Mobile technology-enabled healthcare service delivery systems for community health workers in Kenya: a technology-to-performance chain perspective

Thesis (Ph.D.)--University of the Witwatersrand, Faculty of Commerce, Law and Management, School of Economic & Business Sciences, November 2016Community Health Workers or “CHWs” are often the only link to healthcare for millions of people in the developing world. They are the first point of contact with the formal care system, and represent the most immediate and cost effective way to save lives and improve healthcare outcomes in low-resource contexts. Mobile-health or ‘mHealth’ technologies may have potential to support CHWs at the point-of-care and enhance their performance. Yet, there is a gap in substantive empirical evidence on whether the use of mHealth tools enhances CHW performance, and how their use contributes to enhanced healthcare service delivery, especially in low-resource communities. This is a problem because a lack of such evidence would pose an obstacle to the effective large-scale implementation of mHealth-enabled CHW projects in low-resource settings. This thesis was motivated to address this problem in the Kenyan community health worker context. First, it compared the performance of CHWs using mHealth tools to those using traditional paper-based systems. Second, it developed and tested a replicable Technology-to-Performance Chain (TPC) model linking a set of CHW task and mHealth tool characteristics, to use and user performance outcomes, through four perspectives of Task-Technology Fit (TTF), namely Matching, Moderation, Mediation, and Covariation. A quasi-experimental post-test only research design was adopted to compare performance of CHWs using an mHealth tool to those using traditional paper-based systems. A primary structured questionnaire survey instrument was used to collect data from CHWs operating in the counties of Siaya, Nandi, and Kilifi, who were using an mHealth tool to perform their tasks (n = 257), and from CHWs operating in the counties of Nairobi and Nakuru using traditional paper-based systems to perform their tasks (n = 353). Results showed that CHWs using mHealth tools outperform their counterparts using paper-based systems, as they were observed to spend much less time completing their monitoring, prevention, and referral reports weekly, and report higher percentages of both timeous and complete monthly cases. In addition, mHealth tool users were found to have more positive perceptions of the effects of the technology on their performance, compared to those using traditional paper-based systems. An explanatory, predictive, research design was adopted to empirically assess the effects of a ‘fit’ between the CHW task and mHealth technology (TTF) on use of the mHealth technology and on CHW user performance. TTF was tested from the Matching, Moderation, Mediation, and Covariation ‘fit’ perspectives using the cross-sectional survey data collected from the mHealth tool users (n = 257). Results revealed that there are various unique ways in which a ‘fit’ between the task and technology can have significant impacts on use and user performance. Specifically, results showed that the paired-match of time criticality task and technology characteristics impacts use, while that of time criticality and information dependency task and technology characteristics impacts user performance. Results also showed that the cross-product interaction of mobility task and interdependence technology characteristics impacts use, and that of mobility task and interdependence and information dependency technology characteristics, impacts user performance. Similarly, the cross-product interaction of information dependency task and time criticality technology characteristics impacts user performance. Moreover, results showed that a perceived ‘fit’ between CHW task and mHealth technology characteristics partially and fully mediates the effects of user needs and tool functions on use and user performance, whereas ‘fit’ as an observed pattern of holistic configuration among these task and technology characteristics impacts use and user performance. It was also found that the perfect ‘fit’ between CHW task and mHealth tool technology characteristics leads to the highest levels of use and user performance, while a misfit leads to a decline in use and user performance. Notably, an over-fit of mHealth technology support to the CHW task leads to declining use levels, while an under-fit leads to diminishing user performance. Of the four ‘fit’ perspectives tested, the matching and cross-product interaction of task and technology characteristics offer the most dynamic insights into use and user performance impacts, whereas user-perception and holistic configuration, were also shown to be significant, thus further reinforcing these effects. Tests of a full TPC model revealed that greater mHealth tool use had a positive effect on the effectiveness, efficiency, and quality of CHW performance in the delivery of patient care. Moreover, it was found that ‘facilitating conditions’ and ‘affect toward use’ had positive effects on mHealth tool use. Furthermore, a perceptual TTF was found to have positive effects on mHealth tool use and CHW performance. Of note, this perceived TTF construct was found to be simultaneously a stronger predictor of mHealth tool use than ‘facilitating conditions’ and ‘affect toward use’, and a stronger predictor of CHW performance than mHealth tool use. Consequently, TTF was confirmed as the central construct of the TPC. The findings constitute significant empirical insights into the use of mHealth tools amongst CHWs in low resource settings and the extent to which mHealth contributes to the enhancement of their overall performance in the capture, storage, transmission, and retrieval, of health data as part of their typical workflows. This study has provided much needed evidence of the importance of a ‘fit’ between CHW task and mHealth technology characteristics for enabling mHealth impacts on CHW performance. The study also shows how these inter-linkages could improve the use of mHealth tools and the performance of CHWs in their delivery of healthcare services in low-resource settings, within the Kenyan context. Findings can inform the design of mHealth tools to render more adequate support functions for the most critical CHW user task needs in a developing world context. This study has contributed to the empowerment of CHWs at the point-of-care using mHealth technology-enabled service delivery in low-resource settings, and contributes to the proper and successful ‘scaling-up’ of implemented mHealth projects in the developing world.MT 201

