Tag: HEWs

New Research Paper on Mobile Technologies for Health Workers

We have just had a research paper accepted and published on “Meeting community health worker needs for maternal health care service delivery using appropriate mobile technologies in Ethiopia”. The paper describes our approach and the technologies used in our recent project working with health extension workers in Ethiopia using mobile technologies for recording and managing maternal care visits. We anticipate that the results and approach outlined in this paper would be of great interest to others working in the field of mobile health.

The full open-access article can be found on the PlosOne website, and here is the abstract:

Background

Mobile health applications are complex interventions that essentially require changes to the behavior of health care professionals who will use them and changes to systems or processes in delivery of care. Our aim has been to meet the technical needs of Health Extension Workers (HEWs) and midwives for maternal health using appropriate mobile technologies tools.

Methods

We have developed and evaluated a set of appropriate smartphone health applications using open source components, including a local language adapted data collection tool, health worker and manager user-friendly dashboard analytics and maternal-newborn protocols. This is an eighteen month follow-up of an ongoing observational research study in the northern of Ethiopia involving two districts, twenty HEWs, and twelve midwives.

Results

Most health workers rapidly learned how to use and became comfortable with the touch screen devices so only limited technical support was needed. Unrestricted use of smartphones generated a strong sense of ownership and empowerment among the health workers. Ownership of the phones was a strong motivator for the health workers, who recognised the value and usefulness of the devices, so took care to look after them. A low level of smartphones breakage (8.3%,3 from 36) and loss (2.7%) were reported. Each health worker made an average of 160 mins of voice calls and downloaded 27Mb of data per month, however, we found very low usage of short message service (less than 3 per month).

Conclusions

Although it is too early to show a direct link between mobile technologies and health outcomes, mobile technologies allow health managers to more quickly and reliably have access to data which can help identify where there issues in the service delivery. Achieving a strong sense of ownership and empowerment among health workers is a prerequisite for a successful introduction of any mobile health program.

Open post

Patient visit records graph

Here’s a graph of the numbers of patient visit records the HEWs have been submitting over the last year or so (click to view a larger version):

protocols

The numbers of visit records submitted have been grouped by week, we’re not yet sure why there seem to be so many peaks & troughs in the numbers submitted each week, although the increase in the last couple of months will be attributable to us now having more HEWs and midwives working with us – in total we now have around 30 HEWs and midwives, it varies quite often as staff go away for further study, move on to other jobs, or go on maternity leave.

Demo site for patient management tools

We’ve just set up a demonstration site of our analytics and mobile site for the patient management tools. Previously if someone wanted to test out the tool for themselves, we could really only give them the mobile application and the protocols to look at, but we didn’t have a demo area for the server side. The only demo was on my laptop, and we can’t give access to the live site as it has real patient cases. I took this opportunity to look at using Amazon Web Services (EC2) for setting up the demo server – it all worked out really well and very easy to use.

You can log into the analytics/scorecard site at:

http://odk-demo.digital-campus.org/scorecard/ (username/password is demo/demo)

and the mobile version is at:

http://odk-demo.digital-campus.org/scorecard/mobile (same username/password)

The demo user has supervisor privileges, so is able to see all the data entered, usually health workers logging in would only get to see the data directly related to their patients.

If you would like to see the whole process, from entering the protocols on the smartphone, all the way through to seeing the cases on the analytics scorecard and mobile site, I also set up a demo ODK Aggregate server for submitting protocols. To set this up:

  1. Download and install on your phone our version of ODK
  2. start the app and enter the following settings (go to menu > change settings):
    • Server: http://odk-demo.digital-campus.org/ODKAggregate (note that this is case sensitive)
    • Username: demo
    • Password: demo
  3. Go to ‘get blank form’ – this should connect to the server and show all the available protocol forms – select and download the ones you would like to try out
  4. Enter and submit a few protocols from your phone
  5. You will then be able to see the forms you have entered on the analytics scorecard, and the mobile version – note that the forms don’t appear instantly on the scorecard or mobile site, it may take a couple of hours, as we have some caching running, to make the site run more quickly

Please let us know how you get on – especially if I need to add some more info to the instructions above.

