Evaluation and Development of Android mHealth Application for Community Health Workers in Malawi

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Evaluation and Development of Android mHealth Application for Community

Health Workers in Malawi

Comparison of Commcare and DHIS2 Tracker

Amrit Chhetri

Thesis submitted for the degree of Master in Programming and Networks

60 credits

Department of Informatics

Faculty of mathematics and natural sciences

UNIVERSITY OF OSLO

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Evaluation and Development of Android mHealth Application for Community Health Workers in Malawi

Comparison of Commcare and DHIS2 Tracker

Amrit Chhetri

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Evaluation and Development of Android mHealth Application for Community Health Workers in Malawi

http://www.duo.uio.no/

Printed: Reprosentralen, University of Oslo

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Abstract

Many under developing and developing countries rely heavily on the use of community health workers to fulfill the growing need of Health services , void left by lack of health care professionals. Community health workers performs various set of activities including regular home visit, collecting data , providing health education and awareness etc.the collection and analysis of these collected raw data derive the all important health decision from the ministry of health including the budget allocation ,impacting lives of millions of people directly. so it is of paramount importance that the data is collected regularly and correctly .With the introduction of Health information management system like District Health Information System (DHIS2) and use of mobile application to collected data, this process has been streamlined over past 2 decades.

This thesis aim to explore the most important phase of Health information management cycle which is Data collection and the target audience is community health workers from Malawi.First phase of the research is to have the interaction with the health workers, to understand their perspective on their regular work practice , what factors influence their performance,going on home visit and village clinic with them and observe their work.this helps understand the health workers in person and their work and how can we design and configure the mobile application to match their expectation?. what type of data element is more important to gather maximum information?.

The second and the major part of the research was to test and compare the mobile application built on Dhis2 platform and Commcare platform with same data element and to analyze the user response. The comparison of app was done in term of functionality, ease of use , navigation and so on. firstly i found that the use of multimedia in the Commcare was deciding factor for most of the health workers to choose Commcare.

secondly, the health workers prefers comprehensive mHealth app rather then single purpose app.thirdly, the health workers just want to use the mobile app and don’t want to be in a position to select one or another again highlighting the importance of comprehensive mHealth app .finally, the health workers likes the app to be more informative including feature such as use of tool tips,multimedia inclusion, smaller question length and overall small page length.

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Acknowledgement

First of all, i would like to thank my supervisors Jens Kaasbøll ,Chipo Kanjo and Tiwonge Manda for helping me and guiding me through this research.

Special Thanks to Mathias Næss and our research Guide Mari Iversen for their support through out the research and helping me setting up the Thesis writing .also thanks Mathias for Driving us around for the Interview and sightseeing .Pablo will be sorely missed.Tusen Takk!!

Thanks to Yamikani Phiri ,Lawrence Byson and Akuzike for not only finding HSA to Interview but also helping me during the interview process with the translation - Zikomo!

Thanks to Ilya Nee,John Melin and Zufar Ismanov for being an excellent company during our stay in Malawi.

Thanks to the great people at HISP UiO, saving the world iteration by iteration.Thanks to all participants and other contributors to the research project in Malawi.

Finally, to my family: Thank you for supporting me through a lifetime of education!

Amrit Chhetri March 2018

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List of Figures

1.1 Number of mHealth Apps displayed in App stores in 2016 and 2017,

research2guidance mHealth app developer economics study 2017 . . . 1

1.2 mHealth Supply and demand growth rate 2013-2016,copyright research2guidance 2016 . . . 2

2.1 Component of health information system, pacific health information network 7 2.2 three strategic focus areas of HISP UIO,2014 . . . 8

2.3 DHIS 2 layers: Core, configurable layer and add-ons (adapted from Roland et al., forthcoming) . . . 10

2.4 Data model for DHIS 2 Tracker (Generic Tracker/Event Capture version) . . 11

2.5 Commcare overview . . . 13

3.1 core role of CHW as per American Public Health Association . . . 15

3.2 The mobile system’s user interface, showing a processed diagnostic test for malaria with a positive result . . . 20

3.3 Summary of the videos created during the deployment period . . . 22

4.1 Commcare registration pages . . . 27

4.2 Commcare Case Details pages . . . 28

4.3 Commcare Home visit Screens . . . 29

4.4 Commcare Home visit Screens . . . 30

4.5 DHIS2 Tracker Capture registration pages . . . 31

4.6 DHIS2 Tracker Capture Home visit Screens . . . 32

4.7 Commcare app builder screen . . . 33

4.8 Dhis2 Tracker app Tracked entity creating page . . . 34

4.9 Dhis2 Tracker app Tracked entity attribute creating page . . . 34

4.10 Dhis2 Tracker app Data element creating page . . . 35

4.11 Dhis2 Tracker app option set creating page . . . 35

4.12 Dhis2 Tracker app program rule creating page . . . 36

6.1 DHIS2 Tracker Capture Homepage . . . 52

6.2 DHIS2 Tracker Capture Homepage with duplicate entry . . . 53

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6.3 DHIS2 Tracker Capture option box with no questions included . . . 54

6.4 DHIS2 Tracker Capture Event Status completion positioning issue . . . 55

6.5 DHIS2 Tracker Capture with lot of fields that are unused like relationships and indicators . . . 55

6.6 DHIS2 Tracker Capture use of placeholders . . . 56

6.7 Commcare:use of generic image . . . 57

6.8 Commcare:duplicate cases and the workaround . . . 58

6.9 HSA during the App testing . . . 61

6.10 Dhis2 Tracker capture button positioning . . . 62

6.11 Single question per page commcare vs multi question per page tracker . . . 63

6.12 question asking type of latrine with option set . . . 64

6.13 Village clinic spot,chindenga Village . . . 65

6.14 HSA weighing each baby . . . 67

6.15 paper form use by HSA to collect data . . . 69

6.16 house with clean kitchen . . . 71

6.17 Clean pit latrine with the cover . . . 71

6.18 local stove used for cooking . . . 72

6.19 Bore hole with chlorine dispenser for safe water . . . 72

6.20 hand washing facility that can be operated without using hands . . . 73

6.21 clean bathroom . . . 74

6.22 data aggregated based on the data collected during current home visit . . . 75

