Taking knowledge for health the extra mile: participatory evaluation of a mobile phone intervention for community health workers in Malawi

Abstract

In Malawi, where the majority of the population resides in rural areas, community health workers (CHWs) are the first, and often only, providers of health services. An assessment of health information needs, however, found that these frontline workers often lacked essential health information. A pilot project, implemented in 2 rural districts of Malawi between 2010 and 2011, introduced a mobile phone system to strengthen knowledge exchange within networks of CHWs and district staff. To evaluate the mobile phone intervention, a participatory evaluation method called Net-Map was used, an approach built on traditional social network analysis. Together, 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 powerful evidence of differences before and after the mobile phone initiative. 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. Focus groups with CHWs complemented the Net-Map findings with reports of increased self-confidence and greater trust by their communities. 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. As an innovative, participatory form of social network analysis, Net-Map yielded important visual, quantitative, and qualitative information at reasonable cost.

FIGURE 1.

SMS Network in Nkhotakota and Salima Districts of Malawi Abbreviations: CHW, community health worker; SMS, short message service.

Net-Map participants in Nkhotakota, Malawi, produce a 3-dimensional drawing of their knowledge exchange network.

FIGURE 2.

Baseline and Endline Net-Maps of Information Flows With District-Level Stakeholders in Nkhotakota, Malawi

FIGURE 3.

2010 Baseline and Endline Net-Map of Information Flows With District-Level Stakeholders in Salima, Malawi

FIGURE 4.

Baseline and Endline In-Degree and Out-Degree Centrality Values for Nkhotakota, Malawi Abbreviations: CBDAs, community-based distribution agents; CBOs, community-based organizations; CHAM, Christian Health Association of Malawi; CHWs, community health workers; MOH, Ministry of Health; NGOs, nongovernmental organizations; RHU, Reproductive Health Unit.

FIGURE 5.

Baseline and Endline In-Degree and Out-Degree Centrality Values for Salima, Malawi Abbreviations: CBDAs, community-based distribution agents; CBOs, community-based organizations; CHAM, Christian Health Association of Malawi; HSAs, health surveillance assistants; MOE, Ministry of Education; MOH, Ministry of Health; NGOs, nongovernmental organizations; RHU, Reproductive Health Unit.