Parent and Teacher Perceptions of Adolescent Use of Mobile Technology for Diabetes Care in Kenya

Mobile technology use provides an opportunity for the self-management of health among adolescents, serving as a lifestyle intervention tool to promote well-being and attenuate chronic conditions. However, little is known about how parents and teachers perceive how adolescents with chronic illness use mobile technology. This basic qualitative study aimed to explore teachers’ and parents’ perceptions regarding the use of mobile technology by adolescents who have diabetes in Kenya. This study’s conceptual framework was the unified theory of acceptance and use of technology. Data were collected from semistructured interviews with six teachers and eight parents from two counties in Kenya. The themes that emerged from the coding analysis included general technology use, technology affordability, technology ease of use and acceptance, technology influence, and technology support. Findings indicated that parents and teachers perceive that increased mobile technology use among adolescents could help in diabetes management in Kenya. Also, with reliable and affordable internet service, there is potential for the use of mobile technology to strengthen health services and help prevent or manage diabetes among young people in Kenya. Findings may be used to identify the obstacles to diabetes management that adolescents face, thereby promoting healthier individuals

Use of mobile technology for monitoring and evaluation in international health and development programs

Background: Mobile phones and other technologies are widely used in health programming in developing countries, many introduced by international nongovernmental organizations (INGOs) to accelerate data collection. This research examined; How are INGOs adopting the innovation of mobile technology into monitoring and evaluation (M&E) systems for health care programs in international settings, and what factors are facilitating or inhibiting this innovation? Methods: A mixed-methods approach employed key informant interviews with INGO leaders (n=12) and platform providers (n=9) and an online survey of INGO personnel (n=311). The research used the Diffusion of Innovation (DOI) framework to structure the data collection. Univariate and bivariate analyses of the quantitative data were conducted using SPSS Version 21 and qualitative analysis used MaxQDA Version 11. Results: Of all survey respondents, 70.6% had used mobile technology during the last year, 77.2% were intending to use mobile technology over the next year in their programs, and 72.6% had seen organizations like theirs using mobile technology. Only 55.7% had used mobile technology specifically for M&E applications in health. Three of the five DOI areas--tension for change, innovation-system fit, and support and advocacy--showed INGOs to be far along toward the adoption of mobile technology. Assessing the implications of adoption and dedicating time and resources to the adoption--were relatively further behind. Discussion: The research shows high levels of readiness for change in the INGO community. However, the full power of mobile technology to change the way M&E systems are built and how data are collected at a systems level has not yet taken hold. The high level of organizational readiness for change can be leveraged if organizations are going to adopt mobile technology into M&E systems. The researcher proposed a strategy to assist INGOs that would like to adopt mobile technology into M&E systems that includes disseminating the findings widely among research participants, platform providers, donors and the wider public and to repeat the survey research to track change over time.Doctor of Public Healt

An empirical evaluation of m-health service users’ behaviours: A case of Bangladesh

