Challenges and prospects for implementation of community health volunteers’ digital health solutions in Kenya: a qualitative study

Background The value of digital health technologies in delivering vital health care interventions, especially in low resource settings is increasingly appreciated. We co-developed and tested a decision support mobile health (m-Health) application (app);with some of the forms used by Community Health Volunteers (CHVs) in Kenya to collect data and connected to health facilities. This paper explores the experiences of CHVs, health workers and members of Sub-County Health Management Teams following implementation of the project. Methods Data were collected in December 2017 through in-depth interviews and focus group discussions with CHVs and key informant interviews with health care workers and health managers in Kamukunji sub-County of Nairobi, Kenya. Data coding and analysis was performed in NVivo 12. Results Regarding users and health managers’ perceptions towards the system; three main themes were identified: 1) variations in use, 2) barriers to use and 3) recommendations to improve use. Health workers at the private facility and some CHVs used the system more than health workers at the public facilities. Four sub-themes under barriers to use were socio-political environment, attitudes and behaviour, issues related to the system and poor infrastructure. A prolonged health workers’ strike, the contentious presidential election in the year of implementation, interrupted electricity supply and lack of basic electric fixtures were major barriers to use. Suggestions to improve usage were: 1) integration of the system with others in use and making it available on users’ regular phones, and 2) explore sustainable motivation models to users as well as performance based remuneration. Conclusions The findings reveal the importance of considering the readiness of information and communication technologies (ICT) users before rollout of ICT solutions. The political and sociocultural environment in which the innovation is to be implemented and integration of new solutions into existing ones is critical for success. As more healthcare delivery models are developed, harnessing the potential of digital technologies, strengthening health systems is critical as this provides the backbone on which such innovations draw support.

d) How do you get feedback from the facilities on referrals done? e) What challenges are in the referral system? f) What do you think can be done to strengthen the referral system? Section C: Community Health Information Systems Q1. I would like you to talk about the information collection/reporting systems/tools that you have used over the past one year Probes a) Generally, how do you feel about the information collection/reporting system currently in use? b) How do you collect information from the households allocated? c) What do you use to collect information from the households allocated? d) On average, how much time does it take to collect information from one household? e) How do you report information collected from households? f) How often is your work reviewed? Who reviews your work? g) What are the advantages and disadvantages/challenges of the current system? h) How in your opinion do you think the current system of information collection and reporting can be improved? i) If you have heard of any health related mobile applications used in this community, what is your opinion?

Q2. Now I would like us to talk about your opinions about household information collection activities as part of your work as a CHV. Probes
a) What are the reasons you collect information from households? b) As a CHV, why should you collect information from households? Why shouldn't you collect information from households? c) Do you think it is important that you collect information from households? Elaborate. d) Do you feel respected or disrespected by the community while doing information collection activities? Why? e) Do you think that the community trusts you with the information you collect from them?
Why? Q3. To extend our discussion I would like us to talk about the use of information collected by CHVs. Probes a) How do you think the information collected by you is used? Elaborate b) By whom is the information you collect used? c) Who should use the information collected by you? d) How have you seen the information collected by you is used in the community? Elaborate e) How  Section B: Experience with m-PAMANECH Q2. What was your experience using the phone? Probes a) What was the impact of using the phone on your work in the community? Elaborate (positive or negative) b) Do you think that you would like to use this mobile app frequently? c) What do you think about the functionality of the mobile app: i. Unnecessarily complex? ii.
Easy to use? iii.
I would need assistance to be able to use this mobile app iv.
Various functions in this mobile app were well integrated v.
Inconsistency of the app vi.
I would imagine that most people would learn to use this mobile app very quickly vii.
Confidence using the app viii.
Very cumbersome/awkward to use ix.
I needed to learn a lot of things before I could get going with this mobile app

a. Community Health Assistant (CHA) ICE BREAKER
• Kindly tell me about how one becomes a CHA? The existing FP and maternal health services? viii. Effectiveness of referral system ix.

