CHN on the Go Process Documentation: Round 2 Research Findings

www.innovationsformnch.org
CHN on the Go
Process Documentation
Round 2 Research Findings
Soumya Alva, Sophia Magalona & Amanda Makulec
JSI Research & Training Institute, Inc.

Presentation Outline
 CHN on the Go Theory of Change
 Objectives
 Key Questions
 Methodology
 Summary of Round 1 Findings
 Project Timeline
 Pathways
 Round 2 Findings
 Summary, Overall Impression and Next
Steps

CHN on the Go
Theory
of Change
Learning
opportuniti
es, job aids
& Point of
care tools
Work
planning
ability &
Target
achievemen
t
Ability to
communica
te
Supervisor’
s ability to
track
progress
Staying well
Increased
health
knowledge
Better
work
planning
and
scheduling
Better
communica
tion with
peers
Extrinsic
motivation/
job satisfaction
(job security,
salary, work
environment,
work load)
Module
usage
frequency
INPUTS OUTPUTS
INTERMEDI
ATE
OUTCOMES
DIRECT
OUTCOME
ASSUMPTION: Health workers feel unmotivated and frustrated in their jobs
SYSTEM
BARRIERS
we cannot
address:
• Infrastruct
ure and
resource
limitations
• Nurse
salaries
• Formal
recognition
structures
for GHS
• Formal
promotion
structures
for GHS
Poor
manageme
nt
Resource
Constraints
Isolation
Stress/
Frustration
BARRIERS
Disrespect
by clients
and other
HWs
Limited
advanceme
nt
opportuniti
es
Intrinsic
motivation
(confidence,
connectedness
recognition by
community/
peers,
autonomy)
Supervisor’s
ability to
communica
te with
CHNs
Recognition by
supervisors
Better
supervision
and
management
systems
INDIRECT OUTCOME
Poor
manageme
nt and
supervision
Better
tracking
system for
supervisors
Better
communica
tion with
supervisors
Supervision
dashboard
usage
frequency
Limited
advanceme
nt
opportuniti
es
Availability
of learning
courses and
opportunitie
s
Number of
courses/opp
ortunities
GHS
recognizes
Recognition of
educational
credentials
System-levelchanges
Better
CHN
performanc
e/Nurses
meet their
targets
Improved
maternal,
newborn,
and child
health
outcomes
Better
quality of
care
LINEOFACCOUNTABILITY
Better
work life
balance

SYSTEMS LEVEL

1. Assess fidelity of CHN on the Go activities
to the original design of the project
2. Examine the proposed change pathways
in the theory of change
3. Examine the role of the context -
including the health system - on the
effect of the CHN on the Go pilot
PD Objectives

Key
Questions  Implemented as planned
 Barriers and supportive factors
 Factors and processes driving changes
 Extent of CHN exposure to the modules
 Overall satisfaction
 Perceived link between exposure to the
modules and changes in CHN behavior
 Systemic changes in learning and
supervisory systems

BASELINE
May – Aug 2014
PROJECT START
MAY-June 2014
PD Round 1
Nov - Dec 2014
PD Round 2
July - Aug 2015
Feedback session
April 2015
PROJECT END
MAY 2016
Other data collection activities:
• Monthly field interviews
• Monthly usage monitoring
dashboard
Magpi survey
Dec 2015 – Jan 2016
Magpi survey
April – May 2015
Pop-up questions
June 2015
Pop-up questions
Jan 2016
Feedback
session
PD Round 3
ENDLINE
Feb 2016
Methodology

• In-depth interviews by JSI and ILC staff (July-August 2015)
Interview type No. District
CHN interview 16 All 5 districts (Ningo Prampram,Ada East,
AdaWest, South Dayi, SouthTongu)
Supervisor interview 8 All 5 districts
Client interview 8 Ningo Prampram and South Tongu only
CHN observation 6 Ningo Prampram, South Dayi, and South
Tongu
Primary Data Collection
Other discussions:
• Regional Director (Volta), District Directors (Ningo Prampram,
South Dayi, SouthTongu)
• Nursing and Midwifery Council, GHS (HR Department), GHS PPME
• Ongoing discussions with Grameen Foundation and Concern
Worldwide Ghana staff

Summary
of Round 1
Research
Findings
Learning Center,
Planner, and Point of
Care
CHN on the Go
• Plan and share itinerary
• Communication
• Health knowledge
Discussion related to motivation did not emerge. This
will be explored more in Rounds 2 and 3.

