chn on the go process documentation: round 2 research findings

www.innovationsformnch.org

CHN on the Go Process Documentation

Round 2 Research Findings


Soumya Alva, Sophia Magalona & Amanda Makulec

JSI Research & Training Institute, Inc.


Presentation Outline

CHN on the Go Theory of Change

Objectives

Key Questions

Methodology

Summary of Round 1 Findings

Project Timeline

Pathways

Round 2 Findings

Summary, Overall Impression and Next Steps


CHN on the Go Theory

of Change

Learning

opportuniti

es, job aids

& Point of

care tools

Work

planning

ability &

Target

achievemen

t

Ability to

communica

te

Supervisor’

s ability to

track

progress

Staying well

Increased

health

knowledge

Better

work

planning

and

scheduling

Better

communica

tion with

peers

Extrinsic

motivation/

job satisfaction

(job security,

salary, work

environment,

work load)

Module

usage

frequency

INPUTS OUTPUTS INTERMEDI

ATE

OUTCOMES

DIRECT

OUTCOME

ASSUMPTION: Health workers feel unmotivated and frustrated in their jobs

SYSTEM

BARRIERS

we cannot

address:

• Infrastruct

ure and

resource

limitations

• Nurse

salaries

• Formal

recognition

structures

for GHS

• Formal

promotion

structures

for GHS

Poor

manageme

nt

Resource

Constraints

Isolation

Stress/

Frustration

BARRIERS

Disrespect

by clients

and other

HWs

Limited

advanceme

nt

opportuniti

es

Intrinsic

motivation

(confidence,

connectedness

recognition by

community/

peers,

autonomy)

Supervisor’s

ability to

communica

te with

CHNs

Recognition by

supervisors

Better

supervision

and

management

systems

INDIRECT OUTCOME

Poor

manageme

nt and

supervision

Better

tracking

system for

supervisors

Better

communica

tion with

supervisors

Supervision

dashboard

usage

frequency

Limited

advanceme

nt

opportuniti

es

Availability

of learning

courses and

opportunitie

s

Number of

courses/opp

ortunities

GHS

recognizes

Recognition of

educational

credentials

System

-leve

l chan

ges

Better

CHN

performanc

e/Nurses

meet their

targets

Improved

maternal,

newborn,

and child

health

outcomes

Better

quality of

care

LIN

E O

F A

CC

OU

NT

AB

ILIT

Y

Better

work life

balance


SYSTEMS LEVEL


1. Assess fidelity of CHN on the Go activities to the original design of the project

2. Examine the proposed change pathways in the theory of change

3. Examine the role of the context - including the health system - on the effect of the CHN on the Go pilot

PD Objectives


Key Questions

Implemented as planned

Barriers and supportive factors

Factors and processes driving changes

Extent of CHN exposure to the modules

Overall satisfaction

Perceived link between exposure to the modules and changes in CHN behavior

Systemic changes in learning and supervisory systems

BASELINE May – Aug 2014

PROJECT START MAY-June 2014

PD Round 1 Nov - Dec 2014

PD Round 2 July - Aug 2015

Feedback session April 2015

PROJECT END MAY 2016

Other data collection activities: • Monthly field interviews • Monthly usage monitoring

dashboard

Magpi survey Dec 2015 – Jan 2016

Magpi survey April – May 2015

Pop-up questions June 2015

Pop-up questions Jan 2016

Feedback session

PD Round 3 ENDLINE Feb 2016

Methodology


• In-depth interviews by JSI and ILC staff (July-August 2015)

Interview type No. District

CHN interview 16 All 5 districts (Ningo Prampram, Ada East,

Ada West, South Dayi, South Tongu)

Supervisor interview 8 All 5 districts

Client interview 8 Ningo Prampram and South Tongu only

CHN observation 6 Ningo Prampram, South Dayi, and South

Tongu

Primary Data Collection

Other discussions:

• Regional Director (Volta), District Directors (Ningo Prampram,

South Dayi, South Tongu)

• Nursing and Midwifery Council, GHS (HR Department), GHS PPME

• Ongoing discussions with Grameen Foundation and Concern

Worldwide Ghana staff


Summary of Round 1 Research Findings

Learning Center,

Planner, and Point of

Care

CHN on the Go

• Plan and share itinerary

• Communication

• Health knowledge

Discussion related to motivation did not emerge. This will be explored more in Rounds 2 and 3.


Project Timeline: May 2014-July 2015

MAY JUNE JULY AUGUST SEPT OCT NOV DEC JAN FEB MARCH APRIL MAY JUNE JULY

2014 2015

May - July

2014

Version 1

Training

Late July

2014

Version1

actual

launch

1st week of Aug

2014

Trainings

extended

November

2014

Version 2

Training

November

2014

Version 2

actual

launch

ONGOING DISCUSSIONS WITH GHS, REGIONAL/ DISTRICT DIRECTORS, OTHER STAKEHOLDERS

Jan – Feb 2015

Training for

Volta Regional

Directorate.

NMC

collaborating

partner.

April 2015

Refresher

training.

Version 3

deployed.

Supervisor app

updated.