Section
Responsiveness of the services offered to the needs of the community? x.
Barriers to utilization of the health services. d) Challenges and Opportunities (how to assist mothers and children to access care), improve their work lives (reporting, knowledge and skills) e) In your own view, do you think the relationship between the CHVs and the health facilities has changed? Elaborate (negative or positive) f) How can this relationship be strengthened? g) In your own view, do you think the relationship between the CHAs and the health facilities has changed? Elaborate (negative or positive) h) How can this relationship be strengthened? Q2. Tell me about the referral mechanism from the community to the health facility, over the past one year? Probes a) What is the role of CHVs in referrals? Please elaborate? b) What is the role of CHAs in referrals? Please elaborate? c) Which health facilities do CHVs usually refer clients to? Are these public or private facilities? Why do they prefer these facilities? d) How do CHVs follow up patients referred to ensure they go to the health facilities? e) How do CHVs get feedback from the facilities on referrals done? f) What challenges are in the referral system? g) What do you think can be done to strengthen the referral system? Section C: Community Health Information Systems Q1. I would like you to talk about the information collection/reporting systems/tools that CHVs and health facilities use Probes a) Generally, how do you feel about the information collection/reporting system currently in use? b) How do CHVs collect information from the households allocated? c) What do CHVs use to collect information from the households allocated? d) On average, how much time does it take to collect information from one household? e) How do you report information collected from households? f) Do you receive any information from the health facilities? How do you use it? g) How often is your work reviewed? Who reviews your work? h) How often do you review the CHVs work? i) What are the advantages and disadvantages/challenges of the current system? j) In your opinion, how do you think the current system of information collection and reporting can be improved?
Q2. Now I would like us to talk about your opinions on the household information collection activities as part of your work as a CHA Probes a) In your opinion, what are the reasons CHVs collect information from households? b) As a CHA, why should you collect information from CHVs? Why shouldn't CHAs collect information from CHVs? c) Do you think it is important that you collect information from CHVs? Elaborate d) Do you feel respected by the community while doing information collection activities?
Why? Do you feel disrespected by the community while doing information collection activities? e) Do you think that the community trusts you with the information you collect from them? Why? Q3. Now I would like us to talk about the use of the information collected by CHVs.
Probes a) How do you think the information collected by you is used? Elaborate b) By whom is the information you collect used? c) Who should use the information collected by you? d) How have you seen the information collected by you is used in the community? Elaborate. e) How have you used the information that you have collected from households? Elaborate and give an example. Q4. In your opinion, does the information that you collect from households improve the health situation in your community? Elaborate Probes a) Have you seen that the information collected by you has influenced the decision-making or action planning at the household level? Community level? b) Who makes decisions about activities to improve health in the community? c) What influences decisions made about health in your community? Interaction with the CHVs c) Interaction with sCHMTs Q2. Describe to me the catchment area of this facility? What kind of health services are offered to the community it serves? What services are mostly utilized? Probes a. In your opinion, are the services offered responsive to the needs of the community? Are the services offered of quality? Affordable? Elaborate for each response. b. In your opinion, do you think the facility is accessible? Tell me more. c. What can be done to make things better in these health facilities to better serve the community? Tell me more.

Q3. Over the past one year, describe to me how the link between this health facility and community units in this area have been created and operated.
Probes a. What are your views on the referral system by CHVs? How do the CHVs do the referrals to this facility?
b. How do you give feedback to the CHV? Elaborate for each response c. What are the challenges in the community referral system? What can be done to strengthen it? d. In your own view, do you think the relationship between the CHVs and this health facility is negative or Positive? Elaborate e. What can be done to strengthen that relationship?

Q1. I would like you to talk about the information collection/reporting systems/tools that are used in this health facility
Probes a) Generally, how do you feel about the information collection/reporting system currently in use? b) How does this health facility collect information about the community from the CHVs? c) How does this health facility receive information about the community from the CHVs? d) How do you report information collected from your facility? e) On average, how much time does it take to summarize and report these data? f) How often is your work reviewed? Who reviews your work? g) What are the advantages and disadvantages/challenges of the current system? h) In your opinion, how do you think the current system of information collection and reporting can be improved? Q2. Tell me about the reporting tools used for data collection/reporting by CHVs. Probe: a) What tools are used to collect information from the community linked to this facility? Are they paper or electronic paper? b) Generally, how do you feel about the data collection /reporting system currently in use? What are the advantages and disadvantages/challenges of the current system? c) What is your opinion on a mobile application for information collection and reporting?
Q2. Now I would like us to talk about your opinions on the household information collection activities as part of your work as a health provider Probes a) In your opinion, what are the reasons you households collect information in this facility? b) As a health provider, why should you collect household information? Why shouldn't you? c) Do you think it is important that you receive household information from CHVs? Elaborate d) Do you think that the community trusts you with the information you collect from them? Why? Q3. Now I would like us to talk about the uses of information that is collected at this facility.
Probes a) How do you think the information collected by you is used? Elaborate b) By whom is the information you collect used? c) Who should use the information collected by you? d) How is the information that you have collected from your patients used in the community? Elaborate and give an example.

Q4. In your opinion, does the information that you collect from patients improve the health situation in the community? Elaborate
Probes a) How have you seen the information collected by you influencing decision-making or action planning? b) Who makes decisions about activities to improve health in the community? c) What influences decisions made about the health of the communities that this health facility serves?