6.23 Tracker allowing string to be entered as phone number . . . 77

6.24 Question formatting in Commcare with multi question per page . . . 80

6.25 mandatory field commcare vs tracker . . . 81

6.26 Commcare questions with extra information under the question . . . 82

6.27 use of tool tips in Dhis2 tracker . . . 83

6.28 commcare vs Tracker calender . . . 84

6.29 Dhis2 Tracker scroll issue . . . 85

6.30 Commcare with multiple question per page . . . 86

6.31 Commcare with single question per page . . . 87

6.32 Hand washing facility commonly used in Malawi . . . 90

7.1 Dhis2 Tracker icons without label and complex labels . . . 94

7.2 commcare with phone calling functionality . . . 96

7.3 crowded UI in Dhis2 Tracker . . . 97

A.1 Screen shot of Commcare App used by HSA . . . 105

A.2 Screen shot of Commcare App used by HSA . . . 106

A.3 Paper form used to register child growth monitoring . . . 107

A.4 Paper form used to register child immunization . . . 108

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A.5 Paper form used to register child immunization . . . 109 A.6 Paper form used to register child nutrition status . . . 110 A.7 child referral form for malnourished child . . . 111

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List of Tables

2.1 Timeline and key milestone in the development of DHIS 2 . . . 10 5.1 Summary of HSA Involvement . . . 39 5.2 Overview of research phase . . . 45

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Abbreviations

DHIS District Health Information System HISP Health Information System Programme WHO World Health Organization

CHW Community Health Workers HSA Health Surveillance Assistants DHO District Health Office

DEHO District Environment Health Officer HIS Health Information System

HMIS Health Management Information System UIO University Of Oslo

MA Medical Assistant

NORAD Norwegian Agency for Development Cooperation HMN Health Metrics Network

ICT Information and Communication Technology EDC Electronic Data capture

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Chapter 1 Motivation

1.1 Research Context

Almost 100,000 mHealth Apps have been added since the beginning of last year, amounting to 259,000 currently available on major app stores. In addition, 13,000 mHealth publishers have entered the market since the beginning of 2015, totaling 58,000 [1].Google Play Store is now ( in 2017) home to 158,000 health Apps – a 50 percent increase compared to last year and the highest growth rate among all major app stores. In contrast, iOS has recorded a growth rate of 20 percent[2].the figure 1.1 below shows the number of Apps available in various mobile platforms[2].

Figure 1.1: Number of mHealth Apps displayed in App stores in 2016 and 2017, research2guidance mHealth app developer economics study 2017

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for our research both the application in Dhis2 and Commcare are developed in android platform. As per Research2guidance recent study, the number of new mobile health app is increasing everyday but the demand and downloads for such Apps has gradually decreased over the years.the figure 1.2 below shows the mHealth supply and demand growth rate from 2013 to 2016 .[1].

Figure 1.2: mHealth Supply and demand growth rate 2013-2016,copyright re- search2guidance 2016

1.2 Research Objective

With the demand of mHealth getting low, one tends to think is it just OK to develop new app or to improve the existing app that meets the greater demand of the health workers.Do we develop a single purpose app or multi purpose app?How can we make sure the app being developed is more user friendly then other?How can we make sure the app can increase the efficiency of its intended target for better outcomes.there are many Apps around now days that are intended for community health workers Dhis2 tracker capture being one of them.Dhis2 has been implemented in over 47 countries in either full or par- tial roll-out.Malawi is currently using Dhis2 in full national roll out status. one of their plan is to use DHIS tracker to collect data at local level with the help of community health workers.A community health worker is a front line public health worker who is a trus- ted member of and/or has an unusually close understanding of the community served.

This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and

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improve the quality and cultural competence of service delivery[3].so its necessary that the Dhis2 tracker should function properly to meet the need of the CHWs.

Given the Commcare has reputation for being one of the best health information system to assist CHWs, we wanted too see how Dhis2 tracker capture would compare with commcare in terms of functionality , ease of use, navigation etc and what can we learn from this comparison which can later be used to improve upon the current Dhis tracker.Dhis is implemented in more countries rather as an information system then an data collection tool where as commcare has a specific purpose for data collection in communities.this research will therefore compare the data collection approach used by both application.Also this research will also try to find Do CHW prefer mHealth or Paper Forms?

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Chapter 2 Background

2.1 Current Health Service Scenario In Malawi

In this chapter , i am looking into Malawi and its current health care service system approach in general .

Malawi is one of the poorest countries in the southern part of Africa with population of almost 18 million.Malawi, like other low-income countries, is facing a health care crisis due to severe health worker shortages and an overloaded health care system .[4]. Ranked 179th out of 194 countries in per capita health expenditure, Malawi spends only 93 dollar per capita annually [5]. Similarly, Malawi only has 0.19 doctors and 2.83 nurses and midwives per 10,000 people, putting the number of doctors in the entire country at 302[6] . Output at medical teaching institutions in Malawi is too low to fill current vacant positions, let alone expand access to healthcare services [6].

Due to these shortages, most health centers in Malawi do not have doctors and instead rely on lower-level health workers with varied levels of professional training, ranging from 2 years to little or no professional training [7]. For instance, a typical rural health center in Malawi is run by a medical assistant (MA) supported by other health workers including nurse-midwives, both with over a year of professional training, as well registry clerks, drug store clerks, health surveillance assistants (HSAs), and “attendants” who often have limited or no training, and perform support duties and some aspects of clinical care.[8].

The public hospitals and health centers provide free services where as private hospitals charge fee for their service. there are also health center operated by church.Malawi rely heavily on the support from foreign aid, and we can see lot of foreign organization assisting people to deliver quality health coverage.Malawi has a three-tier health care delivery system based on three levels of health care:

• Primary health care or community care is organized mostly to meet the primary health services. This consists of community initiatives, heath posts, dispensaries, maternity units, health centres and community and rural hospitals.[9]

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• District hospitals constitute the secondary level of health care and provide specialized services to patients referred from the primary health care level, through outpatient and inpatient services and community health services. These services are en- hanced by provision of adequate specialized supportive services, such as laboratory, diagnostic, blood bank, rehabilitation and physiotherapy services.[9]

• Tertiary health care, which consists of highly specialized services, is provided by central hospitals and other specialist hospitals providing care for specific disease conditions or specific groups of patients.[9].

In order to tackle these issue, the government of Malawi wants to implement the Health information system and use the Community health workers as a part of data collection agent so that they can penetrate the local health care setting in providing better care and get help to make better decision can to tackle the growing health necessities.

