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Mobile Instant Messaging for rural community health workers. A case from Malawi

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Background: Mobile instant messaging (MIM) tools, such as WhatsApp, have transformed global communication practice. In the field of global health, MIM is an increasingly used, but little understood, phenomenon. Objectives: It remains unclear how MIM can be used by rural community health workers (CHWs) and their facilitators, and what are the associated benefits and constraints. To address this gap, WhatsApp groups were implemented and researched in a rural setting in Malawi. Methods: The multi-site case study research triangulated interviews and focus groups of CHWs and facilitators with the thematic qualitative analysis of the actual conversations on WhatsApp. A survey with open questions and the quantitative analysis of WhatsApp conversations were used as supplementary triangulation sources. Results: The use of MIM was differentiated according to instrumental (e.g. mobilising health resources) and participatory purposes (e.g. the enactment of emphatic ties). The identified benefits were centred on the enhanced ease and quality of communication of a geographically distributed health workforce, and the heightened connectedness of a professionally isolated health workforce. Alongside minor technical and connectivity issues, the main challenge for the CHWs was to negotiate divergent expectations regarding the social versus the instrumental use of the space. Conclusions: Despite some challenges and constraints, the implementation of WhatsApp was received positively by the CHWs and it was found to be a useful tool to support distributed rural health work.
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This is the author version of an article published in Global Health Action, which
can be retrieved as an open access article:
http://www.tandfonline.com/doi/full/10.1080/16549716.2017.1368236
Mobile Instant Messaging for rural community
health workers. A case from Malawi
Christoph Pimmer;a* Susan Mhangob, Alfred Mzumarab, Francis Mbvundulab
aInstitute for Information Systems, University of Applied Sciences and Arts Northwestern
Switzerland, Peter Merian-Strasse 86, 4002 Basel - Switzerland, phone: T +41 61 279 18 49
fax: +41 61 279 17 98, www.fhnw.ch
bMillennium Promise, Malawi, Zomba, http://millenniumvillages.org/millenniumpromise/
E-mail address corresponding author: christoph.pimmer@fhnw.ch
Mobile Instant Messaging for rural community health workers. A case
from Malawi
Background: Mobile instant messaging (MIM) tools, such as WhatsApp, have
transformed global communication practice. In the field of global health, MIM is an
increasingly used, but little understood, phenomenon.
Objectives: It remains widely unclear how MIM can be used by rural community health
workers and their facilitators, and what are associated benefits and constraints. To
address this gap, WhatsApp groups were implemented and researched in a rural setting
in Malawi.
Methods: The multi-site case study research triangulated interviews and focus groups
of CHWs and facilitators with the thematic qualitative analysis of the actual
conversations on WhatsApp. A survey with open questions and the quantitative analysis
of WhatsApp conversations were used as supplementary triangulation sources.
Results: The use of MIM was differentiated according to instrumental (e.g. mobilising
health resources) and participatory purposes (e.g., the enactment of emphatic ties). The
identified benefits were centred on the enhanced ease and quality of communication of
a geographically distributed health workforce, and the heightened connectedness of a
professionally isolated health workforce. Alongside minor technical and connectivity
issues, the main challenge for the CHWs was to negotiate divergent expectations
regarding the social vs. the instrumental use of the space.
Conclusions: Despite some challenges and constraints, the implementation of
WhatsApp was received positively by the CHWs and was found to be a useful tool to
support distributed rural health work.
Keywords: instant messaging; mhealth; WhatsApp; Global Health; Community Health
Worker
Introduction
Mobile Instant Messaging (MIM) services have seen tremendous growth in the last few years.
MIM is a relatively simple communication technology which offers real-time and
asynchronous communication features. While instant messaging originated as text-based
communication on stationary computers, technological advances have led to the enrichment
of its multimodal capacities. Contemporary features allow users to share audio, images and
video across a range of mobile and non-mobile devices. In contrast to short message services
(SMS) which incorporate point-to-point communication, instant messaging also enables group
conversation, i.e., communication between multiple interactants in one digitally shared space.
