Tag: health extension workers

Field Report: Our recent experiences

The Health Extension Workers (HEWs) in our maternal healthcare project have now been using the smartphones for almost 6 months, so we’re starting to build up a really good picture about what works and where there are issues. Most of the information here is based on field reports Araya has been sending back following the training sessions he has been running and follow up discussions with the HEWs.

For the last 2 months (since mid-November), the HEWs have been using the phones for recording real patient encounters, previously they were submitting test data, whilst they got used to the phones and protocols. We now have around 200 patient encounters recorded from 10 HEWs and 2 Midwives, including 12 delivery records.

The feedback we have received from the HEWs and midwives has been very positive. They seem most comfortable using the Tigrinyan versions of the protocols, HEWs can switch between English and Tigrinyan and are free to enter text data in either Latin or Ge’ez script, although very few questions require any text input. The HEWs and mothers seem very happy with using the protocols, as it checks that all the right questions are being asked during the patient encounter.

From a technical point of view, the phones are working well. There are some times when the GPRS connection is poor, so the HEWs are unable to submit the records immediately, but they are able to once the connection is restored a day or so later. We don’t seem to have had any major problems regarding recharging of the phones, although some HEWs have commented that battery life can be poor.

The main issues we have come up against so far are:
Patient Identification. This was always going to be an issue, since there isn’t a standard regional/national patient record number we can readily use. Each Health Post records patient visits in a log book and the patient id is simply the number of the next row in their log book. To try to save confusion between patients having different references in the log book and the electronic protocols, we are identifying patients by a combination of the health post name and the id from the log book – which also makes it easier to cross-reference between the two systems. Unfortunately we are getting a number of cases where patient id numbers are being entered on the protocols inconsistently or incorrectly. This may cause a visit record to be recorded against a non-existent patient registration, or, worse, against the wrong patient. However we are recording the patient age and year of birth on every protocol form submitted, so this helps to identify where errors may have occurred, but would be good to try to stop this happening in the first place. We are looking at a variety of ways in which we can resolve this, for example barcodes or fingerprints, but none of these are easy to implement.

Length of Visits. Some HEWs have mentioned that using the protocols takes a long time. I think it was always likely that the protocol forms would increase the time for a patient encounter. Not necessarily solely due to the technology, but also because we are asking them to ask quite a comprehensive set of questions and a physical examination. Previously, without the electronic protocols, the patient encounters may not have been as thorough.
From the start/end times (automatically logged by the phones) we can identify roughly how long an ante-natal care visit takes a HEW to complete, for an ante-natal care first visit the average time for the patient encounter is around 20 minutes

HEW engagement. We have a wide disparity in the number of visit records being entered by different HEWs. Some are recording visits regularly, whereas others have hardly entered any. We are looking in to the reasons for this and how we can encourage those who aren’t participating to take a more active role. There are many possible reasons for this, perhaps technical issues, not understanding what advantages using the protocols may bring, or that they have been out of post on other training.

Over the coming few weeks we hope to find ways in which we can address these issues.

Developing an Analytics Dashboard for Maternal Care

Over the last few months, alongside the protocol forms the Health Extension Workers (HEWs) are using to record maternal care patient encounters on their smartphones, we have been developing an analytics dashboard to allow HEWs, midwives, their supervisors and the local health bureaus to track the progress of pregnant mothers, their medical & pregnancy risk factors, and a range of key performance indicators.

Providing information back to HEWs and their supervisors about their performance, we hope will help to increase the number of ANC visits according to the recommended schedule, and provide information for local health bureaus to better prioritize resources and training. The current performance indicators include the percentage of ANC visits made on time, number of protocols submitted, PNC visit made on time and immunization records for both mother and baby.

Analytics Scorecard home page

For the HEWs, we can also provide information about the upcoming appointments, deliveries to assist them to plan their time better. Guidelines from the Ethiopian Ministry of Health encourage all pregnant mothers to give birth at local health centres, so we can use the ANC visit information to inform local midwives on expected delivery dates. Local health bureaus and HEW supervisors are able to compare the performance between different health posts or districts.

