By Carolyne Nansubuga and John Okeya
Evidence from a new study conducted in Banda parish, Nakawa Division, Kampala, has confirmed that community health workers, commonly referred to as village health teams, are facing substantial barriers to delivering essential healthcare services using mobile technologies, fostered by intermittent power supply, high cost of internet connectivity and expensive devices.
Titled, Barriers and Benefits of mHealth for Community Health Workers in Integrated Community Case Management of Childhood Diseases in Banda Parish, Kampala, Uganda: a cross-sectional study, the paper was done by our researchers at Makerere University School of Public Health, including Winnifred Kansiime, Edwinah Atusingwize, Rawlance Ndejjo, Emmanuel Balinda, Moses Ntanda, Richard Mugambe and David Musoke.
Published in BMC Primary Care Journal in May 2024, the study conducted in February 2022 sought to determine barriers and benefits to mobile health among community health workers for integrated case management in Banda, an informal settlement on the outskirts of Kampala, with the expectation to inform policymakers and other stakeholders on good practices and policies to blend mobile health in integrated case management for promotion of primary care.
However, in their findings, the researchers confirm that institutional, community and individual factors aligned based on the Social Ecological Model, were the factors contributing to barriers and impeding the benefits of mobile health services among community health workers for integrated case management in Banda Parish, affecting the usability, acceptability, and sustainability of the technologies in extending primary healthcare services.
Mobile health (mHealth) is the use of mobile devices and wireless technology to support and improve healthcare services, health information, and health outcomes, an innovation that holds significant potential to improve access to healthcare services for remote and underserved places, enhancing the efficiency of health service delivery, providing timely health information and education, and enabling better tracking of health data and outcomes.
On the other hand, community health workers are local, frontline healthcare providers who deliver basic health services, education, and support to the community, often focused on preventive care and connecting people with healthcare resources. In Banda, these have played crucial roles for the underserved informal settlement, ensuring access to basic healthcare at the community level, health education, and early disease detection.
Banda, an informal settlement, is a suburb to the northeast of Kampala, Uganda, with over 10,000 households, each with over five occupants. The parish covers approximately 150 acres, with mainly rural-urban immigrants of several ethnic groups. Most dwellers have low levels of education and engage in informal livelihoods.
Informal settlement dwellers contribute 31 per cent of Uganda’s urban population, with about 40 percent of Kampala’s population dwelling in the settlements, which normally have limited basic infrastructure and the land profile location is near wetlands. They are characterised by congestion, dilapidated and unregulated housing with poor ventilation, inadequate water, sanitation, and hygiene, limited services and low government response to needs and services that create conditions for high morbidity and mortality rates of children under five years.
The qualitative study used a human-centered design as a framework to assess the quality of integrated community case management data collected by community health workers using mobile health data collection tools, determining the barriers and benefits to mobile health among the village health teams in integrated case management using the Social-Ecological Model (SEM) to analyze the data.
It employed 12 key informant interviews (KIIs) among focal persons from Kampala Capital City Authority and NGOs involved in data collected by community health workers, and officials from Uganda’s Ministry of Health and two mixed-sex Focused Group Discussions (FGDs) of community health workers from Banda parish.
In the study community health workers in Banda support integrated community case management of childhood killer diseases through assessment, diagnosis, treatment and referral for diarrhea, pneumonia, and malaria in children under five years of age and registering all community-identified cases, in addition to collecting data using village health team registers, transferred into the Healthcare facility summary form during quarterly meetings and later linked to the Ministry of Health health management information system data.
Normally, these registers are used for recording the cases, health indicators, and basic demographics of sick children as the community health workers interact with the community.
“However, community health workers face several challenges such as inadequate supervision, poor motivation and lack of incentives, poor retention, and limited training on data collection often resulting in poor-quality data. The recording, sharing, and accessing of data records in village health team registers is a manual process which is prone to human errors during recording in addition to data manipulation.” The new study states.
Adding that: “This undermines the reliability and validity of the data. Yet, this data informs health center facilities, district hospitals, referral hospitals, the Ministry of Health (MoH), and associated non-governmental organisations (NGOs) in their decision-making processes. Additionally, the delay in submitting the reports misses an opportunity for early identification of outbreaks in communities,” the study report reads in part.
Despite their essential services, barriers persist. The study highlights institutional and policy barriers, including high costs of training in mobile health, existing demotivation, accidental data loss and infrastructure challenges including unreliable power supply, prohibitive internet connectivity and costs, and expensive mobile device purchase and maintenance, all of which undermine mobile health services provision for the village health teams in Banda parish.
It is worth noting that mobile application systems for health (mHealth) allow community health workers to electronically record data and submit reports while limiting manual inputs. In rural Uganda, this has been shown to increase community health workers' knowledge of the danger signs of childhood illnesses through a health education intervention.
As a major issue, irregular power supply affects community health workers' ability to charge essential mobile devices necessary for data collection and communication, exacerbated by frequent power outages that disrupt crucial activities and data transmission processes.
Internet costs were also noted as a significant barrier. High monthly data plan expenses strain community health workers and the healthcare system's financial resources. Poor mobile network coverage further complicates matters, leading to communication delays and hindering data submission and sharing.
Another challenge stems from mobile device limitations. While smartphones are vital for mobile health initiatives, their high costs and technical vulnerabilities pose challenges. Cheaper alternatives often lack functionality and reliability, impacting community health worker’s efficiency and data security.
Addressing these challenges requires strategic solutions. The study recommends providing spare batteries or portable solar chargers to ensure uninterrupted device functionality, implementing cost-sharing strategies for internet connectivity, and exploring purpose-built feature phones designed for community health workers' tasks.
Furthermore, the study emphasizes the importance of adequate financial incentives, regular supply provisions, and transport facilitation to motivate community health workers and enhance overall program effectiveness.
Despite these barriers, mobile health services hold immense potential for improving healthcare delivery in underserved areas. Targeted investments in reliable power solutions, cost-effective communication tools, and robust mobile devices can significantly enhance data collection, decision-making, and resource allocation, ultimately benefiting vulnerable populations.
The study's findings underscore the urgent need to address power supply issues, reduce internet costs, and improve mobile device quality to fully harness the benefits of mobile health services for community health workers in Banda parish and similar settings.
Access the full scientific paper here.