MIM platforms are also known as ‘Over the Top’’ (OTT) applications, because they allow
communication regardless of the network and the mobile device being used [1]. Key functions
of instant messaging are alerting features such as sound or popups that notify users of new
messages, presence features that reveal information about the users’ current status, and
additional profile information [2]. WhatsApp, which offers this functional repertoire to more
than 1.2 billion active users per month, is one of the most popular MIM platforms [3].
From a communication perspective, the use of mobile and networked communication
has an evolutionary meaning: it frees (bilateral) human communication from both physical
proximity and spatial immobility [4], and allows groups and networks of highly distributed
and mobile interactants to engage in more complex forms of communication, thus offering
interesting features for a global and distributed health workforce [5]. The investigation of
mobile networked communication technology represents, however, a relatively novel area in
the study of global health, especially in low income settings, which has focused on more
restricted technologies to date, such as SMS [6, 7, 8].
To further substantiate the thin, empirical and conceptual understanding of the use and
usefulness of MIM for global health, the implementation and use of WhatsApp groups by
community health workers (CHWs) as a means to support health care work was investigated
in this study, using the case of rural Malawi. Community health workers play a central role in
the setting under investigation and beyond. They provide basic health and health promotion
services regarding hygiene and sanitation, immunizations, growth monitoring, antenatal care,
family planning, disease surveillance [9]. Community health worker programs have shown to
be effective and through ongoing educational and sensitisation activities they may even
change the communities’ health beliefs [10].
Although health professionals are increasingly using instant messaging services, there
are a limited number of studies available to date. Prior work has examined stationary [11] and,
predominantly, mobile instant messaging systems in the communication of clinical teams [12,
13, 14]. For example, Johnston et al. [12] documented how British emergency teams accessed
WhatsApp groups to discuss clinical and administrative information. The participants found
the use of MIM to be efficient and reported that it had flattened team hierarchies. Similarly,
neurosurgical teams had high regard for WhatsApp, which they used as a tool to share patient-
related information, including radiological images. This virtual information exchange was
reported to decrease the time taken for morning handover and it helped remote team members
to remain updated [14]. Khanna et al. [13] found that WhatsApp use by orthopaedic surgeons
significantly increased patient-related awareness and also resulted in swifter handovers.
MIM has also been made available to health workers in disadvantaged or rural areas.
For example, WhatsApp was provided to community health nurses in Ghana with the goal of
increasing motivation and a sense of connection among professionals who work in isolation
[15]. The conclusion, when WhatsApp was used educationally by undergraduate nursing
students and educators in a primary health care module in South Africa, was that it supported
nurses to integrate theory and practical experience [16]. Henry et al. [17] investigated how
Kenyan CHWs and their supervisors started to use instant messaging groups for to support
supervision, professional development, and team building. Their results indicated that the use
of WhatsApp was highly regarded and taken up easily by the study participants. Most of the
messages related to the supervision objectives of quality assurance and creating a supportive
environment.
In essence, despite the increasing usage of MIM, there is limited knowledge available
on the ways in which MIM can be used by CHWs and what are associated benefits and
constraints. This is the gap that the present study seeks to address.
Methods
Research questions
The research design was operationalised in the form of an interpretive case study approach to
understand the use of MIM tools through the meanings that the users (CHWs, senior CHWs
and facilitators) assign to them [18, 19]. Interpretive designs are well-established approaches
for researching information and communication systems in health care [e.g., 20]. They pay
particular attention to how users make sense of digital media in specific sociocultural and
organisational contexts. Given the exploratory character of the study, the research questions
were broadly defined as follows:
RQ1: How and for what purposes do health workers use WhatsApp groups in support
of their work?
RQ3: What benefits and constraints do health workers associate with the use of
WhatsApp groups?
Research setting
The study was part of a larger, eight-month piece of field research on the use of mobile
technology by community health workers carried out within the Millennium Villages Project
sites in rural Malawi. The Millennium Villages Project incorporated a community-led and
integrated development approach which combined disciplines such as health, education,
business, agriculture and infrastructure to tackle the root causes of rural poverty in resource
poor areas.
The research intervention was carried out in two rural sites which were centred around
the two main clinics of the project. Whereas both clinics were linked to the national power
grid, site A was more remote than site B, which was close to the main road. Health
management processes and the organization of the health workforce were identical, as both
were managed under the auspices of the same project. The interventions reported in this paper
lasted for about five months in total. However, the health workers and facilitators continued
with the use of the WhatsApp group also after the end of the research project.