Project Timeline: May 2014-July 2015
MAY JUNE JULY AUGUST SEPT OCT NOV DEC JAN FEB MARCH APRIL MAY JUNE JULY
2014 2015
May - July
2014
Version 1
Training
Late July
2014
Version1
actual
launch
1st week of Aug
2014
Trainings
extended
November
2014
Version 2
Training
November
2014
Version 2
actual
launch
ONGOING DISCUSSIONS WITH GHS, REGIONAL/
DISTRICT DIRECTORS, OTHER STAKEHOLDERS
Jan – Feb 2015
Training for
Volta Regional
Directorate.
NMC
collaborating
partner.
April 2015
Refresher
training.
Version 3
deployed.
Supervisor app
updated.
Feb-March 2015
Training for Volta/
Greater Accra RHMT.
Family Health Division
home unit of CHN
on the Go within GHS.
June 2015
Accreditati
on letter
from NMC
and
MOU
finalized
March – May 2015
National level
training (GHS-FHU,
HR, PPME,MOH-
HR)

Pathways
Communication & Connectedness
Achievement Center
Planner
Learning Center
Point of Care
StayingWell
WhatsApp
Health Knowledge
Work Scheduling
Targets
Relationships
KeepingWell
Confidence
Recognition
Emotional support
Professional
relationships
Time management
MODULES MOTIVATION
Supervisor App Monitoring and Supervision

ROUND 2 RESEARCH FINDINGS
• Overall usage of the CHN on the Go app
• Health knowledge Confidence in providing services
• Work scheduling & time management Burden
• Achievements Recognition & respect
• Communication & connectedness Relationships
• Keeping well Emotional support
• Supervisor App Performance monitoring
• Barriers to use

CHN on the Go
users
TOTAL
55
215

Actual usage
0%
20%
40%
60%
80%
100%
%CHNs
This week
Last week
2 weeks ago
Longer than
2 weeks ago
At CCH
Training
Self-reported usage
(frequency/week)

• Health knowledge Confidence in providing
services
• Communication & connectedness Relationships
• Barriers to use

Health
knowledge
add a pic
Relevant Modules:
Learning Center and
Point of Care
Intended to provide
learning opportunities
and access to necessary
health information

Point of care actual usageSelf-reported last
time used

Favorite section of Point of Care (self-reported)
0%
20%
40%
60%
ANC PNC for mother PNC for baby

Client Perspectives
CHNs are more confident and clients are happier and trust
the information they receive
“[She] is educating you, you will know that that is the right thing
for you to do because she does it with evidence...she made me
know that it’s good for me to do what she is saying rather than
she saying it without any proof.” - Client, South Tongu
“The [visit when] she used the phone was better because
you get to understand more… Her knowledge was
better [when she had the phone] because she knew
what she was doing.” –Client, Ningo Prampram
CHNs used the PoC module to counsel clients on nutrition and
pregnancy (danger signs for example)

Learning Center actual
usageLast time read material
from reference section
(self-reported)

 95% installed all five FP courses
 78% installed all 7 MNCH courses
 In 8 of the 14 available courses, the average final exam
score earns a pass
 The most popular course is FP 101, but the course
with the most completions is Diarrheal Disease
Learning Center

