A human centred approach to digital technologies in health care delivery among mothers, children and adolescents

Background:: Healthcare outcomes in child, adolescent and maternal in Tanzania are poor, and mostly characterised by fragmentary service provision. In order to address this weakness, digital technologies are sought to be integrated in the milieu of health as they present vast opportunities especially in the ability to improve health information management and coordination. Prior to the design and implementation of the Afya-Tek digital intervention, formative research was carried out to ensure that the solution meets the needs of the users. The formative research aimed to examine: the burden of disease and related health seeking behaviour; workflow procedures and challenges experiencing healthcare actors; adolescent health and health seeking behaviour; and lastly examine technological literacy and perceptions on the use of digital technologies in healthcare delivery. This paper therefore, presents findings from the formative research. Methods:: The study employed exploratory design grounded in a qualitative approach. In-depth interview, focus group discussion, participant observation and documentary review methods were used for collecting data at different levels. The analysis was done thematically, whereby meaning was deduced behind the words which the participants used. Results:: Findings suggest that the perceived burden of diseases and health seeking behaviour differ across age and social group. Multiple work-related challenges, such as lack of proper mechanism to track referrals and patient’s information were noted across healthcare actors. There was a keen interest in the use of technologies shown by all study participants to improve care coordination and health outcomes among health system actors. Participants shared their views on how they envision the digital system working. Conclusion:: The formative research provided insightful background information with regard to the study objectives. The findings are used for informing the subsequent phases of the co-development and implementation of the Afya-Tek digital health intervention; with a view to making it relevant to the needs of those who will use it in the future. As such, the findings have to a large extent met the purpose of the current study by envisaging the best ways to design digital intervention tailored to meet the needs of those who will be using it.