We are trying to be careful that this doesn’t become used as a EMRS (electronic medical records system) – there are already plenty of MRS’s available – rather we are looking at ways in which the HEWs can see advantages to recording their patient visits on their smartphones, by providing them with relevant, timely and easy to understand information about the patients in their area. In the future we may look at how to integrate with an MRS system (e.g. OpenMRS), but currently this is not the focus of what we’re trying to achieve.

For the technically minded, the analytics dashboard runs by accessing the ODK Aggregate database directly. We’ve looked at several different data collection tools (especially those focused on medical information collection), but all would require either direct database access (as we have done with ODK) or extraction of the data via an API (which would generally mean exporting to another database then accessing the dashboard from this). We’re still in the process of getting the HEWs and their supervisors up and running with accessing all this information via the web application and smartphone – we also still have some development work to do. Currently our researchers in Mekelle are printing regular reports to give to supervisors and HEWs, also, as this is a research project, it’s important that all the information (from protocols) can be stored as a hard-copy with the rest of the normal patient records at the health posts.

We’re currently developing an application so HEWs are able to access their task/performance information directly on the smartphones – which will work offline when there is no GPRS connection available, and update automatically when a connection is available (most likely using an HTML5 application, rather than a specific Android application)

Screen shots from prototype mobile browser version (personal data has been pixelated)

Using a smartphone platform to deliver this type of information is a good balance & compromise between other platform choices we could have made. Using PCs/laptops/netbooks would involve much more technical support, training and maintenance, and likely to have other issues such as access to electricity, portability etc. Smaller, low-spec phones would not allow us to present the information in such a clear and easy-to-use way.

For those interested the code for the analytics dashboard is available to download from GitHub at: https://github.com/alexlittle/Digital-Campus-Analytics

Initial HEW training with smartphones

I just posted this up on our Digital Campus blog:

Last weekend Araya and Florida ran the first training course for Health Extensions Workers (HEWs) who will participate in our feasibility study. We are starting with a very small group of HEWs – just 5 in this first training session – and the 2 day training consisted of:

  • the basic functions of the HTC hero phones, contacts, making calls, messaging and switching between Amharic and English keyboard layouts
  • charging the phones using the solar lamps and chargers we provided – as most of the HEWs do not have electricity in their Health Posts
  • using the EpiSurveyor client application for entering and sending data, plus using the GPS
  • practice completing and sending the Ante Natal Care protocol forms set up in EpiSurveyor

This first training is simply to get the HEWs used to using the phones, find out what problems and issues they may have, especially with battery life, recharging, completing forms etc – at this stage we’re not looking to collect real data – though we hope they can practise using the forms with real patients.

The feedback we have received is that the training went very well, the HEWs seem very and eager to learn how to use the phones and soon became quite comfortable using them. Over the coming months we’ll introduce the phones to another couple of small groups of HEWs and we’ll find out what challenges may exist and the feasibility for using smartphones for protocol and data collection in this environment.

Visiting Rural Health Posts

I have spent the past 4 days visiting rural Health Posts with my colleague Araya. His phd is looking at the gaps of the Health Extension Workers (HEWs), specifically related to maternal health. Once the gaps are known, the next stage will be to design a programme to fill the hole in knowledge/skills, possibly using technology to help deliver the training.

Altogether he’ll interview 150 HEWs at over 100 Health Posts in 3 districts in Tigray. Over the 4 days I’ve been out with him, he managed to interview 18 HEWs at 14 health posts. Each day has been long – leaving Wukro around 7 am and not returning until after 7pm, so 12 hours to conduct about 5 interviews, each interview lasting about an hour or more.

I’ve been helping with the technology support and will be helping look at what could be appropriate to use in this context. Not all the concerns I mentioned in my earlier post have been realised.

The GPRS coverage has been far better than I’d expected, out of the 13 posts we visited, only one had no mobile or GPRS coverage. A couple had patchy coverage – but it was working for some of the time during our approx 2 hour visits. This is really positive from the point of view of the technology we might like to use in the future.

However, none of the posts had an electricity supply. A couple had electricity poles running very close to the building, but they weren’t connected up. In most cases there wasn’t any electricity supply to the village at all.

