Problematic problem diagnostics: why digital health interventions for community health workers do not always achieve their desired impact

• Published in: BMJ global health Vol. 6; no. Suppl 5; p. e005942
• Main Authors: Newton-Lewis, Tom, Nanda, Priya
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 01-07-2021; BMJ Publishing Group
• Subjects: Beneficiaries; Communication; Community; Community Health Workers; Design; Health Policy; Health promotion; Humans; Information technology; Intervention; Medical diagnosis; Software; Telemedicine; Trust; Workers; Workloads; India; health systems; health policy
• ISSN: 2059-7908; 2059-7908
• DOI: 10.1136/bmjgh-2021-005942

How problem diagnostics problematise CHWs While digital tools cover the whole range of healthcare provider interventions as classified by the WHO,4 many focus on supporting the performance of individual CHWs in delivering routine services, particularly through job aids that assist scheduling and activity planning, provide decision support, and include audiovisual materials that can be used to augment CHW–community interactions. [...]the mobile phone-based job aid known as the Information Communication Technology-Continuum of Care Service (ICT-CCS) piloted in Bihar improved the self-reported skills of Accredited Social Health Activists (ASHAs).6 However, that these interventions target the performance of CHWs as individuals in the system and not as part of a network of actors and processes surfaces their implicit assumption that CHWs have complete agency over the coverage and quality of services they deliver. [...]an evaluation found no significant difference between the number of home visits received by mothers of children aged 2–4 weeks in treatment and control groups, and a small difference in the first week.6 In a separate study, the authors report that the main constraints to home visits were concerns about safety when travelling within the community, the temporary migration of mothers to their maternal homes during childbirth, and unrealistic workloads, limiting the potential effectiveness of job aids.7 Studies of other CHW cadres in India have similarly identified how performance constraints are systemic or structural and thus mainly outside of the control of the worker.8 Implications The risk, therefore, is that digital CHW interventions target the service delivery symptoms of underlying systemic challenges, and that this narrow construction of the problems facing CHWs limits intervention effectiveness. The Cochrane systematic review on health workers’ perceptions and experiences of mHealth technologies shows how interventions can have positive and negative effects on intangible software.3 For example, being custodians of expensive equipment can raise the perceived status of a CHW, and playing videos of behavioural change messages can lend credibility. 88% of ASHAs reported increased trust from village members after using an mHealth intervention.13 On the flip slide, job aids can make worker–beneficiary interactions impersonalised, can cause embarrassment if workers make mistakes in front of clients, can be disempowering for CHWs with low digital literacy, and can reduce the quality of interactions if the technology is cumbersome or not tailored to the local language.