Addressing the “weakest link” in community health worker programmes: a community-based participatory research approach towards the design, implementation and evaluation of a mobile-facilitated blended supervision programme in Uganda

By 2030 it is estimated there will be a global shortage of 18 million health workers, which will disproportionately affect “low- and middle-income countries” (LMICs). As a result, a cadre of lay-health workers, commonly referred to as Community Health Workers (CHWs), have been proposed to help address this gap in the global health workforce. Yet, despite the documented successes of existing CHW programmes, many programmatic challenges remain, one of which is supervision. This has resulted in supervision being termed “one of the weakest links in CHW programmes” to date.
As a result, given the widespread and increasing ownership of mobile phones in LMICs, the use of mobile technologies (also referred to as mHealth) has been suggested as one way to facilitate CHW supervision. However, although the potential benefits of mobile technologies to support CHW supervision have been explored from a technical perspective, there is a relative paucity of work evaluating the implications of such an approach from a pedagogical perspective.
Through this thesis, I therefore seek to answer two key research questions:
1. How do key stakeholders (CHWs, NGO programme managers, health facility workers and government officials) perceive CHW supervision, and specifically the role of mobile technologies in facilitating supervision?
2. What are the effects of using an mHealth intervention, as part of a blended supervision programme, on the nature of CHW supervision?
I address these questions by taking a three-phase Community-Based Participatory Research (CBPR) approach towards the design, delivery and evaluation of a blended supervision programme for CHWs. This work was conducted over a 10-month period in the context of Seeta Nazigo Parish, Mukono District, Uganda. It was done in partnership with CHWs, non-governmental organisation (NGO) partners, government health officials and workers from the formal health sector. I took a mixed-methods approach to my work, using methods including photovoice, individual interviews, focus group discussions and analysis of a mobile group-messaging data set in order to help to answer the research questions.
Through an exploratory phase of work undertaken at the beginning of the project, the CHWs identified ear and hearing disease as a neglected but important problem which they encountered in their daily practice. In keeping with the participatory nature of my work, the focus of supervision largely centred around this topic and was enabled through the use of a shared mobile messaging platform: WhatsApp. The findings from my work also reveal the tensions in how supervision is conceptualised and delivered in this setting and is framed against the complexities of the wider system in which the CHWs work. I analyse how the WhatsApp messaging platform was used to support supervision and explore the nature of supervisory exchanges and how these evolved over the duration of the project. Finally, I take the opportunity to discuss some of the ethical issues raised by taking a CBPR approach and reflect on my own position as a British researcher undertaking ‘global health’ work in a post-colonial space.

Keywords: digital health
Uganda
supervision
village health team
eLearning
community health worker
Mukono
global health
WhatsApp
CHW
education
medical education
mHealth
training
Advisor: Winters, N
Paton, C