AudiencScapes

Health workers who serve India’s poor and rural citizens are often poorly trained and have limited literacy. With mobile phones able to display audio and video health information in multiple languages, these workers are in a better position to educate the public about major health issues.

By Paromita Pain

To improve the health of India’s poor and rural citizens, the government uses a corps of community health workers who fan out to rural villages across the country. The program’s strength lies in simple face-to-face interactions health workers have with citizens about basic health issues. A new project is equipping these health workers with mobile phones that guide them as they talk to clients about pressing health concerns.

CommCare is a mobile-phone based healthcare application developed to assist community health workers in delivering and gathering health information quickly and efficiently. The deployment of CommCare in India is being led by two U.S. companies, Dimagi and D-Tree international (http://www.d-tree.org/). Recently awarded a grant from USAID, the system has been used in more than 60,000 household visits with very low costs per person served.

Serving as an interface between the community and the public health system, community health workers are the first port of call for any health-related demands of rural populations who find it difficult to access health services, especially women and children. They also spread health information to increase awareness about major health issues, like malaria and tuberculosis. The technology makes it easy for health workers to retrieve health information and transmit data about their clients to a central server to manage cases.

For example, a common effort shared by many health workers is ensuring routine vaccinations for children. By using a mobile phone to register children and record the status of their vaccinations, the health workers can manage their cases more easily. The technology provides them with reminders about children not yet vaccinated. In addition, this electronic data can then be submitted to the health ministry which analyzes the effectiveness of its interventions and identifies areas that may need more help.

Challenges and Opportunities Posed By Community Health Workers

The National Rural Health Mission provides every Indian village (population of 1,000 or greater) with a trained female community health worker under its Accredited Social Health Activist (ASHA) program. More than 750,000 community health workers have begun their training as Accredited Social Health Activists and the National Rural Health Mission recruits an average of 150,000 new health workers per year. They are selected from the village where they will work. Women between 25 and 45 are usually selected. They must be literate (having been educated to grade 8) but this rule is relaxed if no suitable person with this qualification is available. The process of joining the program is lengthy: Their training is split in to five separate modules and the entire program takes a year to complete.

“[Community health workers] have demonstrated the potential to substantially improve health outcomes in areas of extreme poverty, notably in maternal health,” explains Derek Treatman, a Dimagi field investigator who works closely with community health workers in implementing CommCare. “However, programs are difficult to run effectively because [health workers] have minimal training and operate independently.”

“There is a large barrier that is difficult to overcome when delivering new health services or education to rural populations,” says Treatman. “Although resources may exist nearby for those in need, they may not know it, know how to access those resources, or are prohibited from seeking treatment due to financial limitations. Illiteracy and varying local dialects make it nearly impossible to spread vital information en masse. However, trained community health workers can overcome these barriers because they live with and know personally those who they are trying to help. A community health workers often goes door to door to ensure that everyone in the community knows about and has access to health services and information.”

Health Information at Their Fingertips

In India, much of a community health worker’s focus is maternal health and ensuring safe pregnancies. The health worker can use the CommCare application on a mobile phone to quiz the women she meets on their knowledge and level of preparedness for childbirth and caring for a newborn. CommCare provides health workers with a list of emergency/danger signs to look for and their respective interventions as well as a safe pregnancy checklist, including a list of suggested practices to ensure a safe delivery. Each prompt allows for a "Yes" or "No" response. Once responses to questions have been recorded, CommCare will display a score and play a message, giving immediate feedback to the soon-to-be mother and helping identify weak points for which the health worker can then provide better education. Information stored on a cell phone can be reviewed during subsequent visits to ensure that all of the right information has gotten across.

“They can enter data, manage a list of clients, and send completed forms to a central server where it is monitored by supervisors,” says Dr. John Jackson, Dimagi’s founder and CEO. “Data is saved on the phone if there is no cell signal available in rural areas and can be sent at a later time. Since its initial implementation which included text only, multimedia support has been added allowing CommCare to now present photos, illustrations, and recorded audio clips.”

Portable Health Info: CommCare’s Innovation

CommCare was developed for public health programs in developing countries. The project came about when its creators realized that underdeveloped nations have the fastest rising rate of mobile phone subscription.

“Mobile telephony is a natural choice when it comes to information gathering in the field, but there are many applications that have to be explored,” says Dr. Neal Lesh, Dimagi’s chief strategy officer. “Through interaction with community health workers in underdeveloped rural areas it was easy to see that many programs lack sufficient tools for management and oversight. Also, much work done by community health workers entails educating those around them, which is extremely difficult due to limited training and often a lack of useful or portable educational materials.”

One of CommCare’s chief advantages is how it incorporates the needs of people with limited literacy skills into its design. Audio clips and images to reinforce each prompt, creating a simple interface accessible to low-literate users. Audio and video clips in local dialects can be recorded and made available at the push of a button.

“One of the greatest hurdles faced has become our new focus: localized content that is culturally appropriate and accessible to low-literate users. Faced with so many languages and unwritten dialects in India, CommCare has been developed to be highly customizable and can change languages with the push of one button,” explains Dr. Lesh.

In the years to come, Dimagi engineers intend to further develop the CommCare website which allows program managers to deploy the system for their health workers. The goal will be to create a deployment process that, from start to finish, does not require the onsite support of a Dimagi field engineer, as is currently required. This online management tool will provide a user-friendly way to localize content by translating text, recording new audio clips in local dialects, uploading new images and illustrations, and download the customized application onto health workers’ phones.

“We will be working with multiple groups of CHWs from the Accredited Social Health Activist (ASHA) program in different parts of India, giving us a wide range of linguistic and cultural variables while focusing on content defined by India’s national rural health program,” says Dr. Lesh.

Watch a video demonstrating CommCare here http://commcare.cs.washington.edu/

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Paromita Pain has been employed with The Hindu Newspaper, Chennai, India since January 2003. She can be reached at paromita.pain@gmail.com.
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