Supporting & strengthening MNCH services
using mobile phones: A research protocol
Frédérique Vallières & Eilish McAuliffe
vallierf@tcd.ie
Phase I: Development of 7-11 into an open source mobile phone application
Background
Inadequate maternal healthcare and delayed referral account for some of the most significant
contributors to maternal and newborn deaths in low-income countries [1]. These occur primarily
because of a shortage of trained health staff, insufficient resources, and broken linkages in the
referral chain [2]. 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 [3,
4]. Their potential however, is hampered by inadequate supervision, lack of supplies, loss of
motivation, poor connectivity to health facilities, and knowledge retention problems [5-7].
The growing availability of mobile phones in low-income countries has the potential to greatly
increase health service delivery; strengthen health information systems; improve data collection
and monitoring; and provide additional support for health workers [8-12]. There is a dearth of
evidence demonstrating the impact of mobile phone applications on the quality of maternal
health services and thus far, we have found no evidence of interventions measuring the impact
of mobile phone applications on CHW motivation, supervision and knowledge retention.
Introduction
The 7-11 mobile phone application requires the development of phone-based forms specifically
designed for each visit. Each of these forms will:
1.Make use of visual and audio tools for the delivery of key health messages. This will encourage
nutrition education and behaviour change at the household level, empowering caregivers to seek
timely
health
services
and
to
adopt
healthy
behaviour.
2.Collect information on the current health status and health seeking behaviours of the household.
Through the regular feedback of data to CHWs, we will build the capacity of rural community
groups to address and monitor local causes of illness, death, and malnutrition, to advocate for
quality
health
service
delivery
and,
to
monitor
home-based
care
services.
3.Follow up on previous health centre referrals and visits to the health centre. Regular
communication between CHWs and health centers will help strengthen partnerships with national
government and other stakeholders to ensure delivery of quality health and nutrition services at
the community level. Moreover, continuous communication between CHWs and local health
centers, facilitated by access to mobile phones, will help ensure a continuum of care to women
throughout their pregnancy and to children under the age of 2.
Phase II: Piloting the 7-11 Application and Training of CHWs
The Centre for Global Health is currently partnering with World Vision Ireland to increase access
to maternal, newborn and child health (MNCH) in five different sub-Saharan African contexts.
As part of this initiative, hundreds of community health workers (CHWs) will be trained in the
delivery of the 7-11 timed and targeted counselling strategy for pregnant women and their
newborn children. 7-11 is an evidence-based framework developed and tested by World Vision,
which focuses on 7 key health interventions for pregnant women and 11 key health interventions
for children under the age of two. These core interventions are promoted through a minimum of
10 timely visits made by the CHW and are summarized in the Table 1:
Coinciding with the selection of CHWs by communities and their subsequent training, Phase II
marks the start of the form piloting. CHWs will initially be trained in the first four visits of the
original 7-11 approach, without the use of the mobile phone application. These first four visits
include three antenatal visits and one postnatal visit within the first week of a child’s life. During
this time, representatives from the MOHS will be trained in the use of the mobile phone application
and the first four forms will be piloted. Our objective at this stage is to have the first four forms
piloted and ready for use by CHWs by the end of October 2012.
Phase III: Research implementation and introduction of mobile phones
Research will be undertaken to determine impact on CHW supervision, motivation and knowledge
retention as well as household health seeking behaviour and knowledge of health issues.
Following the training of CHWs on how to use the 7-11 mobile phone application, four chiefdoms
will be randomly assigned to one of two intervention groups as described in Table 3:
Intervention Group I
Intervention Group II
CHWs from two of the chiefdoms will have CHWs from the remaining two chiefdoms will
received 7-11 training and will receive a phone receive both the 7-11 training and a mobile
WITHOUT the mobile 7-11 application
phone containing the 7-11 application.
Table 3. Description of both intervention groups
Table 1. Summary of the core interventions emphasised in the 7-11 timed and targeting counseling approach
Objectives & Methodology
A total of 356 CHWs in Sierra Leone’s Bonthe District (Figure 1) will be trained in the 7-11 timed
and targeted approach. Together, these CHWs will be responsible for over 16,720 households
across five of Bonthe’s eleven rural chiefdoms. The project is divided into four phases, each
with a 6-month timeframe and is detailed in Table 2.