Study participants and intervention
This study involved CHWs (called ‘Health Surveillance Assistants’ in Malawi), senior
CHWs, who were managing and supervising small groups of CHWs, and facilitators.
Facilitators were more experienced health professionals, for example clinical officers, who
supervised CHWs and senior CHWs and were responsible for specific subject areas, such as
HIV/Aids or Nutrition. The Millennium Villages Project had equipped the study participants
with basic smartphones three years prior to this study. CHWs were using the phone-based job
aid application CommCare as well as a toll-free line to communicate with the wider health
team.
Starting with site A in April 2015, WhatsApp was installed on the CHWs’
smartphones. Site A’s most senior CHW created the WhatsApp group and invited fellow
CHWs and facilitators to join. A short training, of approximately one hour, was carried out for
the participants. The topics included technical instructions, how to protect clients' privacy
(e.g. not sharing patient-identifying information), advice on how to use WhatsApp selectively
to save the battery and a warning not to share any offensive and/or discriminatory materials.
While socialising was permitted, the group was advised to focus on work-related use of the
space. The same procedure was repeated at site B two months later. Due to bandwidth
restrictions, no voice calls were made via WhatsApp during the interventions.
The number of participants in the two WhatsApp groups was 41. The total of 21
participants in group A was made up of 1 facilitator, 4 Senior CHWs and 16 CHWs. The total
of 20 participants in group B included 2 facilitators, 2 Senior CHWs and 16 CHWs. In site A
there were 16 male and 5 female participants, whereas in Site B the number of female
participants exceeded the number of males with 14 vs. 6 respectively. According to the
preliminary survey, the average age of CHWs was similar in both groups with a mean of
30.94 in site A (N = 18, SD = 6.83) and of 32.44 in site B (N = 16, SD = 3.52). The CHWs’
perceived competencies in their abilities to use the mobile phone was 4.30 on a Likert scale
ranging from 1 (Strongly disagree) to 5 (Strongly Agree) (N =20, SD =1.22) in Site A and
4.21 (N = 19, SD = 1.03) in Site B.
Data gathering and analysis
The two main data sources were (1) written conversations in the WhatsApp groups and (2)
focus groups with the CHWs and interviews with facilitators. Although each of the two
sources was used for both RQs, the WhatsApp content served as the central reservoir to
respond to RQ1 whereas the interviews and the focus groups constituted the main source for
RQ2. In addition, RQ1 was supported by the quantitative analysis of the WhatsApp
communication patterns and RQ2 was supplemented by the two open survey questions asking
CHWs about their perceptions of WhatsApp. The four data resources and the respective
methods of analysis are presented in detail as follows:
Thematic content analysis of the WhatsApp conversations was conducted to understand the
nature of information exchange, i.e., the forms and purposes of its use (RQ1). As the
WhatsApp discussions were both in English and Chichewa (the local language), the
anonymised conversations in Chichewa that were made by each group in the first two months
were translated into English. This allowed the non-Chichewa speaking researcher to analyse
the data.
In addition and as a means to examine basic quantitative communication patterns, the content
of the WhatsApp groups of approx. five months of conversations was extracted and analysed
using SPSS v22 for the statistical analysis (site A: 15 Apr - 14 Jun, and site B: 10 Jun to 4
Sept). The number of participants in the WhatsApp groups was 41 (N = 21 in site A and N =
20 in site B). A total of 2,059 messages (N = 845 in site A, N = 1214 in site B) were collected
and quantitatively analysed. Measurements included the average number of monthly messages
per group and participant, and potential differences in terms of written contributions relating
to group or gender.
Secondly, to elicit the participants’ perceptions of benefits and (RQ2), individual
interviews were carried out with each of the three facilitators (one facilitator participated in
the two groups) and four focus groups with 21 CHWs (43 minutes duration, on average) were
carried out in June and July 2015. The interview and focus group guides included a broad set
of questions referring to the forms, patterns and motivations of participation and to the
perceived benefits and constraints. The questions for CHWs and facilitators were the same.
