The challenges of introducing mHealth in a new setting: An update from Hope Through Health in Togo

The following is a guest post kindly prepared by Hope Through Health (HTH) about the mhealth project we funded them to carry out in Togo.

In fall 2013, Hope Through Health (HTH) was fortunate to receive a generous grant from Indigo Trust to implement CommCare – a mobile health platform – with their partner organization, AED-Lidaw, in northern Togo. In collaboration with GlobeMed at MIT, an undergraduate student group that has been partnered with HTH since fall 2012, HTH and AED-Lidaw have been working to design and implement the rollout of CommCare. The goal of this project is to improve collection and analysis of patient data by Community Health Workers (CHWs) who conduct home visits to patients.

This past January a group of GlobeMed at MIT students traveled to Togo to begin designing CommCare forms and training CHWs on basic phone skills using one Android smart phone. This summer, four MIT students are spending ten weeks in Togo working with HTH/AED-Lidaw staff to roll out the use of CommCare by all of HTH’s CHWs. This project was officially launched in early July with the first CommCare training where each CHW was provided with an Android phone and trained on how to use the first CommCare form. This training was followed by field-testing of the newly created CommCare form, in which two MIT students accompanied six CHWs to observe the use of CommCare during their routine home visits.

The first day of field-testing revealed an interesting challenge regarding the balance of control between the CHWs and the CommCare program. One of the goals of the CommCare project is to facilitate the work of CHWs during patient home visits. To this end, the CommCare forms to be completed by CHWs during home visits have been carefully customized using feedback from HTH/AED-Lidaw staff members and the CHWs themselves. Various conditions are built into each form using complex logic to guide and direct the CHW through the form. CHWs are automatically prompted with appropriate follow-up questions and the forms automatically eliminate irrelevant or unnecessary questions based on prior responses. In theory, this advanced technology is designed to make a CHW’s job easier.

However, during the first day of field-testing last week, the limitations of technology built outside of its target setting became apparent. During one home visit, a CHW wanted to mark that their patient was reporting a specific condition: extreme fatigue. Based on the form’s logic, this symptom prompted an immediate referral by the CHW to the nearest health center. While the CHW was able to make that referral, having travelled a long distance for this visit, the CHW also wanted to conduct the rest of the home visit and complete the rest of the CommCare form at that time. However, the form had been designed to discontinue all questions following a referral, assuming that the CHW would not want to continue with a routine visit if the patient was in distress as indicated by an urgent symptom being reported. It is easy to understand the logic behind this design decision. However, field-testing illustrated that the technology actually impeded, rather than enhanced, the job of the CHW in this instance. This example illustrates how the lack of flexibility of a technology or the CHW’s inability to override the technology may get in the way of the CHW’s innate ability to manage a particular situation in the most effective way possible.

Over the next ten weeks, all of the forms being rolled out in CommCare will be field-tested and adapted based on significant CHW input in an attempt to minimize these errors. HTH/AED-Lidaw supervisory staff will also receive extensive training in form design and adaptation. This training will empower local staff with the skills and knowledge necessary to address any issues that may arise in the future. Ultimately, this example demonstrates the limits of technology and reinforces the importance of equipping local staff with the capacity to interpret and adapt technology to best fit a specific situation. In this case, we believe that a balanced solution can be reached and that CommCare will be able to facilitate the work of CHWs without creating an unnecessary barrier or burden to their regular workload. Although we will likely encounter additional challenges in the coming weeks, we look forward to working with our partners to think through the best ways to use technology to enhance the strong community-based work of HTH and AED-Lidaw in Togo.