2.2 Malawi National Health Policy

The Malawi health ministry states that the existing health information system are unnecessarily fragmented and are not capable of generating quality information at the time they are needed.Efforts have been underway, in collaboration with their partners, for harmonizing and synthesizing various data-management systems in the entire health sector. Despite those efforts,Malawi continue to face challenges in the areas of data collection, data analysis, information dissemination, and information use. The problems with regard to data accuracy, time lines of reporting, analysis, and completeness continue to exist [10].

To address these challenges,the Malawi health ministry wants robust health health information system that provides reliable information as solid evidence for making rational decisions that would achieve highest level of efficiency in providing basic essential health care to all Malawians [10]. health information system strategy and policy formulated in 2003 AD are outdated due to change in health sectors.the use of vertical program where the decision and policy made at the top is followed through each levels has not been so successful. to address the need of people, policy and structure from the bottom up approach tends to fare better which shows what actually is going on in the lower level and has there been any change in the heath service delivery with the policies and strategy in place. some of the guiding principle and rules includes [10].

• generation of quality and relevant information in timely manner for all intended user at community,health facility, district, zone, and national levels [10].

• The need to inculcate the use of reliable information for evidence-based decision support, which calls for a shift from data collection to transforming data into information that shall be utilized at all levels for better management [10].

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• Recognition of the need to establish clear HIS structures and adhere to, implement, and utilize such structures in support of the information systems and accountability of its results [10].

• The need to recognize the value of data that are disaggregated by sex, age groups, geographical areas and social income groups to the extent that they have practical use in achieving greater equity, efficiency, and quality [10].

2.3 Health Information Systems

Health information systems refer to any system that captures, stores, manages or transmits information related to the health of individuals or the activities of organizations that work within the health sector.[11].With the advancement of information and communication technology(ICT), health care has seen a lot of improvements and ,when we see the rate of change and recent innovation it is hard to disagree. health care has been more and more accessible ,doctors can collect data from the patients and analyze it using computers to provide better solution, patient and disease centric research and development of software has gone a great length to provide best possible accurate health care. Hugh amount of research has been done and going on to further advance the health care system .Mobile health which is also know as mHealth is direct result of ICT advancement, is a general term for the use of mobile phones and other wireless technology in the field of medical care.

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Figure 2.1: Component of health information system, pacific health information network

The Strong health systems are central to achieving better health outcomes, and strong health information systems (HIS) are the backbone of strong health systems[12].

A properly functioning HIS gets the right information into the right hands at the right time, enabling policymakers, managers, and individual service providers to make informed choices about everything from patient care to national budgets. Strong health information systems support greater transparency and accountability by increasing access to information.[12].please refer to figure 2.1 that shows different component of health information systems.

The first phase is to find the right Health information system resource like Dhis2 that fulfill the need.the second phase is to find the right indicators that give you vital informations in health decisions.third phase is to find the data source, from where you will be obtaining the health related data from people.then that raw data needs to be polished so that we can remove any irregularities in the data.then the data cam be visualized in the form of graphs and pie charts to create the reports .finally the reports are taken into account to form any decision from the higher authority.

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2.4 HISP

HISP (Health information Systems Program) is a global network of people, entities and organizations that design, implement and sustain Health Information Systems. As a network, HISP globally follows a participatory approach to support local management of healthcare delivery and information flows, and was established by the Department of In- formatics at the University of Oslo.[13].At the core of HISP is the development of the open source and free software DHIS 2 (District Health Information System 2), a tool for collection, validation, analysis, and presentation of aggregate and transactional data, tailored (but not limited) to integrated health information management activities[14].

The HISP UiO also provides DHIS 2 software implementations and related capacity building in countries and regions. DHIS 2 is developed and implemented through a network of partners (the HISP network), including universities, ministries of health, international agencies like WHO and NORAD, and implementing partners like HISP India and HISP South Africa. The various members of the network play different roles, ranging from developing human capacity at different levels, managing software development, coordinat- ing educational linkages and helping create strong information cultures within national health services [15].

HISP UiO focuses on moving from mere data collection to an emphasis on data quality and data use, and from fragmentation of information systems to integrated architectures.

Furthermore, HISP UiO promotes the connection of health workers at the point-of-care and district level managers with national, regional and global Health Information Systems [15].The HISP UiO strategy has three strategic focus areas (refer to figure 2.2). They are interlinked and based on and fostering the further development of the network of action:

Figure 2.2: three strategic focus areas of HISP UIO,2014

2.5 DHIS2

The DHIS is a free and open-source software-based highly configurable data collection, aggregation, management and analysis tool that uses a data source hierarchy to capture and report on health data from its source, up to and including well-structured, decision-

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supporting information. It is currently used in more than 40 countries around the world as a routine health management information system and data warehouse.Available in both desktop (MS Access®/Windows®) and web-based (Java™/HTML5) flavours, DHIS offers health care workers and decision makers electronic access to advanced health data, information capture and reporting features.[16].the latest version is DHIS 2.

DHIS2 offers a number of mobile solutions, including SMS, plain HTML, and Java options for feature phones as well as a Web-based solution with off line support for smart phones.

Clients can use their mobile phones for registering cases, events, and personal information, tracking individuals, conducting surveys, and collecting aggregate data [17].

The table below outlines the evolution of DHIS from its inception to full blown DHIS2 platform known today [18].

Timeline Key milestone

south Africa 1994 started as collaborative research project between the University of Cape Town and the University of Oslo.aimed to deliver better health services to the local population.Program primarily aimed at radically reforming health care provisions for the communities that suffered under apartheid.DHIS v1 was developed in South Africa as a free and open source database application based on the Microsoft Office platform 1999 ,India HISP / DHIS project was spread to other countries, first to India and

Mozambique in 1999 and later on to others in Africa and Asia.

2003,inception of DHIS tracker

developed a simple patient module where the idea was to use the same data elements for patients as were used for aggregate reporting, which made the aggregation from the patient level data to the aggregate reporting easy

2004, Java based fully open source platform

development of the Java based and fully open source DHIS v2 started in 2004 with a base in the Department of Informatics at the University of Oslo, Norway

kerala India,2006 DHIS2 was first implemented in Kerala,India in January 2006. Much important functionality was initially lacking, but the system improved significantly over the next couple of years in India, as well as in Vietnam, through the involvement of locally recruited software developers 2007, HISP and

WHO Collabora- tion

In 2007, HISP started collaboration with the WHO-based Health Metrics Network (HMN), which decided to use the DHIS2 to implement their data warehouse based "Technical Framework” architecture approach in Sierra Leone, their first (and only) pilot country

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October 2010, kenya

with the reality of Internet growth,DHIS2 in Kenya was deployed online, hosted by a cloud server and accessed by modems to the mobile Internet.the DHIS2 was implemented countrywide over a four-month period by way of a training scheme involving users from all districts and hospitals in the country.

