Abstract
BACKGROUND: Community health workers are reemerging as an essential component of health systems in low-income countries. However, there are concerns that unless they are adequately supported, their motivation and performance will be suboptimal. mHealth presents an opportunity to improve support for community health workers; however, most interventions to date have been designed through a top-down approach, rarely involve the end user, and have not focused on motivation. OBJECTIVE: To use formative research to explore the views of community health workers in Uganda and Mozambique on the potential role of mHealth in their work delivering integrated community case management of children. METHODS: We conducted 24 in-depth interviews and 5 focus group discussions with community health workers in Uganda and Mozambique. Data were collected on: current phone use, preferred phone and charger characteristics, and perceptions of a range of potential mHealth interventions. Interviews were conducted in the local language, were audio recorded and converted into expanded notes. Interviews were coded for key thematic areas using both deductive and inductive codes. Deductive codes included mHealth's potential impact on motivation and performance. RESULTS: The most salient roles of mHealth in improving performance and motivation were reducing the need for travel, improving efficiency and planning, receiving feedback and information, and improving communication with supervisors and other community health workers. This was mostly through improved voice and short message service (SMS) text communication. Specific components of mHealth interventions that participants felt could improve motivation included increasing their visibility and credibility through branding of phones; providing an SMS response to data submission; and sending SMS messages about the importance of their work and achievements, rather than just reminders or technical messages. Participants identified feasibility issues related to the language of SMS messages, network coverage, and the need for a balance between phone function and battery life. Phones with a dual SIM cards would ameliorate network problems but would reduce battery life. The provision of a solar charger was viewed as beneficial. CONCLUSIONS: Conducting formative research with end users is likely to improve mHealth interventions by: (1) identifying interventions that are likely to have the greatest impact and be the most acceptable, (2) developing salient SMS messages, and (3) identifying feasibility issues. mHealth interventions also could have an important impact on health worker motivation, which should be considered by intervention developers and in evaluations, especially as small modifications could have a significant impact. Our study suggests that using phones to improve direct communication should be considered, even when planners aim to focus on the provision of a specific application.