Feb-March 2015

Training for Volta/

Greater Accra RHMT.

Family Health Division

home unit of CHN

on the Go within GHS.

June 2015

Accreditati

on letter

from NMC

and

MOU

finalized

March – May 2015

National level

training (GHS-FHU,

HR, PPME, MOH-

HR)


Pathways

Communication & Connectedness

Achievement Center

Planner

Learning Center

Point of Care

Staying Well

WhatsApp

Health Knowledge

Work Scheduling

Targets

Relationships

Keeping Well

Confidence

Recognition

Emotional support

Professional

relationships Time management

MODULES MOTIVATION

Supervisor App Monitoring and Supervision


ROUND 2 RESEARCH FINDINGS

• Overall usage of the CHN on the Go app

• Health knowledge Confidence in providing services

• Work scheduling & time management Burden

• Achievements Recognition & respect

• Communication & connectedness Relationships

• Keeping well Emotional support

• Supervisor App Performance monitoring

• Barriers to use


CHN on the Go

users

TOTAL

55

215


Actual usage

0%

20%

40%

60%

80%

100%

% C

HN

s

This week

Last week

2 weeks ago

Longer than

2 weeks agoAt CCH

Training

Self-reported usage

(frequency/week)




• Health knowledge Confidence in providing

services






• Barriers to use


Health knowledge add a pic

Relevant Modules:

Learning Center and

Point of Care

Intended to provide

learning opportunities

and access to necessary

health information


Point of care actual usage Self-reported last

time used


Favorite section of Point of Care (self-reported)

0%

20%

40%

60%

ANC PNC for mother PNC for baby


Client Perspectives

CHNs are more confident and clients are happier and trust

the information they receive

“[She] is educating you, you will know that that is the right thing

for you to do because she does it with evidence...she made me

know that it’s good for me to do what she is saying rather than

she saying it without any proof.” - Client, South Tongu

“The [visit when] she used the phone was better because

you get to understand more… Her knowledge was

better [when she had the phone] because she knew

what she was doing.” –Client, Ningo Prampram

CHNs used the PoC module to counsel clients on nutrition and

pregnancy (danger signs for example)


Learning Center actual

usage Last time read material

from reference section

(self-reported)


95% installed all five FP courses

78% installed all 7 MNCH courses

In 8 of the 14 available courses, the average final exam

score earns a pass

The most popular course is FP 101, but the course

with the most completions is Diarrheal Disease

Learning Center


Health Knowledge:

Reasons for use

Point of reference

Read and refresh

Give right information

“For me, it has

improved my

knowledge on the

courses. How to take

care of the client, how

to counsel the client,

that is for my personal

use too.” – CHN, Ada

East/West


Health Knowledge:

Potential

POC – Standardized protocols

deployed to all health workers

More materials and topics in

Learning Center

Accreditation Pin renewal

Distance learning from training

institutions


Confidence in Providing Services

“[With] the Point of Care, at least it helps you to

render the best of care. I am not a midwife but

I know how to render pregnancy care to my clients

because of the app.” – CHN, Ada East/West

“It has influenced their work because they can

easily refer to the phone and that has boost

their clinical knowledge and gives them

confidence.” –Supervisor, Ada East/West










• Barriers to use


Work Scheduling and Time Management

Relevant Module:

Planner

Intended to help CHNs

plan their activities

through documentation,

planning, and review of

work schedule, as well

as coordinating with

peers and share with

supervisors


Planner actual usage

Last time used the Planner

(self-reported)


Work scheduling &

Time Management:

Reasons for use

Planning

Reminding

Keeping track

“And the Planner too

reminds you. It serves

as an alarm for you to

begin your work.” –

CHN, Ningo Prampram


Burden

“There has been

no increase in

my workload.” –

CHN, Ada

East/West

“When I set the targets, it

reminds me. You will select for it

to remind me daily, monthly or

weekly”

– CHN, Ada East/West










• Barriers to use


Target setting

Relevant Modules:

Planner and

Achievement Center

A reporting tool

Intended to view

progress on courses and

targets

Draws from Planner and

Learning Center


Planner: Target Setting actual

usage

Last time set targets

(self-reported)

Note: Frequency of target

setting up to the CHN


Targets:

Reasons for use

Set targets and goals

View progress

Self-evaluate

Supervisors use information to

keep track of CHNs and

advise them

“So, when you

update it, it tells you

that you have

achieved this target.

It tells us what we

have achieved and

what we have not

achieved.” – CHN,

Ada East/West

“The setting targets it also helps the nurse to know this

is where I am heading to and will I be able to achieve it

by this date. So you push the nurse and remind them

that you are not performing and you should do this, do

this.” –Supervisor, South Tongu


Targets:

Potential

To be used as

supervisory tool across

all cadres of health

workers and as

supervisory tool for

performance monitoring

“[M]ost times her

events do not show. So

when I call or

WhtasApp her and she

set her targets, she

call[s] me on phone to

recheck again whether

it has come. Pertaining

to just the last two

weeks, I WhatsApp

most of the nurses

because most of their

events are not

showing...” –Supervisor,

South Tongu


Recognition & Respect

“Yes it has given us much respect

because it creates communication and

assurance between us and the clients.”