DHIS2 online in 2012

with the Internet revolution in Africa countries like Ghana, Rwanda, and Uganda implemented DHIS2 online in 2012, Burkina Faso, Liberia, Tanzania, and other countries the year after.

Table 2.1: Timeline and key milestone in the development of DHIS 2

From its inception to the present, the main focus with DHIS has primarily been to support the management of routinely collected aggregate health data to be used for decision-making, with a focus on statistics.the Dhis itself as a whole Serve as an platform and provides you set of REST-Full APIs which can be used to create an application over it.Because of its flexible and configurable nature, the new application can be built upon it with out affecting its core components.please refer to figure 2.3 that shoes the layers of Dhis2.

Figure 2.3: DHIS 2 layers: Core, configurable layer and add-ons (adapted from Roland et al., forthcoming)

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2.5.1 Dhis2 Tracker

In general ,public health systems have been recording the data for patient but there is lack of system that can track an individual over a period of time and maintain their history.the Dhis2 team realize this issue and came up with the solution in the form of DHIS2 tracker.The DHIS 2 Tracker is an extension of the DHIS 2 platform and supports management, data collection, and analysis of transactional or disaggregated data [19]. The Tracker shares the same design concepts as the overall DHIS 2 - a combination of a generic data model and flexible meta data configuration through the user interface that allows for rapid customization to meet a wide range of use cases [19].

The tracker lets you to track individual like tracking the pregnancy of an women,her ANC visits, status of the baby and so on or collect data on a community level like finding total number of kids Suffering from Malaria in a given community.the user can create the program stage based on his/her requirement where they can create the data elements they want to track.the collected data can be send to the server and can be visualized in the form of graphs and pie chart and helps in decision making.it also lets user to collect data using android application offline.

Figure 2.4: Data model for DHIS 2 Tracker (Generic Tracker/Event Capture version) the figure 2.4 represent the underlying data model for Dhis2 tracker.The organizational hierarchy defines the organization structure of the DHIS2 instance, such as health facilities,

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administrative areas and other geographical areas.whenever you capture data,you need to specify the organizational units.each program is associated to an organization unit and every program instance should have a tracking entity to track it over time.program can have more then one stages and each stage can its own data element that are captured in the app.the app also provides the relationship option where we can specify the relationship between two entities.

part of my research was to created an android application and test it with the community health workers to gain some feedback.

2.6 CommCare

CommCare is an open source mobile health platform which consists of two main technology components: CommCare Mobile and CommCareHQ. CommCare enables electronic data collection, decision support, and patient/case management. The mobile application is used by client-facing community health workers in visits as a data collection and educational tool and includes optional audio, image, and video prompts. The web application provides reporting, analytics dashboards, user/domain management, and data viewing and analysis. This document serves to describe, in detail, the technology components of CommCare.[20].

CommCare has two platform that work together for its functionality.CommCareHQ is a web based platform where you can create and deploy your mobile app to their cloud server and CommCare mobile ,where you need to download the mobile app.before deploying you need to create the users (mobile workers account) who are going to able to use that application ,with the creator being the administrator. once the app is successfully deployed,the user can log in to the app and start collecting data and send the collected data to the server which can be tracked by the Admin. with Commcare you can create custom mobile app,collect data offline, track data over time,and access real time reports.commcare also supports use f multimedia in the app and multi language .figure 2.5 shows the general overview of what commcare does.

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Figure 2.5: Commcare overview

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Chapter 3 Literature Review

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3.1 Community Health Workers:backbone to the success of Health care in developing countries

As defined by the Community Health Worker Section of the American Public Health Association:

“A Community Health Worker (CHW) is a front line public health worker who is a trusted member of and/or has an unusually close understanding of the community served.

This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy"[21].figure 3.1 shows the core role of CHW.

Figure 3.1: core role of CHW as per American Public Health Association

3.2 Why do we need Community Health Workers

The use of community health workers has been identified as one strategy to address the growing shortage of health workers, particularly in low-income countries.[22]. people in rural area are not used to with the modern health services .they mostly believe in traditional source like traditional healing,medical herbs etc.people don’t want to open themselves to strangers and are mostly skeptical to try new things. it is difficult to involve the people in the participation of modern health services. so it makes sense on use variety of community health aid selected, trained and working in the communities from which they come.community health workers have first hand experience of their community regarding number of people living,areas where it is mostly populated,types of disease

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people usually suffers from etc."CHWs can be men or women, young or old, literate or illiterate. More important is an acknowledgement that the definition of CHWs must respond to local societal and cultural norms and customs to ensure community acceptance and ownership".[22]

the role of community health workers can be diverse depending upon their skill,culture and community requirement.Although CHWs have no formal, professional health care qualifications, they do have basic Primary Health care training, which can vary from 5 to 10 days of training. [23]. the training can go up to 6-8 weeks depending upon the the requirement.the professional health workers should also assist and evaluate their work in order to improve the reliability ad communication.the basic task performed by the community health workers can range from Health Promotion and Preventive Care to Community Mobilization and treatments.here are some of the task performed by community health workers:

• Perhaps the most common role taken on by CHWs is that of health promoter, where the CHW primarily provides information and counseling with the aim of encouraging particular behaviors. CHWs in this role are typically used to promote breastfeeding and child nutrition, family planning, immunization, and other behaviors linked to mother and child health. [24]

• CHW provides preventive health care services by distributing commodities such as bed nets, iron folate supplements and other micro nutrients, con- doms,contraceptives, and certain vaccines.[24]

• CHWs act as community mobilizers, initiating activities such as the digging of latrines, the identification of clean water sources, and the organization of nutrition and sanitation days.[24]

• Diagnosis and management of common childhood illnesses, such as malnutrition, diarrhea, and pneumonia, as well as timely referral to health facilities, when needed.Another aspect of treatment is assistance to women during labor and child birth.CHWs are trained to manage uncomplicated labor and to detect high-risk pregnancies and labor complications so that timely referral can be made.[24]

3.2.1 CHW and their use of mobile app

Mobile health which is also know as mHealth is direct result of ICT advancement is a general term for the use of mobile phones and other wireless technology in the field of medical care.The most common application of mHealth is the use of mobile phones and communication devices to educate consumers about preventive health care services.