A thesis submitted in partial fulfilment of the requirements of the University of Wolverhampton for the degree of Doctor of Philosophy.Mobile health (m-health) services are revolutionising healthcare in the developing world by improving accessibility, affordability, and availability. Although these services are revolutionising healthcare in various ways, there are growing concerns regarding users' service quality perceptions and overall influence on satisfaction and usage behaviours. In developing countries, access to healthcare and low healthcare costs are insufficient if users lack confidence in healthcare service quality. Bangladesh's Directorate General of Health Services (DGHS) provides the only government-sponsored m-health service available to the entire population. DGHS's m-health service, available since 2009, is yet to be evaluated in terms of users' perceptions of the quality of service and its impact on satisfaction and usage. Hence, this study developed a conceptual model for evaluating the associations between overall DGHS m-health service quality, satisfaction, and usage behaviours. This study operationalised overall m-health service quality as a higher-order construct with three dimensions- platform quality, information quality, and outcome quality, and nine corresponding subdimensions-privacy, systems availability, systems reliability, systems efficiency, responsiveness, empathy, assurance, emotional benefit, and functional benefit. Moreover, researchers in various service domains, including- healthcare, marketing, environmental protection, and information systems, evaluated and confirmed the influence of social and personal norms on satisfaction and behavioural outcomes like- intention to use. Despite this, no research has been conducted to determine whether these normative components affect m-health users' service satisfaction and usage behaviours. As a result, this study included social and personal norms along with overall service quality into the conceptual model to assess the influence of these variables on users' satisfaction and m-health service usage behaviours. Data was collected from two districts in Bangladesh- Dhaka and Rajshahi, utilising the online survey approach. A total of 417 usable questionnaires were analysed using partial least squares structural equation modelling to investigate the relationships between the constructs in Warp PLS. The study confirms that all three dimensions of service quality and their corresponding subdimensions influence users' overall perceptions of DGHS m-health service quality. Moreover, overall DGHS m-health service quality has a significant direct association with satisfaction and an indirect association with usage behaviours through satisfaction. While social norms do not influence satisfaction and usage behaviours within the DGHS m-health context, personal norms directly influence users' satisfaction and indirectly influence usage behaviours through satisfaction. Theoretically, the study contributes by framing the influence of users' overall m-health service quality perceptions, social and personal norms on their actual usage behaviours rather than the intention to use. It also extends the existing knowledge by assessing and comparing m-health users' continuous and discontinuous behaviours. Methodologically this study confirms the usefulness of partial least squares structural equational modelling to analyse a complex model including a higher order construct (i.e., overall perceived service quality). Practically, the study demonstrates the importance of users' satisfaction in addition to service quality, as service quality only affects usage behaviours through satisfaction in the current study context. Additionally, knowing that personal norms significantly influence service satisfaction motivates providers of m-health services to strive to enhance users' personal norms toward m-health service to enhance service satisfaction and usage. Overall, the study will help enhance patient outcomes and m-health service usage

The (m)Health Connection: An Examination of the Promise of Mobile Phones for HIV/AIDS Intervention in Sub-Saharan Africa

This thesis offers an examination of the complex opportunities and challenges that characterize the development of innovative, locally appropriate, sustainable, and scalable uses of mobile phones as instruments to support and advance HIV/AIDS work in sub-Saharan Africa. Drawing together the fields of ICT4D and health communication, this thesis establishes a theoretical framework for mobile health (mHealth) interventions in developing countries from a critical media studies perspective. It interrogates the varied applications of mobile phones vis-à-vis health that have been identified, promoted, or piloted in sub-Saharan Africa and elsewhere in the Global South, focusing on the potential for mobile phones to enhance two interrelated aspects of HIV/AIDS work: 1) scaling-up prevention and awareness programs; and 2) enhancing access to treatment, care, and support for people living with HIV. By critically examining real-life applications, focusing in particular on a case study from South Africa (the pioneering mHealth organization Cell-Life), this thesis explores both the opportunities presented by the increasing ubiquity of mobile phones in this region, and the corresponding challenges, limitations, and critical issues that inhibit effective realization of mHealth’s potential in this context

Almanach: a new electronic algorithm to promote evidence-based medicine and rational use of drugs in primary care for Tanzanian children aged 2 to 59 months : from development to pilot implementation