Health Knowledge:
Reasons for use
Point of reference
Read and refresh
Give right information
“For me, it has
improved my
knowledge on the
courses. How to take
care of the client, how
to counsel the client,
that is for my personal
use too.” – CHN,Ada
East/West

Health Knowledge:
Potential
POC – Standardized protocols
deployed to all health workers
More materials and topics in
Learning Center
Accreditation  Pin renewal
Distance learning from training
institutions

Confidence
in
Providing
Services
“[With] the Point of Care, at least it helps you to
render the best of care. I am not a midwife but
I know how to render pregnancy care to my clients
because of the app.” – CHN,Ada East/West
“It has influenced their work because they can
easily refer to the phone and that has boost
their clinical knowledge and gives them
confidence.” –Supervisor,Ada East/West

Work
Scheduling
and Time
Management
Relevant Module:
Planner
Intended to help CHNs
plan their activities
through documentation,
planning, and review of
work schedule, as well
as coordinating with
peers and share with
supervisors

Planner actual usage
Last time used the Planner
(self-reported)

Work scheduling &
Time Management:
Reasons for use
Planning
Reminding
Keeping track
“And the Planner too
reminds you. It serves
as an alarm for you to
begin your work.” –
CHN, Ningo Prampram

Burden
“There has been
no increase in
my workload.” –
CHN,Ada
East/West
“When I set the targets, it
reminds me.You will select for it
to remind me daily, monthly or
weekly”
– CHN,Ada East/West

Target
setting
Relevant Modules:
Planner and
Achievement Center
A reporting tool
Intended to view
progress on courses and
targets
Draws from Planner and
Learning Center

Planner:Target Setting actual
usage
Last time set targets
(self-reported)
Note: Frequency of target
setting up to the CHN

Targets:
Reasons for use
Set targets and goals
View progress
Self-evaluate
Supervisors use information to
keep track of CHNs and
advise them
“So, when you
update it, it tells you
that you have
achieved this target.
It tells us what we
have achieved and
what we have not
achieved.” – CHN,
Ada East/West
“The setting targets it also helps the nurse to know this
is where I am heading to and will I be able to achieve it
by this date. So you push the nurse and remind them
that you are not performing and you should do this, do
this.” –Supervisor, South Tongu

Targets:
Potential
To be used as
supervisory tool across
all cadres of health
workers and as
supervisory tool for
performance monitoring
“[M]ost times her
events do not show. So
when I call or
WhtasApp her and she
set her targets, she
call[s] me on phone to
recheck again whether
it has come. Pertaining
to just the last two
weeks, I WhatsApp
most of the nurses
because most of their
events are not
showing...” –Supervisor,
SouthTongu

Recognition
& Respect
“Yes it has given us much respect
because it creates communication and
assurance between us and the clients.”
– CHN,Ada East/West
“If they are doing well I praise
them, and if they are not
doing well, I see that you are
not even reading these things
at all, you will have to share it
with them.” –Supervisor, Ningo
Prampram
A result of
overall CHN
performance

• Health knowledge Confidence in providing services
• Communication & connectedness
Relationships
• Barriers to use

Communication
&
Connectedness
Relevant Modules:
WhatsApp
Designed to facilitate
communication and
coordination between
nurses, supervisors, and
clients
91% use WhatsApp
to contact fellow CHNs
53% contact family and friends
In the past
communication was
only to the head of
the institutions who
attended meetings.
Now there is
much better
communication
directly with
CHNs.