However, mHealth is also used for disease surveillance, treatment support, epidemic outbreak tracking and chronic disease management.

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Community Health workers provides the first level contact to the health facilities.the efficiency and productivity of CHW results in the performance of the health center.so its imperative that people at the higher level realize this. one way to achieve this is bottom up decision process where the decision should focused on the locally generated information at facility level, that incorporate the CHWs ways of doing things.other approach is incorporation of health information system that facilitate the use of CHWs as the way to collect health information on individual or households using mobile application . 3.2.2 evaluation and selection of mHealth Apps

Mobile applications (apps) to improve health are proliferating, but before healthcare providers or organizations can recommend an app to the patients they serve, they need to be confident the app will be user-friendly and helpful for the target disease or behavior[25].although most of the publisher tends to refer their application being the best in their website or application description page at app store, there is no way of verifying that statement until and unless the end user give their feedback to their app, in this case the feedback from community health workers.so its imperative that we test our app with the end user and get their feedback and improve upon that feedback.

there is not perfect measurement criteria for mobile app evaluation present. since my research is based on participatory research approach,i am looking into following criteria for the comparison of Dhis2 tracker and commcare.

1. Appearance and Multimedia 2. Navigation

3. Usability 4. App creation 5. Efficiency 6. Feedback

3.3 Related Works

Changing data practices for community health workers: Introducing digital data collec- tion in West Bengal, India [26]

The paper performed qualitative interviews, usability testing and timed observations with Bengal Community Health Workers (CHWs) in transitioning from paper to tablet- and mobile-based data collection.The research presented here was conducted as a partnership between the University of Michigan — represented by researchers from

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pediatric neurology, biostatistics, and human–computer interaction — and iKure, a grassroots health care group operating in West Bengal. iKure manages a network of community health providers throughout the state.The Michigan group was seeking to document the prevalence of health risk in a low-resource community in the context of maternal and child health. iKure, which works with MCH data in West Bengal, India, was interested in exploring the feasibility of incorporating digital tools for health data collection as part of their work.two survey , a pregnancy baseline survey and the Ages and Stages Questionnaire (ASQ) was formulated.

ODK(Open Data Kit) form-building tools was used to design and implement these surveys for the CHWs to use on Android tablets and smart phones because the survey forms — once downloaded onto the ODK Collect application — run completely offline, which was necessary given the unreliable connectivity in rural West Bengal.the data and the survey was performed on various stages and the data was collected on tablets, mobile and papers.what the researcher find is that data collection performed on smaller mobile phone interfaces was less efficient compared to paper where as there was no significant difference in the quality of data collected across all three modes. In terms of work practices,they found that while initial interactions with CHWs suggested positive feelings about switching to digital devices, in their actual practices they retained and preferred the use of paper, and had workarounds to circumvent the digital data collection process.during second phase it was found that all CHWs reverted to using paper for data collection when out in the field, and manually typed the data into the tablets upon returning to the iKure office — essentially doubling their own workload.

other issue found was organizational structure and management.the work culture between employees and management is not smooth and CHWs are nervous around the officers and fears of losing the job in case of any mishandling of work . also they noticed that user-centered design principles were not a high priority for iKure in designing and implementing technology into CHWs’ daily roles. Design-wise, CHWs were not involved in the creation of the ODK application and its interface, and there was significant discussion within the iKure team about whether the application needed to be written in Bengali script. Initially there was an interest to build the tools in English for easier transferability to other non-Bengali speaking states where iKure is active as well as to ensure the standardization of medical terminology. However, CHWs had very limited English-language skill beyond numerical literacy and not sufficiently familiar with medical terminology to collect all necessary data.

the interview results also indicated that the iKure tablets were many CHWs’ first exposure to any form of mobile technology. Many actions, such as typing, swiping, and scrolling on a mobile interface were challenging. CHWs also encountered problems when they clicked on the wrong text (on the text for “Age” instead of the text box), and faced unfamiliar drop-down features.

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3.4 Previous Implementation of Dhis2 Tracker and Commcare

In this section i looked into some previous implementation of Dhis2 and Commcare and see what was the results of that implementation.

3.4.1 Commcare implementation

In the paper published in Global Health Action, 2014 called "Electronic data capture in a rural African setting:evaluating experiences with different systems in Malawi [27] four different electronic data capture system (EDC) were studied to see the the advantages and disadvantages of these EDC systems being used simultaneously in rural Malawi:

two for Android devices (CommCare and ODK Collect), one for PALM and Windows OS (Pendragon), and a custom-built application for Android (Mobile InterVA MIVA) .

CommCare was used in two prospective cohort research studies. The first investigated the relationships between pregnancy intentions and maternal and neonatal health. The second was investigating risks of treatment failure in community treatment of pneumonia in children.CommCare was chosen specifically for these two projects because of the ‘case’

function which allowed multiple interviews to be reliably linked, as well as the child’s interviews to be linked to the mother’s in the first project.the researcher finds that commcare application was easy to develop and can be done by non-specialists having no previous experience.its also noted that commcare have user-friendly web-interfaces for designing forms and programming simple logic but requires an Internet connection to build the form and download it on to the smart phone which can be limitation in low connectivity setting.

In term of cost,CommCare, data were uploaded to the server over cell phone Inter- net,costing 30 USD/month and access premium features (starting at 100 USD/month) .Compared to the running costs of a paper-based system, this was considerably less (e.g.

for one data entry clerk and 500 multi-page questionnaires a month, the running cost of a paper-based system in their context would be 350 USD/month). The need for data cleaning was also considerably reduced because of in-built cleaning rules, saving time and costs by reducing the need for field verification. in term of functionality, commcare "case" functionality allowing collected information from questionnaires to be stored on the smartphone and tracked it over time was highly regarded because it was the only software among the 4 tested to do so .Fieldworkers also commented on the ability to take photo- graphs and videos as a positive feature in CommCare and ODK Collect.

the ability to view the data from any INTERNET access point, create routine reports, and monitor fieldworker’s activity in commcare and ODK collect was huge plus factor .it was used for one CommCare project, allowing the project manager to monitor progress while out of country, a very useful function when principal investigators are not always

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on site.

