'It makes you someone who changes with the times': health worker and client perspectives on a smartphone-based counselling application deployed in rural Tanzania.

Mobile health (mHealth) applications have been developed for community health workers (CHW) to help simplify tasks, enhance service delivery and promote healthy behaviours. These strategies hold promise, particularly for support of pregnancy and childbirth in low-income countries (LIC), but their design and implementation must incorporate CHW clients' perspectives to be effective and sustainable. Few studies examine how mHealth influences client and supervisor perceptions of CHW performance and quality of care in LIC. This study was embedded within a larger cluster-randomized, community intervention trial in Singida, Tanzania. CHW in intervention areas were trained to use a smartphone application designed to improve data management, patient tracking and delivery of health messages during prenatal counselling visits with women clients. Qualitative data collected through focus groups and in-depth interviews illustrated mostly positive perceptions of smartphone-assisted counselling among clients and supervisors including: increased quality of care; and improved communication, efficiency and data management. Clients also associated smartphone-assisted counselling with overall health system improvements even though the functions of the smartphones were not well understood. Smartphones were thought to signify modern, up-to-date biomedical information deemed highly desirable during pregnancy and childbirth in this context. In this rural Tanzanian setting, mHealth tools positively influenced community perceptions of health system services and client expectations of health workers; policymakers and implementers must ensure these expectations are met. Such interventions must be deeply embedded into health systems to have long-term impacts on maternal and newborn health outcomes.

Impact of smartphone-assisted prenatal home visits on women's use of facility delivery: Results from a cluster-randomized trial in rural Tanzania.

BACKGROUND: About half of births in rural Tanzania are assisted by skilled providers. Point-of-care mobile phone applications hold promise in boosting job support for community health workers aiming to ensure safe motherhood through increased facility delivery awareness, access and uptake. We conducted a controlled comparison to evaluate a smartphone-based application designed to assist community health workers with data collection, education delivery, gestational danger sign identification, and referrals. METHODS: Community health workers in 32 randomly selected villages were cluster-randomized to training on either smartphone (intervention) or paper-based (control) protocols for use during household visits with pregnant women. The primary outcome measure was postnatal report of delivery location by 572 women randomly selected to participate in a survey conducted by home visit. A mixed-effects model was used to account for clustering of subjects and other measured factors influencing facility delivery. FINDINGS: The smartphone intervention was associated with significantly higher facility delivery: 74% of mothers in intervention areas delivered at or in transit to a health facility, versus 63% in control areas. The odds of facility delivery among women counseled by smartphone-assisted health workers were double the odds among women living in control villages (OR, 1.96; CI, 1.21-3.19; adjusted analyses). Women in intervention areas were more likely to receive two or more visits from a community health worker during pregnancy than women in the control group (72% vs. 60%; chi-square = 6.9; p < 0.01). Previous facility delivery, uptake of antenatal care, and distance to the nearest facility were also strong independent predictors of facility delivery. INTERPRETATION: Community health worker use of smartphones increased facility delivery, likely through increased frequency of prenatal home visits. Smartphone-based job aids may enhance community health worker support and effectiveness as one component of intervention packages targeting safe motherhood. TRIAL REGISTRATION: NCT03161184.