Effect of mobile application user interface improvements on minimum expected home visit coverage by community health workers in Mali: a randomised controlled trial

Abstract

Background: Proactive community case management (ProCCM) has shown promise to advance goals of universal health coverage (UHC). ProCCM community health workers (CHWs) face operational challenges when pursuing their goal of visiting every household in their service area at least twice monthly to proactively find sick patients. We developed a software extension (UHC Mode) to an existing CHW mobile application featuring user interface design improvements to support CHWs in planning daily home visits. We evaluated the effect of UHC Mode on minimum expected home visit coverage.

Methods: We conducted a parallel-group, two-arm randomised controlled trial of ProCCM CHWs in two separate regions in Mali. CHWs were randomly assigned to UHC Mode or the standard mobile application (control) with a 1:1 allocation. Randomisation was stratified by health catchment area. CHWs and other programme personnel were not masked to arm allocation. CHWs used their assigned intervention for 4 months. Using a difference-in-differences analysis, we estimated the mean change in minimum expected home visit coverage from preintervention to postintervention between arms.

Results: Enrolment occurred in January 2019. Of 199 eligible CHWs randomised to the intervention or control arm, 196 were enrolled and 195 were included in the analysis. Households whose CHW used UHC Mode had 2.41 times higher odds of minimum expected home visit coverage compared with households whose CHW used the control (95% CI 1.68 to 3.47; p<0.0005). Minimum expected home visit coverage in the UHC Mode arm increased 13.6 percentage points (95% CI 8.1 to 19.0) compared with the control arm.

Conclusion: Our findings suggest UHC Mode is an effective tool that can improve home visit coverage and promote progress towards UHC when implemented in the ProCCM context. User interface design of health information systems that supports health workers' daily practices and meets their requirements can have a positive impact on health worker performance and home visit coverage.

Trial registration number: NCT04106921.

Keywords: health services research; other diagnostic or tool; prevention strategies; public health; randomised control trial.

Conflict of interest statement

Competing interests: AJ, CW, DL, JEY, KK, SIN’D, YD and YK are employed by the non-profit organisation, Muso. The Muso team designed the Proactive Community Case Management approach. FF and IH are employed by the non-profit organisation, Medic. The Medic team serves as lead developer of the Community Health Toolkit open source project. Both Medic and Muso participated in the development of UHC Mode, as described in the manuscript. Both the CHT and UHC Mode are public goods to be made available open-source. All authors have completed the Unified Competing Interest form at http://www.icmje.org/downloads/coi_disclosure.docx (available on request from the corresponding author) and declare no other conflicts of interest.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1

Trial profile. CHWs, community health workers; UHC, universal health coverage.

Figure 2

Display of information on the household list in the standard CHW application (A1–A2) versus UHC Mode (B1–B2) and on individual household profiles in the standard application (A3) versus UHC Mode (B3). A1 shows the household list in the standard CHW application. A2 shows the household list in the standard CHW application, with default alphabetical ordering. B1 shows the household list in UHC Mode, which displays the time elapsed in days since the last home visit (colour coded red if the date of last visit was 30 or more days ago, and black if the date of last visit was fewer than 30 days ago). Red exclamation point icons emphasise households with fewer than two visits in the month, and a modified traffic light colour scheme (red, orange, light blue) show households receiving zero, one, or two or more visits in the month. B2 shows the household list in UHC Mode, with default chronological ordering by date of last home visit. A3 shows an individual household profile in the standard CHW application. B3 shows an individual household profile in UHC Mode, with information about the date of last visit and the monthly home visit count. CHW, community health worker; UHC, universal health coverage.

Figure 3

Monthly and preintervention versus postintervention CHW service area coverage of minimum expected home visits (percentage of households visited at least twice in a month), by arm, with health catchment areas combined (A) and stratified (B–C). Vertical blue dotted lines show the formal start of the postintervention period. Gray-shaded areas show the roll-out of UHC Mode in March 2019. CHWs, community health workers; UHC, universal health coverage.