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

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