– CHN, Ada East/West

“If they are doing well I praise

them, and if they are not

doing well, I see that you are

not even reading these things

at all, you will have to share it

with them.” –Supervisor, Ningo

Prampram

A result of

overall CHN

performance







• Communication & connectedness

Relationships



• Barriers to use


Communication & Connectedness

Relevant Modules:

WhatsApp

Designed to facilitate

communication and

coordination between

nurses, supervisors, and

clients

91% use WhatsApp to contact fellow CHNs 53% contact family and friends

In the past

communication was

only to the head of

the institutions who

attended meetings.

Now there is

much better

communication

directly with

CHNs.


Communication &

Connectedness:

Reasons for use

Facilitate communication

Stay connected

Display photos

Facilitate counseling

Group diagnosis

“The app has changed

the frequency of

communication. Like

with WhatsApp, when

we want to channel any

information to the

CHNs in this sub-

district, you just use the

WhatsApp. Or even if

you don’t want to

call, you just use the

app.” -CHN, Ada

East/West


Builds Relationships:

Transparency

Communication

Release stress

“It’s good because it

brings about

teamwork; you know

that whatever you are

doing your supervisors

are aware.” -Supervisor,

Ada East/West Enhances the

role of all other

modules


Communication &

Connectedness:

Potential

Disease surveillance

Improved coordination at all

levels

Disseminate information from

higher level

“It has helped my

professional life

because I do not need

to travel all the way to

my sub-district building

to discuss about

meetings or what we

need to do.” –CHN,

Ada East/West










• Barriers to use


Emotional and Social Support

Relevant Module:

Staying Well and

Whatsapp

Intended to enable

nurses to take charge of

inspiring themselves and

help deal with stresses

of work life

Build a sense of

community


Staying Well actual usage

Last time viewed (self-reported)

0%

20%

40%

60%

80%

100%

No Yawa My Wellness Devotional

% C

HN

s

this week

last week

2 weeks ago

more than 2weeks ago

never


Keeping well:

Reasons for use

Release stress

Keep healthy relations

Relate to people

“Even if you are bored at

the house and you read

your WhatsApp, there

may be a post that

says have a lovely day

and at least it brings

you up a little.” –CHN,

Ada East/West

“They’ve been giving me some kind of exercises to be

doing every morning about my life, how to improve

upon my well-being. They’ve been giving me some

topics to be reading to go according to it every

morning before I come to work. Every morning I open

it and what I see I go according to it.” –CHN, South

Tongu










• Barriers to use


Supervisor App

Intended to enable

supervisors to access

progress and activities of

CHNs and guide

feedback and

supervision


Supervisor app actual usage

Last time accessed (self-

reported)

0%

20%

40%

60%

80%

100%

% C

HN

s

This week

Last week

2 weeks ago

Longer than 2 weeks

ago

At CCH Training

Never

80% reported that app

displays all nurses’ targets


Supervisor App:

Reasons for use

Initiate follow up

communication

enhance supervisory role

track and view progress

“Maybe in a week, once. [I use the Supervisor’s

App] at least 45 minutes because I have to

refresh before some of the new activity nurses

are doing comes and then you see whatever

you are looking for.” – Supervisor, South Tongu

Limited use

because not

all supervisors

are tech savvy


Supervisor App:

Potential

Effective tool for performance

monitoring

Use by Supervisors at all levels

of the district health system










• Barriers to use


Phone freezing and app crashing, but new versions are improved

Small screen, difficult to see

Battery runs out quickly

Not enough credit

Barriers to Use


Summary

Learning Center,

Planner, and Point

of Care

Staying Well

Achievement

Center 0%

20%

40%

60%

80%

Most useful modules for

CHNs


Almost all wanted to continue to use the app in future

Improved personal lives very much: 79 %

Improved work lives very much: 88 %

Overall Impression of the App “It is very beneficial because it makes the work

easy. And I also feel connected to friends, family,

and colleagues.” – CHN, South Dayi

“The phone has helped me in general with my

work…previously we were finding it difficult to

send information to our in charges and our

friends. But now with the phone, we are able to

WhatsApp it. And with the Planner, it helps to

remind us of what we have to do that day.” –CHN,

Ningo Prampram


“This intervention was sent at the right place, at the right time for the right people…. Because of this phone, our district has become smaller ….. Because of the phone we are able to send information quickly… We are able to see conditions on the field, take photographs and send it.” – District Director, Ningo Prampram


Next Steps: July 2015-May 2016

JULY AUGUST SEPT OCT NOV DEC JAN FEB MARCH APRIL MAY

2015 2016

November 2015

Version 4 launch

Refresher

training for

supervisor app

and target

setting

ONGOING DISCUSSIONS WITH GHS, REGIONAL/DISTRICT DIRECTORS, OTHER STAKEHOLDERS

March – May

2016

Transition to

district,

regional, and

national levels

March 2016

Final

refresher

training led

by district


Thank You!

chn on the go process documentation: round 2 research findings

Health & Medicine