The effect of mobile phone text message reminders on health workers’ adherence to case management guidelines for malaria and other diseases in Malawi: lessons from qualitative data from a cluster-randomized trial

Abstract

BackgroundMobile health (mHealth), which uses technology such as mobile phones to improve patient health and health care delivery, is increasingly being tested as an intervention to promote health worker (HW) performance. This study assessed the effect of short messaging services (SMS) reminders in a study setting. Following a trial of text-message reminders to HWs to improve case management of malaria and other childhood diseases in southern Malawi that showed little effect, qualitative data was collected to explore the reasons why the intervention was ineffective and describe lessons learned.MethodsQualitative data collection was undertaken to lend insight into quantitative results from a trial in which 105 health facilities were randomized to three arms: (1) twice-daily text-message reminders to HWs, including clinicians and drug dispensers, on case management of malaria; (2) twice-daily text-message reminders to HWs on case management of malaria, pneumonia and diarrhoea; and, (3) a control arm. In-depth interviews were conducted with 50 HWs in the intervention arms across seven districts. HWs were asked about acceptability and feasibility of the text-messaging intervention and its perceived impact on recommended case management. The interviews were recorded, transcribed and translated into English for a thematic and framework analysis. Nvivo 11 software was used for data management and analysis.ResultsA total of 50 HWs were interviewed at 22 facilities. HWs expressed high acceptance of text-message reminders and appreciated messages as job aids and practical reference material for their day-to-day work. However, HWs said that health systems barriers, including very high outpatient workload, commodity stock-outs, and lack of supportive supervision and financial incentives demotivated them, limited their ability to act on messages and therefore adherence to case management guidelines. Drug dispensers were more likely than clinicians to report usage of text-message reminders. Despite these challenges, nearly all HWs expressed a desire for a longer duration of the SMS intervention.ConclusionsText-message reminders to HWs can provide a platform to improve understanding of treatment guidelines and case management decision-making skills, but might not improve actual adherence to guidelines. More interaction, for example through targeted supervision or two-way technology communication, might be an essential intervention component to help address structural barriers and facilitate improved clinical practice.

Mapping Evidence of Mobile Health Technologies for Disease Diagnosis and Treatment Support by Health Workers in Sub-Saharan Africa: A Scoping Review

“…Out of the 10 included studies, three studies reported on the usage of mHealth for treatment support of the following disease conditions: HIV/AIDS (4, 117, 118); HIV and TB (1,14); two on malaria, pneumonia and diarrhoea support (11,17); one on hypertension (119); one on cervical cancer support (120) and one study did not specify any disease (121). Figure 2 shows the distribution of included studies by diseases.…”

“…The characteristics of the included articles are summarised in Table 2. The 10 included articles comprised three qualitative studies (1,117,118), four cluster randomized control trial (4,11,14,17), one quantitative study (121), and two mixed method studies (119,120). All the included articles were published in English language from 2010 to 2019.…”

“…None of the 10 included primary studies reported evidence on mHealth for disease diagnosis by health workers in SSA. In terms of geographical settings, five of the 10 includes studies were conducted in urban settings (17,(118)(119)(120)(121); three studies were conducted in semi-urban settings (1,14,117); one study was conducted in rural settings (11), and only one study was conducted in rural, semi-urban and urban settings (4). Figure 3 shows the distribution of included studies by geographical settings.…”

“…All the included studies reported on the availability of mHealth (1,4,11,14,17,(117)(118)(119)(121)(122)(123).…”

“…Mobile phone technology allows easy remote communication between health workers and their patients in hard-toreach communities with poor access to healthcare due to deplorable roads or transportation challenges (14)(15)(16). Previous studies have demonstrated that mHealth technologies have the capacity to improve healthcare outcomes such as health workers adhering to case management standards and guidelines (11,(17)(18)(19). One main application of mHealth intervention that has the capacity to improve health workers performance is to send these health workers short message prompts, educational materials on new diagnostic and treatment procedures of cases, clinical guidelines and others (11,17,20,21).In SSA, where healthcare systems continuously face problems like inadequate infrastructure, shortage of resources, and an increasing burden of communicable and non-communicable diseases such as HIV, tuberculosis, hypertension, diabetes, among others (22).…”