Date of Award

January 2015

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Elizabeth Bradley

Subject Area(s)

Public health, Information technology, Social research

Abstract

In an effort to assess the effect of mobile clinical decision support (CDS) algorithms on the delivery of antenatal and postnatal care by community health workers (CHWs) in Kosirai, Kenya, we conducted mixed methods that included a cluster- randomized controlled trial, in-depth interviews, and focus group discussions. In the qualitative research of focus group discussions (FGDs), we sought to gain a more comprehensive understanding of how CHWs worked in Kosirai, how the residents understood and utilized community health services, and how the phone hardware and software facilitated or constrained the workflows of CHWs delivering antenatal and postnatal care in Kosirai. A total of eight focus group discussions with women who were pregnant or who had recently delivered in Kosirai (n=44), and six focus groups with CHWs (n=24) were conducted over a two year period. FGD participants were selected by purposeful sampling, and comparison with a concurrent survey conducted by the Academic Model for Providing Access to Healthcare (AMPATH) Primary Health Care demonstrated that FGD participants covered a wide range of population demographics. The initial focus groups were held approximately 18 months after the initiation of the CHW program, when the CHWs were using paper forms and job aids. The subsequent FGDs occurred 6 months after the CHWs had received phones, and 6 after the implementation of the clinical decision support, at the conclusion of the randomized-controlled trial. In this thesis, we discuss two emergent themes identified from the FGDs, and the relevance of the mobile health intervention on each theme. `We are people of their village' covers the relationship between CHWs and the women they served, focusing on the accessibility, availability and acceptability of community-based care as well as the impact of phones on promoting access to health care. `Collective responsibility' examines the familial and sociocultural networks in which the CHWs and their clients seek health care, and the relevance of the phone in this sphere. Through these themes, we explain how the mobile clinical decision support system enabled greater autonomy, flexibility, responsiveness, and quality of service delivery among CHWs, but emphasize how these benefits were limited to a subset of highly committed CHWs.

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