For example, the question “Was the participation in the WhatsApp group useful regarding
your work? Why or why not?” was discussed with CHWs in the focus groups and with
facilitators in the individual interviews. In addition, the facilitators were asked about forms,
patterns and motivations they observed in the CHWs they supervised. For example, regarding
the perceived benefits, facilitators were asked about whether or not they observed that the
CHWs found the participation in the WhatsApp groups useful for their work.
The approach was semi-structured. That is, the question guide was followed with
flexibility, allowing for new themes that emerged during the conversation to be discussed
[21]. With the participants’ agreement, all conversations were audio-recorded, notes were
taken during the conversations and the audio episodes were transcribed verbatim by a
professional translation service. In support of RQ2, a short survey was carried out. The survey
consisted of two open-ended questions asking CHWs about (1) what they liked and (2) what
they disliked the most about using WhatsApp. The paper-based survey was administered
during the weekly coordination meetings and involved nearly all CHWs who participated in
the interventions (Site A, n=19 out of 20; site B, n=17 out of 18).
The interview transcripts, the answers to the survey questions and the written and
translated conversations of the two WhatsApp groups were entered into the software NVivo8.
Considering the limited level of former knowledge, an inductive approach was used [22]
following principles of an interpretive design.
In the open coding phase, the complete data set was read and the material was labelled
according to the themes that emerged within the main domains specified by the research
questions (purposes of use, benefits and constraints). The sub-categories were descriptive and
close to the empirical data. Different sub-categories were further grouped and the relationship
between these categories was examined [22]. The first author read and analysed the whole
data set. Each of the three co-authors analysed approximately 30% of the data. The emerging
categories were developed independently, and were repeatedly discussed and refined among
the research team until consensus was reached. Finally, the findings were contrasted with
related literature.
Results
Purposes and forms of use
The qualitative thematic analysis of the WhatsApp group conversations and of the interviews
and focus groups revealed two main purposes of use, instrumental and participatory, with
three sub-categories each.
Instrumental purposes
The first main category is instrumental purposes, which encompasses the deliberate use of the
digital space to achieve health-service and project-related goals.
Mobilising resources: The content analysis showed that facilitators and senior CHWs used the
group space for vertical task division and resource allocation, mapping tasks to individual
CHWs or the whole group in a top-down format. Examples include mobilising human
resources for meetings, trainings and health promotion campaigns, and allocating material
resources, such as drugs or solar chargers. The quote below illustrates written instructions in
the WhatsApp group provided by a facilitator regarding the preparation for a campaign and
acknowledging responses from CHWs.
[the campaign] will include measuring length in under 2 children alone. Special forms
for recording the length of the children will be provided. All HSAs [CHWs] will then
be required to enter […]. … Please arrange for height boards or lengthmats among
yourselves
10:59, May 9 - CHW7: Thnx bossv
14:42, May 9 - CHW 11: Thanks, we will do bebeautiful job […]
(WhatsApp conversation)
In addition, the content analysis also revealed that CHWs used the space for lateral task
division and also requested information from senior CHWs and facilitators. This made the
information exchange multilateral and cross-hierarchical, involving both pull and push
mechanisms.
Problem solving and information sharing: The participants used WhatsApp to identify and
discuss health-related, as well as technical problems and to develop and share attendant
solutions. A simple example of this included a CHW who ran short of airtime and was helped
out by his colleagues. Another example included redistributing polio vaccines after
identifying a lack in one area. In addition to problems brought in from ‘outside’, the group
conversations also proved to be a primary source for identifying work-related challenges. For
example, in a conversation where a facilitator encouraged CHWs to use a stopwatch app to
measure fast breathing in children, it was found that – in contrast to what had been assumed
no such app was available. These apps were subsequently installed. Facilitators and senior
CHWs also responded to day-to-day health questions from CHWs, for example, regarding
food groups. To a lesser extent, CHWs shared lessons learnt and insights from their daily
work with the group, with an example being sharing good practice for treating malnourished
children. In the interviews, facilitators conceived the opportunity to share identified solutions
with the whole group as one of the group’s key features:
Yes for me, yes I’ve had some areas, maybe one HSA [CHW] can experience a
problem [..] and at the same time I can share with them all [all CHWs] at once so that
they can also learn from what this one HSS experienced. (interview facilitator)
Visualising and acknowledging performance: Facilitators started using the digital space to
share data regarding the CHWs' performance. This monitoring information was extracted
from the mHealth app CommCare, which CHWs use to collect data during household visits.