Both groups of CHWs will then be sent to register and begin counselling pregnant women in their
communities while continuing to train for visits 5-10. Once pregnant women have been registered
by the CHW, ongoing collection of data by CHWs from both intervention groups during their
household visits will allow us to explore whether the use of the mobile phone application ultimately
has a greater impact on changing household health seeking behaviour and knowledge of health
issues compared to the 7-11 CHW training alone. In addition, a combination of qualitative and
quantitative tools will be used to regularly monitor and assess CHW motivation, knowledge
retention, data collection quality, strength of supervision, acceptability of the mobile application by
both CHWs and households, frequency of communication and coordination between CHWs and
health centers. The In Country Project Coordinator and Principal Investigator will collect the latter
every six months in the form of surveys, knowledge attitude & practice surveys (KAPs), and focus
group discussions. During their second assessment, CHWs will also be given performance
feedback by the MOHS.
Phase IV: Final Evaluation
Figure 1. Map of Sierra Leone with Bonthe District highlighted in blue (Source:
http://en.wikipedia.org/wiki/Bonthe_District)
The latter part of this phase marks the initiation of visits 5-10 for the children of the pregnant
women who were followed by CHWs throughout their pregnancy. It also marks the end of the 7-11
strategy training for the first cohort of CHWs. A second performance feedback will be given to
CHWs following their fourth and final assessment and a final evaluation of the entire programme
will be undertaken. Results will be used to inform the use of the 7-11 mobile phone application
across the various contexts where this strategy is currently being implemented. The successful
development of a 7-11 mobile phone application, available free of charge to anyone with a Javaenabled phone, implies that we can standardise the care CHWs provide during home visits;
provide a continuum of care to pregnant women and their children; and improve maternal and
child health outcomes without putting additional and unnecessary strain on already overburdened
health systems.
References
Table 2. Detailed schedule of how each phase will be carried out over the project’s two-year timeline.
1.Bhutta, Z.A. and S. Soofi, Community-based newborn care: are we there yet? Lancet, 2008. 372(9644): p. 1124-6.
2.ten Hoope-Bender, P., J. Liljestrand, and S. MacDonagh, Human resources and access to maternal health care. Int J Gynaecol Obstet,
2006. 94(3): p. 226-33.
3.Bhutta, Z.A., et al., Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A
Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems, 2010, World Health
Organization: Geneva. p. 391.
4.Lewin, S., et al., Lay health workers in primary and community health care for maternal and child health and the management of
infectious diseases. The Cochrane Library, 2010(3): p. 209.
5.Willis-Shattuck, M., et al., Motivation and retention of health workers in developing countries: a systematic review. BMC Health Services
Research, 2008. 8(1): p. 247.
6.Rahman, S.M., et al., Factors affecting recruitment and retention of community health workers in a newborn care intervention in
Bangladesh. Human Resources for Health, 2010. 8.
7.Kash, B.A., M.L. May, and M. Tai-Seale, Community health worker training and certification programs in the United States: findings
from a national survey. Health Policy, 2007. 80(1): p. 32-42.
8.Fraser, H.S. and J. Blaya, Implementing medical information systems in developing countries, what works and what doesn't. AMIA Annu
Symp Proc, 2010. 2010: p. 232-6.
9.Routen, T., et al., Using Mobile Technology to Support Family Planning Counseling in the Community, in International Conference on
ICT for Africa 20102010: Yaoundé, Cameroon.
10.DeRenzi, B., et al., e-IMCI: Improving Pediatric Health Care in Low-Income Countries, in Proceeding of the Twenty-Sixth Annual
SIGCHI Conference on Human Factors in Computing Systems2008, ACM: Florence, Italy. p. 753-762.
11.Svoronos, T., et al., CommCare: Automated Quality Improvement To Strengthen Community-Based Health, 2010.
12.Rotheram-Borus, M.J., et al., Project Masihambisane: a cluster randomised controlled trial with peer mentors to improve outcomes for
pregnant mothers living with HIV. Trials, 2011. 12: p. 2.
Acknowledgements: We would like to thank the Ministry of Health and Sanitation, Sierra Leone; World Vision Ireland and World Vision UK; Irish Aid and the UK Department for International Development (DFID)