Recognising & supporting informal mhealth in Africa through grassroots interventions (REIMAGINE)

移动设备扩大医疗保健服务（移动医疗）的潜力受到广泛赞誉，特别是在低收入和中等收入国家的农村地区。然而，这种做法还没有达到宣传的效果：严重依赖捐助者的资金以及与国家卫生系统的整合不力意味着，当资金枯竭时，项目往往会失败。与此同时，社区卫生工作者（chw）正在自己动手，在工作中主动使用个人设备：我们称之为“非正式移动医疗”。在我们对加纳、埃塞俄比亚和马拉维的3000名CHWs进行的调查中，超过97%的CHWs报告说，他们每天使用个人移动设备进行与工作相关的工作，给病人打电话/发信息，组织物流，计算药物剂量，甚至使用火炬功能接生婴儿（相比之下，只有15%的人使用“正式”移动医疗电话或应用程序）。这些发展得到卫生工作者和服务使用者的积极评价，促进了沟通、后勤和病人护理，甚至挽救了生命。然而，它们也带来了成本和挑战，特别是对在偏远社区工作的卫生保健员来说，包括管理电话费用的经济困难、24/7全天候服务带来的压力和倦怠、患者保密风险以及评估在线信息时缺乏数字素养。这些都令人担忧：非正规移动医疗正在大规模发生，但费用由收入最低的卫生工作者骨干承担，其中大多数是妇女。在与卫生工作者和政策制定者的讨论中，我们确定了三种可能的低成本干预措施，以认可和支持卫生工作者的现有做法：(1)提供有关数字素养、在线安全和使用相关开放获取应用程序的基本培训；(2)制定和实施适合当地的个人移动设备在医疗保健中的使用指南；(3)补偿与工作有关的电话开支。我们现在寻求在加纳、埃塞俄比亚和马拉维（每个国家2个）6个不同的农村地区（“难以到达”）开发和试验一种包含所有三个要素（培训、指南制定和经济补偿）的参与式干预措施。在每个站点，我们将使用c.106集群与服务使用者（社区成员）和本地管理人员/主管一起接受干预。至关重要的是，虽然框架对所有地点都是通用的，但培训和指南的内容和交付将与卫生工作者和社区代表共同设计，并将针对每个地点，建立和支持现有的良好做法。为了评估干预措施的可行性和可接受性，以及评估对健康护理工作者、服务使用者和管理者可能产生的影响，我们会在基线和干预后收集相关数据。所有参与的chw（每个国家至少212名）将完成问卷调查，以衡量工作实践和与工作相关的幸福感（包括倦怠和保留意愿）的变化。后续的焦点小组讨论将与每个站点的卫生工作者、服务用户和当地主管/管理人员（每个国家至少16个小组）进行，以更详细地了解这些不同群体的关注点和优先事项，并帮助阐明观察到的变化的潜在因果途径和机制。国家和地方利益相关者的持续参与是该项目的核心。在之前研究期间建立的牢固工作关系的基础上，我们将在每个国家召集一个国家利益相关方小组（NSG），帮助监督项目，为后续扩大规模提供投入和规划。在每个研究地点，我们会成立一个本地督导小组（LSG），成员包括卫生工作者和社区代表，以及本地管理人员。社区用户组将定期举行会议，协调项目的每个阶段，并向每个参与卫生站的社区用户组提供干预措施

The potential for mobile devices to expand access to healthcare (mHealth) has been widely lauded, especially in rural areas of Low- and Middle-Income Countries (LMICs). However, the practice has not yet lived up to the hype: heavy reliance on donor funding and poor integration into national health systems means that projects often fizzle out when the funding dries up. Meanwhile, Community Health Workers (CHWs) are taking matters into their own hands, using personal devices on their own initiative in their work: a phenomenon we call "informal mhealth." Of 3000 CHWs we surveyed in Ghana, Ethiopia and Malawi, over 97% reported using a personal mobile device for work-related purposes on a daily basis, calling/messaging patients, organising logistics, calculating medicine dosages, and even using the torch function to deliver babies (compared with only 15% using "formal" mhealth phones or applications).These developments were viewed positively by CHWs and service users, facilitating communication, logistics and patient care, and even saving lives. However, they also brought costs and challenges, especially for CHWs working in more remote communities, including financial hardship in managing phone costs, increased stress and burn-out from 24/7 availability, risks to patient confidentiality, and lack of digital literacy in assessing online information. These give cause for concern: informal mhealth is happening at scale but the costs are borne by the lowest-paid cadre of health-workers, most of whom are women.In discussions with CHWs and policy-makers, we identified three possible low-cost interventions to recognise and support CHWs' existing practices: (1) providing basic training on digital literacy, online safety and use of relevant open-access applications; (2) developing and implementing locally-appropriate guidelines on use of personal mobile devices in healthcare; and (3) compensating CHWs for work-related phone expenditure.We now seek to develop and trial a participatory intervention incorporating all three elements (training, guideline development and financial compensation) in 6 contrasting rural ("hard-to-reach") sites across Ghana, Ethiopia and Malawi (2 sites per country). In each site, we will engage a cluster of c.106 CHWs to receive the intervention, alongside service users (community members) and local managers/supervisors. Crucially, while the framework is common to all sites, the content and delivery of the training and guidelines will be co-designed with CHWs and community representatives and will be specific to each location, building on and supporting existing good practice.In order to assess feasibility and acceptability of the intervention, and to assess possible impacts on CHWs, service users and managers, we will collect relevant data at baseline and post-intervention. All participating CHWs (minimum 212 per country) will complete questionnaires to measure changes in working practices and work-related wellbeing (including burn-out and retention intentions). Follow-up focus group discussions will be conducted with CHWs, service users and local supervisors/managers in each site (minimum 16 groups per country), to obtain a more detailed understanding of the concerns and priorities of these different groups, and to help elucidate potential causal pathways and mechanisms for changes observed.Ongoing engagement of national and local stake-holders is core to the project. Building on strong working relationships developed during our previous study, we will convene a National Stakeholder Group (NSG) in each country to help oversee the project, provide input and plan for subsequent scale-up. In each study location, we will form a Local Steering Group (LSG), comprising CHW and community representatives, and local managers. LSGs will meet regularly to coordinate each stage of the project, and deliver the intervention to Community User Groups (CUGs) at each participating health post