The rapid spread of antimicrobial resistance is a global public health threat fastened by the overuse of these drugs. Essential to control resistance, rational use of antimicrobial is a challenge in low income countries, where mortality due to infectious diseases is high and diagnostic tools to identify causes of fever are scarce. To improve primary care management of acute illnesses for children under 5 years, WHO and UNICEF developed in the 1990’s the Integrated Management of Childhood Illness (IMCI). Implemented in more than 75 countries, IMCI has had a limited impact on health workers’ performance and overuse of antimicrobials. The main reasons for this limited impact are the insufficient compliance to recommendations, the insufficient specificity of diagnostic classifications, and the lack of guidance for the management of fever once malaria has been ruled-out. To address this public health concern, we developed and tested an innovative approach for a safe rational use of antimicrobials in primary care for Tanzanian children. The project had three major components: (1) Developing a new evidence-based clinical algorithm for childhood illness and its electronic version on mobile devices. (2) Assessing the safety of the algorithm as compared to routine practice in term of health outcome and antimicrobial prescription. (3) Assessing the impact of the implementation of the new electronic algorithm on health workers’ performance

Eye quietness and quiet eye in expert and novice golf performance: an electrooculographic analysis

Quiet eye (QE) is the final ocular fixation on the target of an action (e.g., the ball in golf putting). Camerabased eye-tracking studies have consistently found longer QE durations in experts than novices; however, mechanisms underlying QE are not known. To offer a new perspective we examined the feasibility of measuring the QE using electrooculography (EOG) and developed an index to assess ocular activity across time: eye quietness (EQ). Ten expert and ten novice golfers putted 60 balls to a 2.4 m distant hole. Horizontal EOG (2ms resolution) was recorded from two electrodes placed on the outer sides of the eyes. QE duration was measured using a EOG voltage threshold and comprised the sum of the pre-movement and post-movement initiation components. EQ was computed as the standard deviation of the EOG in 0.5 s bins from –4 to +2 s, relative to backswing initiation: lower values indicate less movement of the eyes, hence greater quietness. Finally, we measured club-ball address and swing durations. T-tests showed that total QE did not differ between groups (p = .31); however, experts had marginally shorter pre-movement QE (p = .08) and longer post-movement QE (p < .001) than novices. A group × time ANOVA revealed that experts had less EQ before backswing initiation and greater EQ after backswing initiation (p = .002). QE durations were inversely correlated with EQ from –1.5 to 1 s (rs = –.48 - –.90, ps = .03 - .001). Experts had longer swing durations than novices (p = .01) and, importantly, swing durations correlated positively with post-movement QE (r = .52, p = .02) and negatively with EQ from 0.5 to 1s (r = –.63, p = .003). This study demonstrates the feasibility of measuring ocular activity using EOG and validates EQ as an index of ocular activity. Its findings challenge the dominant perspective on QE and provide new evidence that expert-novice differences in ocular activity may reflect differences in the kinematics of how experts and novices execute skills

An exploration of the strengths and weaknesses of using text messaging as a tool for self-report data collection in psychological research

Short Message Service (SMS) has immense potential for self-report data collection because it makes use of mobile phones that people already own, and allows researchers to communicate with participants regardless of physical location. Though interest in the possibilities of SMS as a tool for psychological research is slowly growing, to date, there has been no structured investigation of how this potential may be applied in psychological research. The research within this thesis examined the feasibility of using SMS as a tool for self-report psychological research, focussing on its strengths and weaknesses as a research mode. Across fifteen studies, this was investigated using a mixture of literature review, meta-analysis, surveys, and interviews. Participant samples varied from the broad (general population, university students) to specific (the elderly, the deaf). Strengths of SMS as a tool for self-report psychological research included growing interest in research community; positive perceptions of SMS as a research tool amongst potential sample; prompt responses and high response rate; suitability for frequent repeated sampling; and usefulness as a reminder prompt to support other modes of data collection. Weaknesses included a disconnect between stated willingness to participate and actual participation; response incompleteness; unsuitability for infrequent sampling; and some problems with psychometric equivalence in relation to other research modes like online or paper surveys. This was the first structured evaluation of SMS as a tool for self-report data collection in psychological research. Conclusions are limited by somewhat arbitrary design choices (such as the psychological topic within surveys) made in the absence of guiding background literature. Future research can refine these choices and use the logic presented here to guide further investigation into how SMS performs with more varied samples, different psychological topics, and as part of different research designs. This research has shown that while SMS has great potential as a tool for psychological self-report research, it has a number of weaknesses. Identifying these strengths and weaknesses, and some design choices which may mitigate the weaknesses, will open up possibilities for a wide range of future psychological research