Taking Knowledge for Health the Extra Mile: Participatory Evaluation of a Mobile Phone Intervention for Community Health Workers in Malawi

"To evaluate the mobile phone intervention, a participatory evaluation method called Net-Map was used, an approach built on traditional social network analysis."

This research evaluates a mobile phone intervention pilot project, implemented in 2 rural districts of Malawi, between 2010 and 2011, that introduced a mobile phone system to strengthen knowledge exchange within networks of community health workers (CHWs) and district staff. The research describes the Knowledge for Health (K4Health) Malawi project mobile health intervention and "explores the effects of the intervention on knowledge exchange, focusing particularly on the qualitative and quantitative data collected through a participatory action research methodology called Net-Map. The article also explores some of the impacts that the Net-Map sessions had as interventions in and of themselves."

This project, addressing family planning/reproductive health and HIV/AIDS, "trained and provided mobile phones, solar chargers, and airtime to 253 CHWs in Nkhotakota and Salima Districts - 30% of all CHWs in the 2 districts combined," with 385 more receiving the tools and training in a second distribution to bring SMS (texting) coverage to 77%. When a question needed an answer or a restocking of pharmaceuticals was needed, a district coordinator or supervisor at the Hub (central message site) would respond to messages. Also, "a worker could reach a specific supervisor directly by using defined keywords, which the Hub would recognize and forward to the phone of the supervisor." Using several qualitative and quantitative methodologies, including Net-Map research, Lot Quality Assurance Sampling (LQAS), and focus group discussions, researchers evaluated project effectiveness and cost.

For the Net-Map analysis, "the CHWs and district personnel discussed information needs and gaps and the roles of different actors in their information networks. They then used drawings and 3-dimensional objects to create baseline and endline maps showing the linkages and levels of influence among members of the information network. Net-Map provided them with... evidence of differences before and after the mobile phone initiative."  Steps included: identifying the actors in the network; linking the actors; mapping the influence; facilitating discussion of the results; and comparing changes in mapping as an ongoing exercise, in this case using the question: "Of the links, which have been strengthened as a channel for information and knowledge flow due to the mobile phones?"

At workshops, project evaluators entered data from hand-drawn maps into VisuaLyzerTM software to create computer-generated maps. On the maps, the size of each node corresponded to the height of the "influence tower" for that actor, as seen in the baseline and endline maps. This allowed evaluators to quantify centrality of the roles: "Degree centrality is a quantitative measure that is basic to social network analysis. It defines the positions of the actors in a network by a score that indicates the number of links each actor has with other network members. In this way, it is a measure of connectedness: the extent to which the actor can access needed information from and provide relevant information to other network members."

"These qualitative results were bolstered by surveys that showed decreases in stockouts of essential medicines, lower communication costs, wider service coverage, and more efficient referrals." The Net-Map process demonstrated the effects of the mobile phone intervention and was supported by the quantitative method results. The baseline mapping showed a hierarchical information flow. However, mapping after the introduction of mobile phones showed that "CHWs who were using mobile phones had turned from passive recipients of information to active information agents who sought and provided information back up the hierarchy and across the network to one another as colleagues on the front lines." Participants in workshop and focus group discussions in 2011 explained that all actors in the district were now relying on these workers to provide clients with HIV/AIDS and reproductive health information. In addition, there was increased self-confidence in CHWs and increased trust by clients and communities, as well as an increased ability to cover more clients and 90% less travel time. "At baseline, CHWs were not mentioned as actors in the information network, while at endline they were seen to have significant connections with colleagues, beneficiaries, supervisors, and district health facilities, as both recipients and providers of information."

The study concludes that, as a participatory form of social network analysis, "Net-Map yielded important visual, quantitative, and qualitative information at reasonable cost." In addition, mobile phones provided "new channels for communication .... and supplying these channels with content and processes for knowledge sharing.... [F]uture projects aiming to improve knowledge flows through information technologies should focus both on developing technically feasible and robust channels and on encouraging knowledge sharing behavior." The workshops on constructing Net-Maps "made it clear to participants that the ...changes in the communications network for frontline health workers were due to the use of mobile phones and links made through the Hubs to the district supervisors and coordinators as sources of information and assistance", supporting sustainability of the project. However, difficulty in maintaining virus-free computers ended Hub support, but CHWs retained mobile phones and their own networks for information exchange.