In another article published in 16th International Conference on Human-Computer Interaction with Mobile Devices and Services (MobileHCI ’14). September 22-26 2014, Toronto, Canada called "Field Evaluation of a Camera-Based Mobile Health System in Low-Resource Settings [28]" presents an in depth field evaluation of a mobile system that uses a smartphone’s built-in camera and computer vision to capture and analyze diagnostic tests for infectious diseases.health worker in a rural clinic has been issued a mobile device to assist with clinical tasks. The health worker enters a patient exam room to assess a patient. After spending time interacting with the patient and using the device to collect patient data, the health worker decides to perform a diagnostic test for malaria.

(S)he obtains a blood sample from the patient and administers a rapid diagnostic test for malaria. Then, (s)he uses the device’s built-in camera to capture an image of the test. The system processes the image, displays the test result on the screen, and transmits the data to a database if and when there is sufficient connectivity. Finally, based on the test result, the health worker recommends the appropriate treatment or selects another test to run.our system performs all of the computation and image processing on the device, which allows the system to be fully functional in the absence of a network connection.refer figure(3.2) thats how the images of the device from malaria test is processed in the app itself to give the relevant treatment.

Figure 3.2: The mobile system’s user interface, showing a processed diagnostic test for malaria with a positive result

In addition to capturing and processing images, system also allowed users to collect

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and report additional data (including text,bar codes, GPS data, etc.) about the patients seen and diseases detected. image processing components of the system with was integrated CommCare for this.Over a two month period health workers captured and transmitted 1828 malaria tests using Commcare with only 114 (6.2 percent) identified as having errors.

The median time it took to capture and process the test and record patient data was 1.5 min. Strong agreement was demonstrated between the system’s computed diagnoses and trained health workers’ visual diagnoses, which suggests that the system could aid disease diagnosis in a variety of scenarios .

in the paper Using mHealth for HIV/TB Treatment Support in Lesotho: Enhancing Patient–Provider Communication in the START Study [29] published in Journal of Acquired Immune Deficiency Syndromes (1999), the research study to find the impact the impact of using SMS service by village health workers(VHWs) to provide support to the HIV and TB patients was conducted.The mHealth intervention comprised the design and delivery of a standardized, automated SMS system to provide real-time adherence support to patients on HIV and TB treatment. The study team developed a simple SMS reminder application using CommCare, an open source mobile platform developed by Dimagi .Tools available online were used to build an application to send appointment and medication SMS reminders to mobile phones based on a predefined algorithm. SMS messages were sent “one-way,” which meant that recipients could not respond

Patients and treatment supporters received automated, coded medication and appointment reminders at their preferred time and frequency, using their own phones, and 3.70 dollar in monthly airtime. Facility-based VHWs were trained to log patient information and text message preferences into a mobile application and were given a password-protected mobile phone and airtime to communicate with community-based VHWs.appointment reminders were sent 2 days and 1 day before patients’ scheduled monthly clinic appointments and medication reminders were sent daily for the first 6 weeks of ART, and daily or weekly thereafter according to individual preferences.

From April 2013 to August 2015, the automated SMS system successfully delivered 39,528 messages to 835 individuals, including 633 patients and 202 treatment supporters.

Uptake of the SMS intervention was high, with 92.1 percentage of 713 eligible patients choosing to receive SMS messages. Patient and provider interviews yielded insight into barriers and facilitators to mHealth utilization. The intervention improved the quality of health communication between patients, treatment supporters, and providers. HIV- related stigma and technical challenges were identified as potential barriers.

another article Software Support for Creating Digital Health Training Materials in the Field [30] talks about how the local health trainer can use the multimedia to create create digital training content for low-literate Community Health Workers (CHWs) in Lesotho the digital content being mobile videos created from combining images,

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voice over, and/or video clips.results show that when health professionals who are based in rural areas were empowered by the tool to create their own content, they were able to supplement nationally and globally produced health training materials with more locally relevant content that addresses unique information needs within their communities.software like CommCare supports multimedia is used for collecting data and assisting the visits CHWs pay to mothers/patients in their communities.

Windows Presentation Foundation (WPF) application was built for testing.application produces videos by combining images and voice, and/or video clips.Modifying a project, the trainer can delete or add a frame. S/he can also delete voice on a frame, leaving the image.the videos were used for training and the CHWs can use those videos in the home visits as well.the figure (3.3) below shoes the Summary of the videos created during the deployment period for this research.

Figure 3.3: Summary of the videos created during the deployment period

CHWs discussed their experiences and they stressed the value of the videos in helping them remember the concepts they usually forget easily. In one comment, they likened carrying the phones with the health content to having access of the trainers’ knowledge with them everywhere they go.Additionally, CHWs revealed that some of the videos help them communicate content that they are normally uncomfortable discussing in their villages (e.g., sexuality).

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chief trainer created around one video per month, based on the needs she observed in the community, and amongst the CHWs. This showed that she took ownership of the software, and started to visualize how it would help her in achieving her work goals. On the fourth month into the deployment, the CHWs themselves started making requests to the nurses about what content to create for them in the months to come (they requested for the video on First Aid) which showed benefit of locally created content as it was easier for the CHWs, who are the ones who spend the most time in the villages, to request for content that will directly address the issues they face on a daily basis.Interestingly, the CHWs did not only use the videos for building their own competence, but they used them to teach other members of their communities as well.

3.4.2 Dhis2 implementation

In the article published in Bio medical center(BMC) medical informatics and decision making called "Strengthening district-based health reporting through the district health management information software system: the Ugandan experience [31]" documents Uganda’s experience in strengthening routine health data reporting through the roll-out of the District Health Management Information Software System version 2 (DHIS2).DHIS2 in Ugandan was adopted at the national level in January 2011.the system was initially pi- loted in 4 districts before it was rolled out to all the 112 districts by July 2012.completeness and timeliness of outpatient and inpatient reporting for the period before (2011/12) and after (2012/13) was compared to assess improvements in health reporting.implementation of DHIS2 was customize to suit the Ugandan environment and involved definition of data elements, data sets, dash boards, and designing of data entry form

Remarkable improvement in both completeness and timeliness of data reporting was seen after the installation of DHIS2.Completeness of outpatient reporting increased from 36.3 percent in 2011/12 to 85.3 percent in 2012/13 while timeliness of outpatient reporting increased from 22.4percent to 77.6 percent. Similarly, completeness of inpatient reporting increased from 20.6 percent to 57.9 percent while timeliness of inpatient reporting increased from 22.5 percent to 75.6 percent.

limited technical staff at district level who can train as well as offer technical support supervision to health workers during the roll-out phase was one of the biggest challenges which let training to cut back from 10 days to 5 days.interrupted electricity supply to computers and lack of qualified staff to operate the computers was also the challenge faced.