We conducted a qualitative exploratory study. We employed qualitative methods of data collection such as in-depth interviews, focus group discussion, participant observation, and documentary review. The study was conducted from November 2019 to February 2020. The design offered an opportunity to gain a deeper understanding of required aspects of the community and health practices and experiences prior to the co-development of the digital health intervention. The study was inspired by the principles of grounded theory [10] as such the study was iterative in nature. Continuous field data analysis and interpretation provided insights used to revise the interview guides on an ongoing basis. The Afya Tek project operates in two administrative district councils of Kibaha District in the Coast Region. Administratively, Kibaha is divided into two councils: Kibaha District Council (DC) and Kibaha Town Council (TC). Kibaha is bordered to the North by the Bagamoyo District, to the South by Kisarawe District, to the East by Dar es Salaam, and to the West by Morogoro Region. It is directly linked with Bagamoyo town by seasonal road, while connected to other district headquarters such as Kisarawe, Mkuranga, Kilindi and Utete (Rufiji). The 2012 census conducted indicated that the total population of Kibaha amounts to 200,000 people. Kibaha is inhabited by people from different ethnic groups and cultural diversities, including religion. The main ethnic groups found in the district include Zaramo, Kwere, Doe, Masai, and Barbaig. Kibaha has a vast area of land that allows people to engage in various economic activities, including agriculture, livestock keeping, beekeeping, trade, processing (timber, flour mills) and small-scale entrepreneurship. This study is part of the larger Afya Tek project which is being implemented in the two councils in Kibaha. The research participants were purposively sampled to ensure that relevant information as per the study objectives is obtained. The sampling strategy based on the principles of gradual selection, as well as maximal variation to capture prospective differences in responses between the participant groups [11]. Our sampling based on saturation principles, that is, we continued sampling new participants until no new information emerged from the responses [12]. The recruitment of participants was conducted through the existing community-based networks in Kibaha TC and DC. Responsible district councils’ authorities in Kibaha TC and Kibaha DC were aware of the study, and supported us by ensuring a successful data collection exercise. Data were collected at different levels of potential users of the Afya-Tek intervention, beneficiaries and other relevant stakeholders in the two Councils (Table 1). Participants in the study In this section we are describing the demographic information of the participants. Religion wise, most of the participants were Muslims. It should be noted that Kibaha is one of the coastal towns where Islamic religion is dominant. Regarding the level of education, there were variations between the groups; most of CHWs, both adult males and females, aged 27–50 years, had completed secondary education. In terms of occupation, apart from their formal CHW work, most CHWs were also farmers and entrepreneurs. Healthcare providers comprised registered nurses, assistant medical officers, medical doctors, CHW supervisors, reproductive and child health staff, clinical officers, data managers, and CHMT members. Health providers’ age range was 35–48 years. Majority of the ADDO dispensers were women, and also worked as nurses in health facilities, farmers and entrepreneurs. Most of out of school adolescent girls, aged 15–19 years, had children. They are engaging in small-scale entrepreneurship jobs like selling buns, fish and other food stuffs. Majority of them had completed primary education while others had dropped out of secondary school because of pregnancy. Adolescent boys, aged 15–19 years, who were part of the study were either in secondary school or out of school. 14 experienced research assistants were recruited and trained by the research team, using the developed preliminary Swahili interview guides. The data were collected in Swahili language by a team of trained researchers and research assistants. We collected primary data through qualitative (in-depth) interviewing method, focus group discussions, and participant observations. The rationale for using these methods was based on the reality that understanding background information in relation to the study objectives prior to project design and implementation required in-depth exploration of first-hand accounts and behavior of the participants. One to one form of interviews was carried out among three groups of participants (ADDO dispensers, health facility staff, and district officials) at their workplaces. Community Health Workers were interviewed at their convenient locations within the community, which included health facilities and village offices. The interview process was flexible enough to allow ADDO clients/fellow staff to access services in-between. Healthcare providers at health facilities were interviewed at their respective facilities when they had free time. Patients and community members were interviewed at their homes or in other private locations as per their preference. At the national level, in-depth interviews were conducted with the Pharmacy Council Registrar and officials from PO-RALG. The length of each in-depth interview would take between 45 and 60 min. Focus group discussions were held with maternal, pregnant women, adolescents, CHWs and CHMTs at different places including village/ward offices, health facilities, and schools. Focus group discussions followed key interviews (in-depth interviews) after identifying knowledgeable individuals to hold group discussions. Focus group discussions were employed to gain social groups general consensus and mapping predominant social ideals on issues under study. The length of each FGD would take between 60 and 90 min depending on the activeness of the participants and emerging issues under discussion. All the in-depth interviews and focus group discussions were recorded with audio recording devices but at the same time, research assistants also took notes of the key issues raised during the sessions. A total of 30 participant observations were conducted in the CHW, ADDO, and health facility settings; For easy management of observations and cases, 5 observations per group of stakeholders (CHWs, ADDOs and health facilities) were carried out from each of the two councils. This involved taking part in daily routine of healthcare seekers and deliverers to further explore health seeking and delivery behaviours among patients and caregivers. It also involved extensive engagement in community health activities to further explore patient interaction, use of referral forms and patient registers at both CHW and ADDO levels. At the health facility, the system of receiving patients was observed, along with patient files and registers, which are all currently paper based. The interview data generated from IDIs and FGDs were in the form of personal handwritten notes based on researcher memos, and the digital audio-recordings. The observational data was recorded through diary and fieldnotes. The primary data were then converted into written electronic form and transferred into computer databases. All digital recordings of IDIs and FGDs were transcribed verbatim in Swahili, and where needed translated into English. Overall data processing and organization was managed using the NVivo QSR (Version 12+). This computer assisted qualitative data analysis software helped sort and organize the bulk of raw data generated. Thereafter, data was transformed into meaningful findings. This required engaging thematic analytic procedure to analyse the data in line with research questions. The data was deduced behind the words which the participants used. Code frames were developed to generate themes. Coding was done by four different research assistants before final agreement on the final codes to ensure consistency and agreement. This list of thematic codes was reviewed and grouped into categories and themes for analysis by the team of four researchers. Analysis was undertaken using a framework of grouping relevant themes that answer key issues as per the study objectives. This was then used to facilitate the analysis of thematic concerns and trends arising from the narratives. Ethical clearance was sought and obtained from the National Institute for Medical Research of Tanzania (NIMR) and the IRB of Institute of Tropical Medicine, Antwerp. An information sheet about the study was written in Swahili, explaining why it is being carried out, by who, what it will involve, as well as the rights of the participants. During recruitment and prior to participation, informed consent was sought from all participants by a written form. For adolescents who were under the age of 18 years, consent was sought from their parents or guardians, while for those adolescents and remaining participants aged 18 years and above, the consent was given by themselves. Among the key concerns taken into consideration was to safeguard the dignity, rights as well as safety of the participants. Confidentiality of all study participants was assured through practices of pseudonymisation. For the purpose of ensuring confidentiality, all data presentation has used pseudo names.

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