Communication &
Connectedness:
Reasons for use
Facilitate communication
Stay connected
Display photos
Facilitate counseling
Group diagnosis
“The app has changed
the frequency of
communication. Like
with WhatsApp, when
we want to channel any
information to the
CHNs in this sub-
district, you just use the
WhatsApp. Or even if
you don’t want to
call, you just use the
app.” -CHN,Ada
East/West

Builds Relationships:
Transparency
Communication
Release stress
“It’s good because it
brings about
teamwork; you know
that whatever you are
doing your supervisors
are aware.” -Supervisor,
Ada East/West Enhances the
role of all other
modules

Communication &
Connectedness:
Potential
Disease surveillance
Improved coordination at all
levels
Disseminate information from
higher level
“It has helped my
professional life
because I do not need
to travel all the way to
my sub-district building
to discuss about
meetings or what we
need to do.” –CHN,
Ada East/West

Emotional
and Social
Support
Relevant Module:
Staying Well and
Whatsapp
Intended to enable
nurses to take charge of
inspiring themselves and
help deal with stresses
of work life
Build a sense of
community

Staying Well actual usage
Last time viewed (self-reported)
0%
20%
40%
60%
80%
100%
No Yawa My Wellness Devotional
%CHNs
this week
last week
2 weeks ago
more than 2
weeks ago
never

Keeping well:
Reasons for use
Release stress
Keep healthy relations
Relate to people
“Even if you are bored at
the house and you read
yourWhatsApp, there
may be a post that
says have a lovely day
and at least it brings
you up a little.” –CHN,
Ada East/West
“They’ve been giving me some kind of exercises to be
doing every morning about my life, how to improve
upon my well-being.They’ve been giving me some
topics to be reading to go according to it every
morning before I come to work. Every morning I open
it and what I see I go according to it.” –CHN, South
Tongu

Supervisor
App
Intended to enable
supervisors to access
progress and activities of
CHNs and guide
feedback and
supervision

Supervisor app actual usage
Last time accessed (self-
reported)
0%
20%
40%
60%
80%
100%
%CHNs
This week
Last week
2 weeks ago
Longer than 2 weeks
ago
At CCH Training
Never
80% reported that app
displays all nurses’ targets

Supervisor App:
Reasons for use
Initiate follow up
communication
enhance supervisory role
track and view progress
“Maybe in a week, once. [I use the Supervisor’s
App] at least 45 minutes because I have to
refresh before some of the new activity nurses
are doing comes and then you see whatever
you are looking for.” – Supervisor, South Tongu
Limited use
because not
all supervisors
are tech savvy

Supervisor App:
Potential
Effective tool for performance
monitoring
Use by Supervisors at all levels
of the district health system

 Phone freezing and app crashing, but
new versions are improved
 Small screen, difficult to see
 Battery runs out quickly
 Not enough credit
Barriers to
Use

Summary
Learning Center,
Planner, and Point
of Care
StayingWell
Achievement
Center
0%
20%
40%
60%
80%
Most useful modules for
CHNs

 Almost all
wanted to
continue to use
the app in future
 Improved
personal lives
very much: 79 %
 Improved work
lives very much:
88 %
Overall
Impression
of the App “It is very beneficial because it makes the work
easy.And I also feel connected to friends, family,
and colleagues.” – CHN, South Dayi
“The phone has helped me in general with my
work…previously we were finding it difficult to
send information to our in charges and our
friends. But now with the phone, we are able to
WhatsApp it.And with the Planner, it helps to
remind us of what we have to do that day.” –CHN,
Ningo Prampram

“This intervention was sent at the right place, at the
right time for the right people….
Because of this phone, our district has become
smaller …..
Because of the phone we are able to send information
quickly…
We are able to see conditions on the field, take
photographs and send it.”
– District Director, Ningo Prampram

Next Steps: July 2015-May 2016
JULY AUGUST SEPT OCT NOV DEC JAN FEB MARCH APRIL MAY
2015 2016
November 2015
Version 4 launch
Refresher
training for
supervisor app
and target
setting
ONGOING DISCUSSIONS WITH GHS, REGIONAL/DISTRICT DIRECTORS, OTHER STAKEHOLDERS
March – May
2016
Transition to
district,
regional, and
national levels
March 2016
Final
refresher
training led
by district

Thank You!

CHN on the Go Process Documentation: Round 2 Research Findings

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CHN on the Go Process Documentation: Round 2 Research Findings