For example, a facilitator shared individual and total performance statistics for monthly
household visits and monthly salaries, including bonuses in both of the groups. Originally, all
data and experiences were communicated during the weekly meetings and this process shifted
from face-to-face settings to the social media space. Facilitators and CHWs used the
performance data as a source for mutual acknowledgement and motivation, as the next
extracts show:
Facilitator: 85% [households coverage] is alot! Congratulations Keep it up guys! Just
don’t forget [to measure and enter the] MUAC [Mid-Upper Arm Circumference as a
measurement to detect nutrition status]
CHW3: We Will continue working hard&hard,....we are proud of you [directed
to facilitator]
…. (WhatsApp conversation)
Participatory purposes
The second main category is 'participatory' purposes, which, in contrast to managerial and
task related activities, revolve around CHWs’ participation in a socio-professional
community. These include enacting (em)phatic ties, disclosing and accumulating claims and
engaging in cross-boundary debates which emanates through the health workers’ social and
political participation in the media space.
Enacting (em)phatic ties: As the analysis of the WhatsApp groups revealed, a central category
was made up of communicative episodes in which CHWs, senior CHWs and facilitators
reconnected socially and emotionally, for example, by greeting each other in the morning or
saying good night, asking about each other's work or conveying birthday wishes. The most
overt form of empathy was emotional and spiritual support when CHWs fell sick or were
injured. Interestingly, the underlying goal of many of these communications was not
information exchange but rather mutual reassurance of the (virtual) co-presence of the group
distributed in geographical space, as the next statement illustrates:
18:54, Jun 6 - CHW1: People, where are you?
18:55, Jun 6 - Senior CHW: No, we are here Ma’am
18:56, Jun 6 - CHW1: Ok I see [!] you
(WhatsApp conversation)
Disclosing and accumulating demands: CHWs also started to use the group for micro-
political purposes about work-related claims. By disclosing and repeating challenges and
demands related to the accomplishment of their work, such as the lack of solar chargers, they
could make their voice heard more easily. An example from health service delivery showed
how CHSW pointed to financial means needed for their work. This reminded and helped to
alert senior CHWs and facilitators, who were also in the group. These needs were expressed
directly ("CHW7: Supervisor, where is the money issue of praz [allowance for drug
distribution] on now?") and indirectly. In particular humour was often used as a moderator for
uttering needs. This pattern did not only came to the fore through the WhatsApp content
analysis, but also in the focus groups: CHWs explicitly acknowledged their tactic of voicing
their needs in a soft and humorous, but consistent way towards senior CHWs and facilitators,
who also confirmed these practices:
… so they started discussing it [financial resources needed] … it was their
way of communicating to us as their supervisors to say we should push, .. it
was for a week, talking … (Interview facilitator).
Engaging in cross-boundary debates: The WhatsApp group also harboured discussions that
went beyond health service delivery and health promotion including themes such as culture,
religion, cuisine, sport and politics. This rendered the space a broader news and discussion
portal. Examples included sharing news from their district along with news about lifestyle,
wellbeing and religious practices. Political dynamics were also debated, for example, the
xenophobic incidents in South Africa and the political situation in Zimbabwe. Interestingly,
health-related aspects were interwoven into many of these broader debates as, for example,
the next excerpt from a sports discussion illustrates. The CHW interlaced central themes from
their daily health practice (such as distributing ORS or painkillers) into an ongoing debate
about an upcoming sports event.
CHW 13: Before you start watching the Flames [The Malawi national football
team] make sure you do the following....