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Chapter 4 System setup

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4.1 System setup(tracker and Commcare)

The app that we used for this Comparison is called "Sanitation tracker".Malawi suffer from common issue like clean and safe drinking water and access to latrine.so targeting this issue to collect data on the household sanitation activities seems to be a good idea.we gather the data element from spreadsheet created based on monthly report form .the same data elements were used on Both commcare and Dhis2 to make sure we are playing on same level field.both App allow data to be captured offline and send to the server when INTERNET connection is available.the app has two section .

The first section of the app is the registration section where each household is registered and act as tracking entity. all basic information about the family,house and house owner is recorded.The second section of the app is Home visit form ,where once the Household is Register,HSA then perform the Home visit and do inspection and recored it in the app.

the home visit is scheduled for visit to check if the condition is improved from last visit or not.the screen shots of the data element is provided below.

4.1.1 Data element and their description

Data element used for the registration are:

1)Date of Registration:the date when the household is First registered in the App.

2)House Owner Full name: full name of the House Owner

3)House Owner Id:the unique National Id of the Owner.Currently the National id system is not implemented in Malawi but will be implementing soon.we were asked to implement it in the app.

4)House Owner Gender 5)House Owner Age

6)Village:name of the village the house belongs to

7)Traditional Authority (TA):each village belongs to some Traditional Authority (TA).we were asked to implement it in the app.

8)Physical Address of Household:this field is used to enter the address that make it easier to track the house.the example will be "house opposite to naisi water point"

9)Phone Number

10)No of Family Members

Data element used in Home visit Screen1)Date of Inspection:date of house inspection 2)Does this House have a pit latrine?:"yes" or "no" option set.

3)Is the Pit Latrine Covered to protect from flies ?:"yes" or "no" option set.

4)Status of Latrine:"Clean/Satisfactory" or "Not clean/ Unsatisfactory" or "Not applicable" if the house has no latrine

5)Do you wash your hand after using latrine?:"yes" or "no" option set.

6)What type of refuse disposal facilitates do you have?:"receptacles(bins) and satisfactory"or"refuse

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pits and satisfactory"or"receptacles(bins) and unsatisfactory"or"refuse pits and unsatisfactory"or

"Not applicable" if the house has no refuse disposal facilitates

7)How is the condition of bath shelter?:"Satisfactory" or "Unsatisfactory" or "Not applicable" if the house has no bath shelter

8)What type of hand washing facilities close to latrines/urinal does this house have?:"Traditional facilities" or "Hand washing Basing/tap" or "Not applicable" if the house has no hand washing facilities

9)Do you have Kitchen in the House?:"yes" or "no" option set.

10)Do they Have protected water source in the house?:"yes" or "no" option set.

11)Do the house have 2 cup system for drinking water?:"yes" or "no" option set.

12)Do they have covered water container?:"yes" or "no" option set.

13)Is this house clean and tidy?:"yes" or "no" option set.

14)No of Family Members:ask the family if they have any change in the family members since the registration or last home visit.

15)How many time did you visit this House Hold?:for first visit then enter 1, if 2nd visit enter 2 and so on.this counter should be increased by 1 for every home visit.

16)GPS Location:

17)Did you remind them to Clean the latrine and wash the hand after latrine use?:this question is a reminder for HSA

18)Visit Comment/Advice:any comment HSA want to enter regarding the house visit

These app were updated several times during the interview period based on the feedback provided by the HSA.all the screen-shots mentioned here are from the final app.

4.1.2 Commcare Setup

commcare provides us two option to create an application i.e survey and case management.If we want to use CommCare to track information about something over time, then we have to use case management where each entry will be treated as a case.A case in Com- mCare can be literally anything that you want to track and monitor over time.in our app each house hold will be a case and its owner as its identifier. the registration screen is attached .please refer figure 4.1.the sequence of the image is from left to right.

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Figure 4.1: Commcare registration pages

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Before going to Home visit form, commcare provide extra case details screen. The case detail screen appears after selecting a case from the case list. It usually includes more information than the case list and is helpful for checking if the user has selected the correct case and providing additional information.by clicking continue button at the top of the screen,the user can enter the home visit screen.please refer figure 4.2.the sequence of the image is from left to right.

Figure 4.2: Commcare Case Details pages

please refer to figure from 4.3 and 4.4 for screen shots of Home visit screen from Commcare app.the sequence of the image is from left to right.

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Figure 4.3: Commcare Home visit Screens

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Figure 4.4: Commcare Home visit Screens

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4.1.3 Dhis2 Tracker Setup

The Tracker Capture Android app allows you capture, modify and list tracked entity instances with its enrollments and events. in this App,Each house hold is a tracked entity instance with House owner as tracking entity.please refer to figure 4.5 for the registration screen shots.the sequence of the image is from left to right.

Figure 4.5: DHIS2 Tracker Capture registration pages

please refer to figure 4.6 for the Home visit screen shots for Dhis2 tracker capture.the sequence of the image is from left to right.

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Figure 4.6: DHIS2 Tracker Capture Home visit Screens

4.1.4 personal comments on App creation

Having developed the app from scratch in both platform, here are my thoughts on which platform is more convenient for the app creator in brief .Even though we only developed a simple application for our research, both the platform offers more complex feature for bigger applications.but one things commcare does better is they provide a comprehensive app builder screen where you can build your app without having to move around a lot of other screen.C. King et al [27]) also points in his paper that he find commcare have user-friendly web-interfaces for designing forms and programming simple logic compared to other application he used in his research.the same screen also provide app preview feature which shows how your app will look like in your smart phone.please refer to figure 4.7.Commcare pride itself with the fact that you don’t need have a advance computer knowledge to build their app,and its shows.they also support drag and drop functionality.

