phase taking place over the course of 18 months. Three subsequent follow-up questionnaires and interviews will be administered in May 2013, November 2013, and May 2014, respectively. Follow-up questionnaires will follow a cohort design whereby the same CHWs will be interviewed a total of four times throughout the course of the entire research. Performance indicators such as the number of emergency referrals, pregnancy registrations, and missed or tardy household visits by a CHW will be gathered on a monthly basis from each of the 26 PHUs. Focus group discussions and key informant interviews with key stakeholders will also take place at the above 5-6 month intervals. Data gathered at each of these intervals will be entered and analysed on a rolling basis.
The third and final phase of this study will take place between June and December of 2014 and is marked by the completion of the data analysis phase. Interpretations of the data, major findings and recommendations will be collated in the form of policy briefs, executive summaries, final reports, and manuscripts for publication as part of the research dissemination process.
Limitations
The most important threats to our research are; a lack of a no-intervention group allowing the comparability of all in the intervention factors against the status quo of CHW-based MNCH interventions; inadequate measurement or analysis of confounding factors that can distort our understanding of key relationships in the data; and the spill-over of the intervention into comparison communities as word spreads of the mobile component to the intervention. In order to minimize contamination between the intervention groups, CHWs will be assigned according to their affiliated PHU. In other words, all CHWs attached to a particular PHU will belong to the same intervention group. Moreover, the repeated-measure design of our study introduces possible practice effects. All PHU workers, irrespective of which intervention group their CHWs belong to, will be trained in the use of the mobile application and each PHU will be given a phone with the ttC application. We recognise that there are inherent risks in undertaking research that involves a technological component. The challenge of charging mobile phones in areas with no national power grid for example, will be addressed with the use of solar chargers for CHWs and their affiliated PHU.
Ethical Considerations (250 words)
Ethical approval for the first objective of this proposed research has been awarded by the Health Policy & Management Research Ethics Committee, Trinity College Dublin and the Sierra Leone Ethics and Scientific Review Committee, Connaught Hospital, Freetown. Ethical approval for the second objective of this study will be sought from the same. The informed consent process took place during November 2012. All eligible CHWs and in-charges for the 26 PHUs were by a 7-11/ttC development facilitator and asked if they would be interested in learning more information about participating in a study as part of 7-11/ttC.
Expected Outcomes & Dissemination
The National Telecommunication Company (NATCOM), Sierra Leone’s national telecommunications regulatory body has already given their full support of the programme and our partnership with the MOHS ensures that our results will be utilised to advance the delivery of health services in Sierra Leone. The findings from the proposed research not only have important implications for MNCH outcomes, services and policy in Sierra Leone, but also greatly contribute to the programming of ttC across the entire World Vision Partnership with the potential to scale-up this programme across 20 countries.
Expected outcomes include the improved quality and timely use of maternal and child health services through improved health worker performance, an increase in the uptake of MNCH services through more consistent communication between community structures and health centres and through creating a greater demand for service, and strengthened operational structures in support of 7-11/ttC programming. By gaining a greater understanding of the mechanisms through which 7-11/ttC supports community-based health care delivery, we can better address existing challenges, increase programme sustainability, and ensure the effective scale-up of the programme.
Internationally there is growing interest and enthusiasm for the potential of mobile health to improve access to and quality of health services in low-income countries. However, this is not matched by corresponding evidence or understanding of the potential contribution such technology might have. There are potentially many obstacles to the rollout of mobile health interventions across the health services, just as there may be many positive consequences (as yet unknown). The findings from this in-depth exploratory study can yield important lessons that inform future developments in mobile health.
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