1. Make sure your BP [blood pressure] is tested to avoid sudden death
2. Get some painkillers to prevent severe headache
3. Buy ORS to prevent diarrhea
(WhatsApp conversation)
Quantitative communication patterns
According to the quantitative content analysis of the WhatsApp groups, communication
patterns were similar in both groups, with an average of 13.85 messages shared per day in site
A and 13.95 messages in Site B. Calculating the messages that were shared on average per
participant per month, again similar patterns were found between the groups, with 20.06 (SD
= 22.94) in site A, and 21.22 (SD = 23.33) in site B. A Mann-Whitney test confirmed that the
monthly number of contributions per participant were not significantly higher for site A (Mdn
= 13.96) than for site B (Mdn = 12.94), U = 190.0, p = .602, two-tailed. Within both groups
the range of monthly contributions varied considerably from 1.00 to 96.24 messages in site A
and from 2.80 to 103.49 messages in site B. Regarding the impact of gender (N = 22 male
CHWs, N = 19 female CHWs) on the number of monthly contributions, no significant
differences were found between male (Mdn = 13.45) and female CHWs (Mdn = 12.94) using
a Mann-Whitney test, U = 192.5, p = .666, two-tailed.
Benefits and constraints
Benefits: manageability, connectedness
As the analysis of the interview and focus group data and the open-ended survey questions
revealed, the positive perception of MIM was, in part, grounded in its usability aspects. This
was particularly recognised through a number of statements in the survey such as: "it's easy to
use" or "it’s user friendly". More centrally, MIM’s value was associated with its ability to
integrate the coordination of distributed resources in one communication space. Most
prominently, allowing for the whole team to be reached at once in a reasonable time frame.
This quality can be compared to the previously time-consuming one-to-one communication
chain when information was passed in the form of phone calls from the facilitator to the most
senior CHW of the respective clinic, then to the other senior CHWs who finally forwarded it
to the individual CHWs. These processes were particularly cumbersome in view of the
repeated efforts needed to reach CHWs who were temporarily unavailable because of a lack
of power or network coverage. The previous ways of communication were also conceived to
be more error-prone, resembling the dynamics of “Chinese whispers”, as a facilitator
indicated in the interview: "The message might change [in the process of forwarding it], yes.
That happens a lot... ". MIM communication was no longer dependent on intermediaries and
potential misconceptions were clarified earlier. The simple act of posting a message was
valued because the responsibility for forwarding the information was delegated to the tool,
making repeated calls obsolete. In essence, MIM helped to make a geographically distributed
workforce more manageable. A facilitator explained this in respect to organising a campaign:
When I give a message I feel it’s much better than giving the message to the
senior. When I put it on WhatsApp I know everybody is reached […] For the
child happy days they [CHWs] were supposed to take the length of under two
years children. I just gave them the message on WhatsApp and everybody was
able to do that. (Interview, facilitator)
From the perspective of those receiving the information, enhanced communication
was tied to MIM’s capabilities to integrate on and offline discussions, for example, allowing
CHWs to access and contribute to past conversations. Supporting this perception, CHWs
valued the heightened levels of information circulation between peers, senior CHWs and
facilitators, which they linked to an increased awareness of work-related activities of the other
CHWs beyond their own clusters:
We know what is [...] going on in every cluster using WhatsApp. (Focus group,
CHW)".
we are getting updated to anything that is happening out there since we are
using the WhatsApp. (Focus group, CHW)
The perception of the WhatsApp groups as information and knowledge platforms also
manifested in statements such as: "We also learn a lot from WhatsApp". The focus group
analysis revealed that the ongoing interactions of information among participants cumulated
in a more steady feeling of connectedness. The WhatsApp group extended the communicative
terrain of the CHWs who tended to work in relative professional isolation, meeting only once
a week as a group. As could be seen also in the analysis of the WhatsApp content, the
platform allowed them to ‘gather’ in between these regular meetings with lengthy, parallel
and discontinuous streams of discussion which extended past typical working hours into the
CHWs' personal spheres. This was deemed to nurture a feeling of virtual togetherness, as
expressed by a CHW:
it’s like since we just stay in the different areas and maybe it takes us a week to
meet [..], so when you see your friend posting [..], oh it’s like you, it’s like
getting us together … (Focus group, CHW)
Constraints
Although media literacy was reported to be a minor challenge in the focus groups, the small
number of written contributions by some of the CHWs was explained by their lack of
technological competencies (i.e., typing and sending messages) in the interviews. A more
prevailing constraint for the whole group was finding the balance between instrumental,
work-related, and more social conversations. Reconciling the different expectations among
participants was an ongoing negotiation process. While forms of use were, for example,