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Figure 4.7: Commcare app builder screen

The same cannot be said about Dhis2 tracker.in order to create a application you first need a tracker entity( please refer to figure 4.8) which in our app was each House Hold.you have separate screen for that,and for its attribute you have different screen called tracker entity attributes( please refer to figure 4.9).to create a data element (please refer to figure 4.10) for the programming stages ,you again have data elements screen.if your data element have some option selection questions, you need to go to different screen where you have to create a new option set (please refer to figure 4.11)and assigned to that data element.if you need to set the program rules you have another screen ( please refer to figure 4.12) for that which itself has a very complex screen and have a lot of information to track .so you have to move around a lot of screens to create a simple application.thats makes the app building process a lot more complex and half of the time, you will lost your way around.

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Figure 4.8: Dhis2 Tracker app Tracked entity creating page

Figure 4.9: Dhis2 Tracker app Tracked entity attribute creating page

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Figure 4.10: Dhis2 Tracker app Data element creating page

Figure 4.11: Dhis2 Tracker app option set creating page

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Figure 4.12: Dhis2 Tracker app program rule creating page

So in summation ,Dhis2 really need to simplify the app creation process so that anyone use it to create app without lot of hassle.

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Chapter 5 Research Methodology and Approach

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5.1 Research Methodology

Note:Community health workers in Malawi are called Health surveillance assist- ants(HSA).from now on we will refer CHW as HSA.

This chapter presents the research approach and methodology used for data collection and analysis during this study. A brief overview of the research context in the Malawi current health system setting is first presented .This section is followed by a more detailed presentation of the Approach and methods used.This study falls under the umbrella of HISP research

5.1.1 Research Context Background

Whenever any health decision and policy are made from ministry of Health and population, it reflects on the performance of the health information system over past year and how that performance has led to the upcoming policies. The performance of the health system depends directly on how the information system is handed like how the data has been collected, processed and presented to the persons responsible for planning and policy making. Any discrepancies in either of the stage will lead to misleading planning.so it is important that necessary steps should be taken from data collection to the planning stage to overcome any issue arises.As per Ministry of health information system policy 2015,the current information systems are not capable of generating quality information at the time they are needed.

so Government of Malawi along with HISP and other private partners is working to Ensure an adequate provision of information support to all stakeholders in the health sector for evidence-based decision making in the planning and management of health service [10].Dhis2 will act as national repositories for patient level data and aggregate data which hold disaggregated time series data on all national health indicators repository[10].

Dhis2 itself is a complete Health information system.this research deals with the data collection part of the information system which uses HSA to compensate the lack of qualified workforce in Malawian health sector. Dhis2 uses Dhis tracker capture android application for data collection.this thesis aim to gather information and data on how to improve the Tracker to meet the needs of HSA

5.1.2 Research Approach

For this research, we traveled to Zomba, Malawi for two different time period, one in October,2017 for 2 weeks and next on January,2018 for 4 weeks.since i am from Nepal, i had a visa trouble because Nepalese citizen are not allowed on arrival visa to Malawi and must have visa approval from Malawi consulate before traveling. this forced me to skip my first travel to Malawi in August and caused my second visit to be completed in January

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which should have been completed by the end of November.

Upon arrival in Zomba, we were assisted by the personnel involved from Chancellor College, university of Malawi.the research was divided into two section, first part include general interview with the Health surveillance assistants about their daily work activities, the activities they perform and the problem they faced everyday in their work and what are they expecting from us where as the second part include the comparison of commcare and Dhis2 tracker. For the data entry, we prepared a Sanitation Tracking App both on Commcare and DHIS tracker with similar data set where HSAs first do the registration of the household and go for the Home inspection visit. We also prepared a sample answer set for them to enter.see refer to appendix A.1 and A.2 and A.5 for the questioners

we recorded their feedback and based on the feedback the app got changed (data elements)multiple times to incorporate those feedback over time.then we also perform some home Visits with the HSA when they were collecting data on Sanitation. we also conducted Home visits where HSA were using the Tablet and the app to collect some data on few household to see their performance.

The intended research outcome of this study was to gain the insights on HSAs daily activities and how can we use the Tracker to incorporate those task .and the comparison of tracker with commcare was done to see what can we learn from commcare and what functionality of commcare can be implemented in tracker to make the tracker more relevant to the HSAS.we interviewed 12 HSA in three different Heath center.their feedback was recorded in the notebook.Chancellor college Zomba helped us to land the interview with the HSA.Some of the student also accompanied us and helped us to translate. it was very difficult to land the interview because HSA only work on weekdays and they are very busy.in some of the activities i was working alone and get help from fellow students and supervisor in others.refer to the table 5.1 below for basic summary of the HSA involvement.

Table 5.1: Summary of HSA Involvement

HSA Activity count

Total HSA Interviewed 12

Male HSA Interviewed 9

Female Interviewed 3

HSA Interviewed with mHealth experience 3 HSA Interviewed without mHealth experience 9

Number of Health clinic visit 3

For experiment 2 in Naisi health center There was two different set of DHIS2 application that were tested in this interview. one was DHIS2 tracker app created by Mari Iversen who was a researcher and our mentor . she was also working on creating a comprehensive

Evaluation and Development of Android mHealth Application for Community Health Workers in Malawi

Evaluation and Development of Android mHealth Application for Community

Health Workers in Malawi

Comparison of Commcare and DHIS2 Tracker

Amrit Chhetri

Thesis submitted for the degree of Master in Programming and Networks

60 credits

Department of Informatics

Faculty of mathematics and natural sciences

UNIVERSITY OF OSLO

Evaluation and Development of Android mHealth Application for Community Health Workers in Malawi

Comparison of Commcare and DHIS2 Tracker

Amrit Chhetri

Abstract

Acknowledgement

Contents

List of Figures

List of Tables

Abbreviations

Chapter 1

Motivation

1.1 Research Context

1.2 Research Objective

Chapter 2

Background

2.1 Current Health Service Scenario In Malawi

2.2 Malawi National Health Policy

2.3 Health Information Systems

2.4 HISP

2.5 DHIS2

2.6 CommCare

Chapter 3

Literature Review

3.1 Community Health Workers:backbone to the success of Health care in developing countries

3.2 Why do we need Community Health Workers

3.3 Related Works

3.4 Previous Implementation of Dhis2 Tracker and Commcare

Chapter 4

System setup

4.1 System setup(tracker and Commcare)

Chapter 5

Research Methodology and Approach

5.1 Research Methodology