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Getting Better, Faster Feedback with Mixed Methods in mHealth

By Guest Writer on December 14, 2016

There are several projects that use mobile multimedia for health education in hard-to-reach rural settings, where video, being non-textual, enables the educational content to reach populations that cannot read. The missing link in these programs, however, is an effective feedback loop that connects the rural communities that consume the health content to the health professionals that plan, create and disseminate the content.

In the case of The Bophelo Haeso project in Lesotho, for example, rural-based nurses had created multimedia content on varying topics for over three years. In that time, Community Health Workers (CHWs) carried the videos on their mobile phones into the villages and used them to educate the members of their communities. However, there was little feedback from the villages to the nurses on how the content was received, and how future content could be improved in order to fully address the issues that affect the communities being served.

In Apps and Skits: Enabling New Forms of Village-To-Clinic Feedback for Rural Health Education, Maletsabisa Molapo, Melissa Densmore, and Limpho Morie describe a study that sought to find ways to give CHWs a voice; to give them new channels through which they could effectively communicate, enabling them to relay feedback from the villages in which they live to the health centres where the health education content is planned and created.

We present the CHW-led village-to-clinic feedback mechanism, which was achieved by role play in combination with a collaboratively designed mobile asynchronous-voice platform.

Mobile Asynchronous-voice Feedback

We sought to find ways to situate the new asynchronous voice solution within the CHWs’ current ways of life and work, and atop existing tools they already use. This includes focusing on offline transmission of voice from the rural villages to the centrally located clinics because the costs of uploading voice over the web or calling over an interactive voice response system would not be feasible and affordable in rural Lesotho. Additionally, we wanted to explore the complementary power of a non-technical approach to feedback generation, which is role-play, and sought to find ways to use both approaches in combination.

The audio reports help nurses to understand multiple issues, including:

  • Cultural beliefs that women are seen to be weak when they start antenatal care at the health centres.
  • Traditional herbalists were selling herbs that are potentially dangerous to mothers and their foetus.
  • Poor handling of patients at health centres,and frequent absence of medical equipment discouraging visits.

As a result of the feedback, the clinics are re-designing some of the services they offer to the communities, and nurses are creating new videos to address the needs identified through the feedback.

Role Play Feedback

On the quest to complement the asynchronous-audio feedback, we use role-play where CHWs 1) simulate their interactions with the public in their villages and 2) report actual experiences that they went through at some point in the past. The ‘skit-workshops’ were held three times in the 12-month feedback deployment period. Before the Bophelo Haeso project, role-play had been used in the training of CHWs in the past, to reinforce concepts, so it was not an entirely new experience, and it was one with which they felt comfortable.

The core of the CHW skit-reporting is that the CHWs create their own scenarios and decide on the storyline to be staged. They are not told what to act, or what to focus on. They design the entire script for their skits, assign actors to parts, and self-direct the play: a truly CHW-created, CHW-directed skit. Discussions among the larger group with the nurses and researchers follow the performances.

A number of contextual details emerge from the CHWs’ skits, including:

  • The settings in which some patients are treated.
  • The external influences within families that are against good health practices.
  • The people’s attitude of preferring to hide health challenges.
  • General knowledge gaps on basic health issues like the symptoms of TB.

We discovered that with role play, the skits do a great job in getting the CHWs out of their reserved, non-articulate selves. Being forced to be a different person than the reserved woman a CHW is cultured to be, the CHW can be more expressive and demonstrate struggles that would not be easy to articulate in a discussion.

Complementary Tech and Non-Tech

In-situ reporting and role-play reporting complement each other, as each offers different affordances. Mobile phone reporting in the comfort of a CHW’s home, happening soon after a CHW’s interaction with members of her community, enables her to articulate a fresh experience, including useful details and demographics.

With group skits, we observed that in-group reflections allow collaborative reporting, and integration of experiences into one performance, enabling easier peer-to-peer communication and sharing of experiences among CHWs. Drama also allows CHWs to imagine better due to the embodied experience that might spark imagination and creativity in ways that may not occur otherwise.

Looking at the results of both employed approaches, we realise the benefits of leveraging them together; and we confirm previous research that demonstrated that while mobile technologies are powerful and ubiquitous, sometimes, a complete solution lies not only in a technological intervention.

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