Research article published on role of HEWs

Araya, one of the PhD students from Ethiopia we have been working with for the last few years, has just this week had his first journal article published: “The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study”. More details on BioMed Central or PubMed. Abstract:

Background

Community health workers are widely used to provide care for a broad range of health issues. Since 2003 the government of Ethiopia has been deploying specially trained new cadres of community based health workers named health extension workers (HEWs). This initiative has been called the health extension program. Very few studies have investigated the role of these community health workers in improving utilization of maternal health services.

Methods

A cross sectional survey of 725 randomly selected women with under-five children from three districts in Northern Ethiopia. We investigated women’s utilization of family planning, antenatal care, birth assistance, postnatal care, HIV testing and use of iodized salt and compared our results to findings of a previous national survey from 2005. In addition, we investigated the association between several variables and utilization of maternal health services using logistic regression analysis.

Results

HEWs have contributed substantially to the improvement in women’s utilization of family planning, antenatal care and HIV testing. However, their contribution to the improvement in health facility delivery, postnatal check up and use of iodized salt seem insignificant. Women who were literate (OR, 1.85), listened to the radio (OR, 1.45), had income generating activities (OR, 1.43) and had been working towards graduation or graduated as model family (OR, 2.13) were more likely to demonstrate good utilization of maternal health services. A model family is by definition a family which has fulfilled all the packages of the HEP.

Conclusions

The HEWs seem to have substantial contribution in several aspects of utilization of maternal health services but their insignificant contribution in improving health facility delivery and skilled birth attendance remains an important problem. More effort is needed to improve the effectiveness of HEWs in these regards. For example, strengthening HEWs’ support for pregnant women for birth planning and preparedness and referral from HEWs to midwives at health centers should be strengthened. In addition, women’s participation in income generating activities, access to radio and education could be targets for future interventions.

Open post

Health post map

The map below shows the health posts and centres we’re currently working with, there are a few missing as I’ve not got all the GPS coordinates yet, so I’ll add to these as soon as I get the data (and some photos too):

Open post

Mobile training course content and quizzes

We’ve recently been looking at how we can embed some of the Open University HEAT training content (for HEWs in Ethiopia) onto mobile phones and have these integrated alongside interactive self assessment questions (SAQs).

We restricted the content to just putting the introduction, learning outcomes, summary and SAQ for each of the study sections, otherwise there is far too much text content for users to comfortably read on screen – so this is designed to supplement (rather than replace) their existing course manuals.

The quizzes can be taken anytime, whether they have an internet (GRPS) connection or not, and results are submitted back to the mQuiz server (or stored for later upload if no connection is currently available). All the content and quizzes are stored directly on the phone. Users need an internet connection to initially log in, but once logged in they won’t need to re-enter their details (unless they log out or change their password).

Their SAQ results are stored on the phone, along with a ranking for how they have performed against others who have taken this assessment exercise.

Here is a quick demo video of this running on my mobile:

The next steps are to test embedding video and audio content.

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.

Protocol Forms

For those interested in the protocols forms we’re using for the maternal care project you can now access these on GitHub, see: https://github.com/DigitalCampus/Digital-Campus-Protocols. These are the forms that the Health Extension Workers are using (with ODK) to manage their maternal care visits. Please feel free to reuse these forms for your project, they’re released under a creative commons license. Over the coming days we’ll post up some more information about how to use these forms and some of the other developments we’ve been working on.

I’ve also posted up the code for our Ethiopian Pregnancy Calculator Android app (code and info) and the Amharic/Ge’ez keyboard (code and info)

Health Extension Worker technical training

Last week I spent several days visiting the training Araya and Florida are running to show the groups of Health Extension Workers how they can use smartphones for data collection.

We first visited a group in Adi Gudem (about 30km south of Mekelle), they’ve had the phones for several weeks now, so are already familiar with them. The training revolved around them using an updated client application (we’ve also changed the server software to use OpenDataKit, but this ought to be invisible to the end users) and the new ante-natal care protocols that we’ve developed over the last few weeks. For the second group in Wukro (about 40km north of Mekelle), this was their first training session, so they’d not used the phones at all before.

All seemed to go well, we had a couple of technical issues that I need to look at this week – but this is to be expected given that we’re still in the technical feasibility stage, we won’t be starting the intervention study until early next year. One of the issues we’re still finding is the level of English of the HEWs – it seems likely that we’ll need to provide the protocol questions in both English and Tigrinyan.

Some photos from the training sessions (plus a few other pics):

Posts navigation

1 2
Scroll to top