Building an evidence base to support and enhance community health workers' (informal) use of mobile phones in Ghana, Malawi and Ethiopia

非洲最近的通信“革命”使人们乐观地认为，使用移动电话促进健康（移动医疗）可以帮助弥合医疗差距，特别是对于难以接触到的农村人口。然而，尽管移动医疗试点的规模仍然有限，但整个非洲大陆的社区卫生工作者都拥有移动电话。卫生保健员是整个非洲卫生保健服务的重要组成部分，许多国家正在扩大其部署（目标是100万卫生保健员）。因此，这里有巨大的未开发潜力。虽然许多研究都集中在正式的移动医疗倡议上（小规模的成功，扩大规模的挑战），但我们几乎不知道非洲各地的卫生工作者用自己的手机做了什么，以及对医疗保健有什么影响。去年，我们发表了我们认为是第一个认真研究这个问题的研究（Hampshire等人，2016年，卫生政策与规划）。我们非常小规模的初步研究，基于对加纳16名卫生工作者和马拉维18名卫生工作者的采访，揭示了卫生工作者经常（通常每天）使用自己的手机与同事和病人沟通，在紧急情况下获得帮助，寻求信息，组织工作后勤，如药品供应等。相比之下，只有一个人曾经参加过正式的移动医疗项目（现已不存在）。因此，我们所说的“非正式移动医疗”在资源有限的环境中加强初级保健的潜力可能非常重要。我们采访的chw都很有创新精神，善于利用手机上的新功能来帮助管理他们的工作。然而，我们的研究也指出了患者护理和卫生工作者福祉方面的挑战，包括：电话费用的经济负担和全天候为患者服务的情感负担；减少与患者面对面的交流；通过私人电话沟通时对患者保密的担忧；难以获取可靠的网络信息等。我们这一基金赠款的目标是在加纳、马拉维和埃塞俄比亚（这三个国家致力于开展主要的卫生保健项目）建立一个强有力的证据基础，以了解目前社区卫生工作者使用移动电话的情况，从而提高“非正式移动卫生”的有效性并应对挑战。如果我们的假设是正确的，并且卫生工作者的“非正式”移动电话使用是广泛的，那么这项研究可以为支持在资源有限的环境中加强卫生系统的创新方法提供关键证据。方法：1)对每个国家的卫生保健规划和移动卫生倡议进行全面的政策审查，并分析影响实施的卫生系统和环境因素。2)对每个国家的卫生工作者进行问卷调查，以估计与工作相关的手机使用水平，并收集可比较的数据：(a)在正式和非正式移动医疗使用以及功能/目的（例如与患者、同事、后勤、信息寻求等进行沟通）之间进行划分；(b)使用电话的估计财务费用和由谁支付这些费用；(c)这种“非正式移动保健”给保健员和病人带来的好处和挑战加纳和马拉维的卫生保健员以及埃塞俄比亚的1000名卫生保健员（那里的卫生保健员总数要高得多）将在多个地点取样，以涵盖一系列城市、半农村和农村住区类型。3)在调查前后，将分别召集两组焦点小组，分别由卫生保健工作者（最少14人/国家）和患者（最少6人/国家）组成，以反思目前的做法和经验（结合调查结果），并确定支持、加强和分享良好做法的可能方法，以及应对挑战。4)在整个项目期间与国家利益相关者进行会议和持续讨论，以纳入政策/实践（见影响摘要）。

Africa's recent communications 'revolution' has generated optimism that using mobile phones for health (mhealth) can help bridge healthcare gaps, particularly for rural, hard-to-reach populations. However, while scale-up of mhealth pilots remains limited, community health workers (CHWs) across the continent possess mobile phones. CHWs form a vital part of healthcare delivery across Africa and many countries are scaling up their deployment (target of 1 million CHWs).There is thus enormous untapped potential here. While much research has focussed on formal mhealth initiatives (small-scale successes, challenges of scale-up), we know almost nothing about what CHWs across Africa are doing with their own mobile phones, and with what implications for healthcare. Last year, we published what we believe to be the first study to have looked seriously at this issue (Hampshire et al, 2016, Health Policy & Planning) Our very small-scale preliminary study, based on interviews with 16 health-workers in Ghana and 18 in Malawi, revealed that CHWs used their own mobile phones regularly (often on a daily basis) to communicate with colleagues and patients, obtain help in emergencies, seek information, organise work logistics such as drug supplies, etc. By contrast, only one had ever participated in a (now defunct) formal mhealth programme. The potential for what we have called 'informal mhealth' to enhance primary care in resource-limited settings could thus be very significant. The CHWs we interviewed were innovative and adept at harnessing new features on their phones to help manage their work. However, our study also pointed towards challenges, both for patient care and health-worker wellbeing, including: the financial burden of phone costs and emotional burden of being available to patients 24/7; decreased face-to-face interaction with patients; concerns about patient confidentiality when communicating through personal phones; and difficulties in accessing reliable online information, etc. Our aim for this Foundation Grant is to build a strong evidence base of current mobile phone use among community health workers in Ghana, Malawi and Ethiopia (three countries committed to major CHW programmes), in order to enhance the effectiveness of 'informal mhealth' and address challenges. If our hypothesis is correct, and CHWs' 'informal' mobile phone use is widespread, this study could provide crucial evidence to support innovative ways to strengthen health systems in resource-limited settings. Methods:1) Comprehensive policy reviews of CHW programmes and mhealth initiatives in each country, plus analysis of health systems and contextual factors affecting implementation.2) Questionnaire survey of CHWs in each country to estimate levels of work-related mobile phone usage and collect comparable data on: (a)Split between formal and informal mhealth usage, and function/purpose (e.g. communicating with patients, colleagues, logistics, information seeking, etc.); (b) Estimated financial costs of phone use and who meets these costs; (c) Perceived benefits and challenges arising from this 'informal mhealth' for CHWs and patients.500 CHWs in Ghana and Malawi and 1000 in Ethiopia (where the total number of CHWs is much higher) will be sampled across multiple sites to cover a range of urban, semi-rural, rural settlement types. 3) Two sets focus groups of CHWs (minimum 14/country) and patients (minimum 6/country) will be convened before and after the survey, to reflect on current practices and experiences (incorporating survey findings), and to identify possible ways of supporting, enhancing and sharing good practice, and addressing challenges.4) Meetings and on-going discussions with national stake-holders throughout the project to feed into policy/practice (see impact summary).