Background
Methods
Setting and participants
Age, mean (years): | 41 |
Female (%): | 91 |
Mean time as CHW (years): | 6 |
Mean time using Geohealth (years): | 2 |
Data analysis
Results
CHW experiences with the Geohealth mobile application and computer program
Many ways of using Geohealth | I’ve been using Geohealth for 3 years. I use it on home visits to register families, to look up things about my area like how many kids I have in my area. I write the summaries in the homes by hand, and then I transfer it to the Geohealth system using a cell phone or computer. Usually computer because my Geohealth phone broke. I don’t use [Geohealth] in home visits. For example, let’s say today I did 10 visits. Tomorrow I do 10 more. At the end of tomorrow, I’ll sit down and put all 20 visits into the computer. I don’t like typing on the phone. It is better at a computer. Sometimes I’m in the middle of a visit, and then another community member comes along and I have to answer a quick question for them—but there is no way to do these two visits simultaneously on Geohealth. Sometimes it takes 15 min just to turn on, or to find a SUS [identification] number in the system—that’s the time my entire visit should take. I use the computer 90% of the time for Geohealth. |
Organization | I use Geohealth to register families, and to update information about families. If there is a new baby or new family member, or death. Families are always changing… Each month a new family arrives or leaves. |
Accountability | I still use paper to collect signatures at every house I visit to prove that I went to the house. You have situations where a community member goes straight to the health center asking for an appointment and says that a CHW never visited. I can show them that they signed on such and such day proving that I did go there. This helps avoid a lot of confusion. It is a strategy community members have: to say we didn’t go to their house to try to get seen sooner. We need to account for every house we visit. |
Many ways of using Geohealth
Organization
Accountability
Main benefits of the Geohealth mobile application
Saves time spent on bureaucratic paper work | Geohealth makes things faster, you can quickly make lists, filter community members, find all of your hypertensives, and find particular families. So I think Geohealth makes things faster, but the information is safer on paper. It is faster with Geohealth at the end of the month because we have one day of accounting, so to speak. We used to have to count manually—hypertensive by hypertensive— going through all the forms. Before we had to look through each folder and manually count, manually look for each kid under age 2. Geohealth is way better. |
Faster access to information | Geohealth makes the quality of our work better. It helps me make lists of community members in my area. I can choose, for example, to see only the pregnant women in my area, or only the 2 year olds, and then I have a complete list right away Another example, let’s say a community member has a question about an appointment from a few months ago, like when it was. I can just pull it up right away! Before Geohealth, I’d have to go back to the health center and look through piles of paper to find that information. But it is all stored in Geohealth. Or another example, if a community member has a doubt about what medication she was prescribed. I can pull it up on Geohealth in her house during the visit. I don’t have to come back later. “It [Geohealth] is really important. It is fundamental. I write down all sorts of information during visits like diabetic’s insulin levels and blood pressure. I write it in the observation field. Then at their next visit I look up their values from last time to see how they’re doing. This is different from the paper system, because paper is saved in the health center. And then I wouldn’t have access.” |
Weight | I like it because it means less paper for me. In our work we walk a lot, and our backpacks are heavy, and we end up taking off our backpacks in community members’ homes and forgetting them there. Biggest difference between Geohealth and paper? My bag is lighter with Geohealth! I don’t have to carry as much paper. I typed the family number and it had all the information about that family. It was the size of my hand versus [carrying] a mountain of paper. Better to have the device. If Geohealth had all the forms it would eliminate a ton of paper and work for us. |
Saves time spent on paperwork
Faster access to information
Weight
Main barriers to effective use of the mobile application
Technical barrier: inefficiency | The negative side is that Geohealth would crash or freeze in the middle of a visit. It would stop all of a sudden and oh, how it would make you angry. You can get an interview done in less time than it takes to open the application. [The mobile application] wasn’t a good interface. You had to jump from screen to screen in a random order to get what you wanted. You could organize the pages so it is more efficient. You had to jump between all these different screens. It would be better to have it all on just one screen. Sometimes there is duplicated data [with the mobile application]. So I always write down my numbers and can check them against Geohealth. If one day Geohealth says I have 202 families, but I have written down that I have 198, and I haven’t registered any new families, I know there is a problem in Geohealth. Geohealth doesn’t always remember the changes we make. For example, when a community member dies, we delete the record from Geohealth. But then later it keeps popping up again, and we know that person is dead. We take community members out of the system and then they reappear. Paper doesn’t delete the information. The only annoying thing is when I type a huge amount about the visit, then look up from the phone to the community member, and accidentally hit the home button. The phone leaves Geohealth and I lose everything I wrote. I accidentally delete it all. |