My phone battery got to be a real problem for me, despite having wireless and bluetooth turned off, I found that battery was only lasting for about 8-9 hours. I was using the GPS quite a lot, but even on the first couple of days when I was only briefly turning the GPS on (to get the coordinates for the posts), this only gave me a couple of extra hours battery life.

All except one of the HEWs we met had a mobile phone. The reason for the one exception was that she worked at the post with no mobile coverage, so she’d given her phone to a relative. Which for me than raised the question of how they charge the phones given there’s limited power supply. The answer to this was that they must travel to the town to charge their phones (this could be a 2-3 hour walk), or they send the phones with someone else going to town.

The HEWs have very limited English (although much better than my Tigrinya), so delivery of any training materials must be in either Amharic or Tigrinya to have any chance of being effective. One of Araya’s questions is about their use of text messaging, many don’t use text messaging simply because they don’t know the latin alphabet well enough.


What I’ve seen over the past few days is only a small proportion of all the posts that Araya will eventually be covering, but it’s likely that the further interviews will reinforce what we’ve already found out – rather than raising any new issues or significantly altering the results to date.

Over the coming months (after some more of the interview have been conducted), we’d like to get the results from the technology aspects written up into a paper.

Using smart phones for health research in rural areas

I recently became the owner of an unlocked HTC Dream smartphone (running Android 1.6). Smart phones are still quite a rarity in Mekelle (and I’d guess in much of the rest of Ethiopia), so despite this not being the most recent model, everyone who sees me using it asks me to have a look & play around. I have seen a few people with Nokia E71 phones, but when you look closer they’re actually Nokla E71′s (yes, that’s Nokia with an L instead of an i).

In a couple of days I will be heading out to some rural areas with a colleague doing his doctorate in public health. He’s testing different smartphones and applications for data collection whilst he’s interviewing Health Extension Workers (HEWs). I’m joining him to see what some of the issues are with using these types of phones and applications in this context, with a view to spending some time over the coming months seeing how these devices may be used to deliver training.

I’ve only really been using the phone for the past week or so and there are a couple of areas where I can already see we may run into problems.

Firstly, the battery life. With my usage, not particularly heavy, the battery usually only lasts just over a day. Given that we’ll be using these devices for data collection, then they’re likely to be having heavy use in areas with little or no mains power. We are testing out some small solar power chargers.

Secondly, the GPRS coverage. GPRS is not used widely here and coverage in extremely patchy (even in large city like Mekelle) and it’s not yet been rolled out to other more rural areas (or even large towns). Sim cards need to be specifically enabled to use GPRS – it’s not turned on by default. The applications we’re testing out (EpiSurveyor and Sana) will both allow data to stored until an area with coverage is reached, but unless the user visits Mekelle on a regular basis then the data will never get uploaded.

I’m sure that improvements in the phones and the phone network infrastructure will eventually make both of my concerns invalid – it’s just a question of when they will be addressed.

The other questions and areas I’d like to look at include:

1) How easy is inputting the data on such a small screen? Might a tablet or netbook PC be more appropriate? Perhaps they’ll work well for short, relatively simple surveys, but not for others?
2) Do any of the HEW’s already have java enabled phones? If so, this would enable them to use the EpiSurveyor application without any new phones.
3) Do any of the phones support input using ge’ez (the alphabet used for Amharic and Tigrinian)? I can’t see how to input these characters on my phone (if anyone knows how I’d be pleased to hear from you), but I can display the characters.
4) How long do the phones take to get a GPS signal? For each record input we can automatically attach the location coordinates – but I’ve noticed that sometimes the phones can take a long time getting a GPS fix. With the power issues it’s unlikely they’d want to leave the GPS on all the time.
5) Would they really be used? Getting reliable data in these areas (even just for the number of births/deaths) is extremely difficult – reporting processes are often unreliable or just not used. Using these phones could help with gathering this info – but obviously only if they are used.
5) What are the other uses for the phones? E.g. providing remote diagnostic support, clinical support, training content/activities or reference, or perhaps for fun/social activities.

Plus I’m sure many other questions and possibilities will arise over the coming days.

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