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

移动设备扩大医疗保健(MHealth)的潜力得到了广泛赞誉，特别是在低收入和中等收入国家(LMIC)的农村地区。然而，这种做法还没有达到炒作的效果：对捐赠者资金的严重依赖以及与国家卫生系统的糟糕整合意味着，当资金枯竭时，项目往往会以失败告终。与此同时，社区卫生工作者(CHW)正在自行处理问题，在工作中主动使用个人设备：我们将这种现象称为“非正式的mHealth”。在我们调查的加纳、埃塞俄比亚和马拉维的3000名CHW中，超过97%的人报告每天使用个人移动设备用于与工作相关的目的、呼叫/给患者发送消息、组织后勤、计算药物剂量，甚至使用Torch功能接生(相比之下，只有15%的人使用“正式的”mHealth手机或应用程序)。这些发展得到了CHW和服务用户的积极评价，促进了沟通、物流和患者护理，甚至拯救了生命。然而，它们也带来了成本和挑战，特别是对于在更偏远的社区工作的CHW来说，包括管理电话费用的财务困难、全天候服务增加的压力和疲惫、患者保密的风险，以及在评估在线信息方面缺乏数字素养。这些令人担忧：非正式的mHealth正在大规模发生，但费用由收入最低的卫生工作者队伍承担，其中大部分是女性。在与社区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，以认可和支持社区卫生工作者的现有做法：(1)提供有关数字素养、在线安全和相关开放获取应用程序使用的基本培训；(2)制定和实施适合当地情况的关于在医疗保健中使用个人移动设备的指南；以及(3)补偿CHW与工作相关的电话费用。我们现在寻求在加纳、埃塞俄比亚和马拉维(每个国家2个地点)的6个不同的农村(“难以到达”)地点开发和试验一种参与式干预措施，其中包括所有三个要素(培训、指导方针制定和经济补偿)。在每个站点，我们将与服务用户(社区成员)和当地经理/主管一起，聘请一群约106名社区卫生工作者接受干预。最重要的是，虽然该框架对所有站点通用，但培训和指南的内容和交付将与卫生福利院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。为了评估干预的可行性和可接受性，以及评估可能对卫生福利院、服务使用者和管理人员的影响，我们将在基线和干预后收集相关数据。所有参与的社区卫生工作者(每个国家至少212个)将完成问卷，以衡量工作实践和与工作相关的福祉(包括工作倦怠和留任意向)的变化。将与每个地点的社区卫生工作者、服务用户和当地主管/管理人员进行后续重点小组讨论(每个国家至少有16个小组)，以更详细地了解这些不同小组的关切和优先事项，并帮助阐明所观察到的潜在原因路径和机制。国家和地方利益相关者的持续参与是项目的核心。在我们上一次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攸关方小组(NSG)，以帮助监督该项目，提供投入，并为随后的扩大制定计划。在每个研究地点，我们将成立一个地方指导小组(LSG)，成员包括社区妇女和社区代表，以及当地的管理人员。LSG将定期开会，协调项目的每个阶段，并在每个参与的保健岗位向社区用户组(CUG)提供干预

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