Technical barrier: signal strength | It’s just the device that doesn’t work. We always have to wait for the signal and for it to start working. The signal. The signal could be better. Sometimes it gets stuck searching for a signal and you have to force quit. Then you have to re-type everything. That’s annoying. |
Technical barrier: the device | I used it [Geohealth] for just over a year, but then the device broke on me. I sent it in to be fixed. After 6 months, it came back, but it was still broken in the same way. Now I don’t have one [a smartphone]. The biggest problem is the reception. After that, the battery. After charging it in the morning, the battery is dead by the afternoon. The device is terrible but the computer system helps us a lot. I use it a lot on the computer. I didn’t like the Geohealth phone. The computer was much better. I couldn’t pay attention to the community members when I was using the phone. Cell phones are distracting. Their keys are too small. I update Geohealth information on my computer at home. |
Social barrier: community member perceptions | The community members, especially the older ones, complain. They say, look at me! I’m telling you a story, pay attention! Eye contact is so important. Sometimes a community member doesn’t say he’s in pain, but you see it in their face. Keeping an elderly person company has no need for Geohealth. The idea of having Geohealth is to make your life easier, but that doesn’t mean it makes the lives of the community members easier. I use Geohealth on the computer. Like I said, I don’t use the Geohealth cell phone. It sits in the closet. I never use it. It isn’t good for community members. You have to listen to them, and you can’t listen if you are sitting there trying to type. Community members lose their connection with you when you’re on the cellphone. You can’t show them that you’re not texting and that you’re completing the work if they’re illiterate. |
Social barrier: safety | I work in a risky area. There is a lot of drug trafficking. If the police pass by, and they see my typing on the Geohealth, they think I’m alerting drug traffickers that they are here. Or if a drug trafficker sees you typing they think you are alerting the police. But I also have to be more discrete with Geohealth. There is some danger of robberies. We are a little hesitant to use it on the street. We have to be. Even though it is an old phone, someone might think it is nice. Anything we use has to be discrete so it doesn’t catch the attention of thieves. What I do to prevent it from being stolen is I show the drug dealers the phone. I know them because they are the same kids from the preschool where I worked previously. I show them the phone and say ‘you could steal it if you wanted to. You’d be able to unlock all the functions that are blocked. But I’ll have to report it because it isn’t mine. It is public property, so I’ll have to report it to the police. I have no choice. And if I lose it, I have to pay for it out of my own salary.’ |
Technical barrier: inefficiency
Technical barrier: signal
Technical barrier: the device
Social barrier: community member perceptions
Social barrier: safety
Recommended improvements to Geohealth
Include more data | Include ALL of our paperwork. Have you seen our paperwork? [she goes into another room and brings back a stack of different papers that CHWs use for their work and for their monthly tallies of data at the end of each month. She shows me each form and how tedious it is to do the counts.] All of this could be done automatically on Geohealth. And then at the end of the month, we’d just print it and be all set. The end of the month days when we have to do these counts. It’s very tense. It is a lot of work: everybody is stressed out. Sometimes I wake up at 3 am to finish. And when you’re new, it is even worse. Oh, it’s a real headache. The point of technology should be to get rid of all these papers and little papers. They should integrate ALL of our forms, not just form A and the home visits. |
Communication | It would be wonderful if we could send and receive messages because right now we use WhatsApp. We could contact the family directly if we needed some kind of information. If community members could send text messages with questions for the CHW’s from their personal phone to the CHW’s Geohealth app, that would be incredibly helpful. It [the mobile application] couple be improved if it allowed more communication between the team. I have no way of communicating with my team except for my personal cell phone. I don’t give my WhatsApp number to my community members because I need a barrier between personal and work life—it doesn’t work out to mix them. I have to cut it off somewhere. It would be nice if we could send texts with the Geohealth phone. We could alert community members if their exam results arrived, or if they have an appointment coming up. Something like WhatsApp to communicate with community members. My Geohealth phone sits in the closet. But if I were able to use it to send messages to community members, then I would use it. |