Section C: Experience with m-PAMANECH
Q5. Tell me about your experience working with the web portal? Probes a) What are your views on the use of the web portal to collect/report information & make referrals/ follow-ups? b) What was the impact of the CHAs using the web portal on your work in the community?
Elaborate (positive or negative) c) Overall, what do you think about the user-friendliness of this product? d) Have you faced any challenges functioning on the portal? Elaborate. e) What do you think can be done to address these challenges? Q6. What are your views on the use of the decision support tool for CHVs to collect/report information & make referrals/ follow-ups?

c. KII: Sub County focal person ICE BREAKER
• Kindly tell me about your position or designation in this sub county?
• The existing FP and maternal health services? xiii. Effectiveness of referral system xiv.
Responsiveness of the services offered to the needs of the community? xv.
Barriers to utilization of the health services. d) Challenges and Opportunities (how to assist mothers and children to access care), improve their work lives (reporting, knowledge and skills) e) In your own view, do you think the relationship between the CHVs and the health facilities has changed? Elaborate (negative or positive) f) How can this relationship be strengthened? g) In your own view, do you think the relationship between the CHAs and the health facilities has changed? Elaborate (negative or positive) h) How can this relationship be strengthened? Q2. Tell me how the referral mechanism from the community to the health facility has been working over the past one year? Probes a) What is the role of CHVs in referrals? Please elaborate? b) What is the role of CHAs in referrals? Please elaborate? c) Which health facilities do CHVs usually refer clients to? Are these public or private facilities? Why do they prefer these facilities? d) How do CHVS follow up patients referred to ensure they go to the health facilities? e) How do CHVs get feedback from the facilities on referrals done? f) What challenges are in the referral system? g) What do you think can be done to strengthen the referral system? Section C: Community Health Information Systems Q1. I would like you to talk about the information collection/reporting systems/tools that CHVs and health facilities use Probes a) Generally, how do you feel about the information collection/reporting system currently in use? b) How do CHVs collect information from the households allocated? c) What do CHVs use to collect information from the households allocated? d) On average, how much time does it take to collect information from one household? e) How do you report information collected from households? f) Do you receive any information for the health facilities? How do you use it? g) How often is your work reviewed? Who reviews your work? h) What are the advantages and disadvantages/challenges of the current system? i) How in your opinion do you think the current system of information collection and reporting can be improved? j) What is your opinion about mobile applications for data collection and reporting?
Q2. In your opinion do you think the CHV decision support tool has made CHVs perform duties and responsibilities effectively? How is that? Probe a) What were your expectations of the project? b) Have they been met? (elaborate) c) What could have been done better? (elaborate) Q3. Now I would like us to talk about your opinions on the household information collection activities as part of your work as the sub county focal person Probes a) In your opinion, what are the reasons CHVs collect information from households? b) As the sub county focal person, why should information be collected by CHVs? Why shouldn't information be collected by CHVs? c) Do you think that the community trusts you with the information you collect from them? Why? Q4. I would like us to talk about the use of information collected by CHVs.
Probes a) How do you think the information collected by you is used? Elaborate b) By whom is the information you collect used? c) Who should use the information collected by you? d) How have you seen the information collected by you is used in the community? Elaborate e) How have you used the information that you have collected from households? Elaborate and give an example.

Q5 In your opinion, does the information that CHVs collect from households improve the health situation in the sub county? Elaborate
Probes a) How have you seen the information collected influencing decision-making or action planning? b) Who makes decisions about activities to improve health in this sub county? c) What influences decisions made about health in this sub county? Q6. Now I would like to talk about how the information collected from households is given back to the community. Through what ways has information collected by CHVs been given back to the community? Probes a) What does the information on the chalkboard mean? b) Is there a functional community health committee in this community? Who sits in that committee? What are their roles? (list them) c) How often do you organize community health dialogue days? What happens on a community dialogue day? Who facilitates community dialogue days? d) How often do you participate in community health action days? e) What happens on a community health action day? Who facilitates community health action days? f) Do you think there are better ways to relay the information collected back to the community?

Q7. Tell me about your experience working with the web portal?
Probes f) What are your views on the use of the web portal to collect/report information & make referrals/ follow-ups? g) What was the impact of the CHAs using the web portal on your work in the community?
Elaborate (positive or negative) h) Overall, what do you think about the user-friendliness of this product? i) Have you faced any challenges functioning on the portal? Elaborate. j) What do you think can be done to address these challenges? Q8. What are your views on the use of the decision support tool for CHVs to collect/report information & make referrals/ follow-ups?