A Clinic-Level View ofthe MomConnect Implementation

ICT4Health ConferenceBrendon Wolff-Piggott

25 November 2015

Research Setting

<<graphic of connected mothers >>

Use Cases from Training MaterialOption Use CaseOption 1 Health Education Class and MomConnect Information => Consultation

with Nurse (record of decision and EDD) => File to Data Capturer

Option 2 Health Education Class and MomConnect Information => Consultation with Nurse (record of decision and EDD) => Nurse signs mother up (recorded in clinic file)

Option 3 If no Health Education Class => Clinic staff member tasked to hand out informational fliers to mothers while waiting => Consultation with Nurse => Nurse signs mother up (recorded in clinic file)

Research Question

What are the key influences on how a mobile health application is routinely used in a public clinic setting?

Research DesignMultiple case study

Exploratory investigationOpen codingHermeneutic analysis

Framed using Activity Theory

Data Collection Open-ended Interviews with Key Staff

Facility ManagersANC SistersSupporting staff using MomConnect

Observation of MomConnect Registration

Observation of General Clinic Routines

Data Analysis Interviews

Recorded and transcribedLoaded and coded in Atlas-TIGroup codes

ObservationsReviewed and highlightedCorrelations and contradictions with

transcripts notedHigher-level Analysis drawing on Activity

Theory

ResultsGeneral perceptions and work practices

MomConnect use issues

Other issues

Perceptions of MomConnect useCode Quotes Type of SourceInappropriate for professional health workers

“ Professionals don't do this, really. There are volunteers who can do this”

Facility manager / nursing sister interview

Shortage of time and professional nursing staff

"The work is being added (to) every day. … Work is added ... (by) this Mom Connect, it's on top of other things"

Facility manager / nursing sister interview

Delaying professional tasks

"If the phones are not going through it means I don't start working. Because I connect to Mom Connect before I take bloods, I do everything"

Nursing sister interview

MomConnect RegistrationCode Quotes Type of SourceRegistration errors

“there are times when like, when was it? Monday or Nursing sister interviewTuesday, the phones were not going through. And that lady, I've forgot her name from Mom Connect office, she was here. I told her that I'm frustrated”

Nursing sister interview

English literacy “we thought she was slow, but she can’t read English”

Observation

Registration errors

Touch-screen phones are difficult Observation

Handset UseCode Quotes Type of SourceHandset presence

"… some of them they don't even have the telephone numbers, the telephones, they say they can't have these telephones because they come very early. Most of them here they give the history that they have lost their phones and it's difficult because you need to use your own phone”

Facility manager / nursing sister interview

Handset use “... if a patient doesn't have a phone then I use my phone and I enter that patients phone number. But when ... they have a cell phone but they don't know how to use them, and that bothers me the most. "

Facility manager / nursing sister interview

Client concerns "Some antenatal patients are sceptical when it comes to registration process. Because some of them are HIV positive”

Facility manager / nursing sister interview

Discussion

How is the application used in practice?

Can this be thought of as an Activity System?

What influences may be identified?

Actual work practicesWork practices

User Groups

Reasons given

Relevant dynamics

Who Primarily support staff

“Not professional work”Time constraints

Professional / non-professional divideResource constraints

How (Why)

Multiple modes

Nurses said so / excluded from ANC space

Power relations Contradictions between nurse and auxiliary aims

When In-between routine ANC tasks. Registration after

Keeps nurses from doing their work

EfficiencyContradictions between nurse and mother’s interests

Actual Work Practices

MomConnect

Presentation Consultation

JointRegistratio

n

Presentation Details on paper

Consultation

Registration

Registration by CHW

Registration by ClientsTechnical System

Work Environment

Subject Object Outcome

Tools

Rules Community Division of Labour

The ActivitySystem Model

National Department

of Health

MomConnect Registrations

Improved Health for Women and Children

MomConnect SystemClinics

National MomConnect Activity

Levels of FocusUnit of Analysis Subject Focus

Clinic Facility Manager Activity: Curative & preventive

care delivery

Antenatal Care

Section

ANC Sister Activity: Physical examination,

calculation of EDD, & referral

for further test as required

ANC Health

Promotion

Health Promoter /

Volunteer

Activity: Health Management

Presentation and MomConnect

Registration

National Department

of Health

Registration ofPregnant Women

All clinics

National MomConnect Activity

Clinic Care Activity

Antenatal Care Activity

MomConnect and Clinic ANC Care

ImplicationsLocal clinic characteristics, existing work practices and

staff dynamics – Task shifting

MomConnect characteristics also shape staff perceptions and ease of use

Activity Theory can help understand why observed dynamics occur, and suggest useful interventions

Practice: Short term – improve feedback to facility managers and staffLong term – expand the role of CHW / Health Promotion

staff, and locate “ownership” there

LimitationsFieldwork only undertaken in clinics where

MAMA was implemented previously

Limited access to staff because of workload and language barriers

No formal access to technical service providers

Way forwardExtend investigation to include rural clinics

Repeat interviews and observation to obtain longitudinal perspective

Examine digital traces from registration database

Thank You!