Logistic improvements | Also, there is no way to get a signature on the cell phone. I have all my community members sign on paper when I visit their house so that I have a way of keeping track, or proving that I visited them, so they can’t say I didn’t go later. I ask for a signature at every visit. Why don’t they add a function for a digital signature? Like a fingerprint? They could just put their thumbprint into the cell phone to sign. That also helps the illiterate community members too. It would also be nice if it had little alerts or reminders for individual community members who needed exams. Like if I went to someone’s house, when I opened the visit form it would remind me that this person needs a mammogram, and I could talk about that at the visit. I don’t always remember everything every person needs. This would make it more effective. She said that the information collected could be used to educate community members. It could be used to show them “research” about their health. She gave the example of community members who buy medication on the street and ask her about it. Again, she would like to be able to give them information that she doesn’t know during the visit rather than waiting a month to get back to them. She would also like to record her visits. She also thought that Geohealth could be used to connect community members to health resources. For example, it could have our work cards—instead of writing down when we come and leave work each day, it could be recorded in Geohealth. It could have our teams, calendars, and keep track of all the work I do. I know what I do each day so I’m not keeping track for myself. It would be nice if there was a built-in tracker of how many visits we had done each month to keep track of our monthly goals. Everything could be compact in this one device. It is necessary for us to have more information about health. Most of what I learn about health is from the news—TV journals. Sometimes our community members see health programs on TV and it is something we don’t know. We say, oh, really? I would want that information in my smart phone. |
Individually suggested innovations | There are Facebook groups for lots of things. I had a cousin who had her gallbladder removed and needed advice. She found a Facebook group for other patients recovering from the same surgery. That would be good. We have a garden here that we use to teach community members and CHAs about herbs and teas for different conditions- like hypertension. You could have different groups with the garden. There are many people who like gardening, especially old people, who don’t have good places at their house. Some people don’t like gardening they just like drinking tea. You could have different groups for those who like gardening and those who like drinking tea. I think you would get more people involved that way, off their couch and away from the tv. We have a problem here. Old people think that when you retire you stop being active. It’s hard to change their thinking. It would be good to provide activities for them and I think more would come if you could remind them. Geohealth could be programmed to help us understand the demands of the health center. How many visits, how many medications…it would make predictions based on the data. We could type in how much insulin patients are using, and if they are getting it but not using it at home. We could also use it to motivate community members by showing them how they are improving. For example, if a community member was taking good care of a wound but didn’t think it was healing, we could show them a photo from last week and say “look here! It is better.” It is a way of incentivizing community members to take care of their wound because we are documenting it. I’d use a camera to take photos—to motivate community members. For example, we have groups of hypertensives, diabetics, and we do activities with them. We have workshops and things. It is important to take pictures of these events. To document our work, and it is a way of motivating them to come. People love photos, the community members love photos. We observe the entire house. We’d like to take a photo, sometimes we use our own phone to take photos. I take pictures of trash pile. Sometimes I put pictures of trash on social networks to show the government how things are here. I take pictures of things that call my attention. |
Improved device | How can the system be improved? A tablet with a stylus would be great, because they we could write with the stylus... it is more natural than typing. I think the community members would be more comfortable with that too because it doesn’t look like we are typing on WhatsApp. It is also faster than typing. Tablets would be better perceived by community members because the community member could see what I am doing on the screen and the keyboard would be bigger. I would only change the device - it deletes the visit. Also, having more computers to enter the visits who help. We have to make a summary for the nurse and this is a lot of work. It takes a lot of time to enter all of the visits in the computer. |