discussed during the weekly meetings, tensions remained until the end. Twelve CHWs stated
in the final survey that receiving inappropriate, non-work related messages was what they
disliked the most about MIM. However, completely dispelling social communication was
deemed to be counterproductive by the facilitators, because of the risk of diminishing the
acceptance and use of this inherently social, peer-to-peer communication medium. Instead,
facilitators acknowledged that WhatsApp's success as an instrument for Global Health was
grounded in an ongoing calibration process, which required their guidance:
.. prohibiting them [CHWs] completely on the social aspect it might even end
up like frustrating them and then they might not even use the media […] We
[the faciliators] need just to put in place the measures on how best they can
balance that. They should socialise but at the same time they should really
make use of this media for work related issues. (Interview, facilitator)
Some minor concerns were raised by CHWs who criticised the use of MIM during late
hours. Late postings were deemed especially inappropriate in controversial debates, as those
who had switched off their phones could not respond to allegations in a timely manner. This
tension can be connected with the micro-political pressure that some senior CHWs and
facilitators found themselves exposed to when CHWs used MIM to utter work-related needs,
as one facilitator exemplifies:
they felt like that was the forum, they could express what is burning inside, yes,
so I didn’t blame them, but I thought it was not good. (Interview, facilitator)
Another challenge was that although the CHWs read the facilitators' organising and
instructional messages, the majority tended to not acknowledge receipt of them. CHWs also
criticised the lack of immediate comments and responses by some of their peers which was
linked to a poor power supply. Issues with the power also resulted in some CHWs only being
able to use WhatsApp sporadically. Given the linear way in which WhatsApp constructs
reading paths, delayed responses also manifested in parallel discussions. That is, contributions
were sequentially strung together, one after another, without the ability to build thematic
structures (e.g. in the form of threads). Although simplicity is a key feature of the tool's
success, it also inhibited the continuity and depth of discussion, as one facilitator remarked
regarding the sharing and discussion of nutrition guidelines.
I think they forget [the guidelines], because sometimes there were
conversations changed on the WhatsApp group. You could see we’ve already
diverted from this [debate on nutritional guidelines] instead of concentrating,
yes. (Interview, facilitator)
Discussion
In the following sections, the results of this study are linked to previous communication
concepts and literature from global health. It is worth reiterating that the use of the instant
messaging tool was received well by CHWs and their facilitators and was used regardless of
gender. The purposes of MIM use and attending effects are synthesized in Figure 1 and
discussed in the following sections.
Insert Figure 1 Purposes and benefits of MIM for geographically distributed and
professionally isolated health workers
Instrumental communication for a distributed health workforce
Mobilising resources (organisation), visualising and acknowledging performance (rewards)
and problem solving and information sharing (capacity) are key to the functioning of any
organisational unit [23]. Integrating the coordination of scattered resources, people and
materials in one extended communication zone can be linked to an enhanced manageability of
the target group. This is of particular value in settings where the management of health
workers is inhibited by geographical distances and lack of transport, a phenomenon which is
very typical for many global health contexts [24, 25]. In addition, the use of MIM to visualise
and acknowledge performance (beyond exclusive control and monitoring purposes), which
has been revealed in this study, is relevant in view of the widely acknowledged lack of
supervision tools and practices that facilitate recognition and feedback mechanisms in global
health work [24, 26, 27].
The perceptions of MIM as a capability enabler were grounded in the facilitators'
information sharing of health and management guidelines and in its use for problem solving.
The second aspect helped facilitators with continuous visualisation and problem solving
beyond geographical and temporal constraints of on-site visits which are also common
beyond the setting of this study [28]. The findings of this research indicate that through the
use of MIM, supervisors and facilitators could trace developments of their groups more
continuously and develop a more persistent problem-based support. The sharing of knowledge
in the group was, however, ephemeral, being intertwined with the vibrant stream of other
discussions. Thus, it could never supersede the focused learning and teaching of on-site
training or the concentrated attention of face-to-face supervision, but should be conceived to
be an additional layer. Nevertheless, the provision of an additional space for problem solving
and knowledge sharing is certainly of value in the context under investigation – in typical
Sub-Saharan African settings where health workers have limited access to knowledge
resources [29], peers and supervisor support.
Participatory communication for an isolated health workforce
'Participatory' purposes of enacting (em)phatic ties, disclosing and accumulating claims and
engaging in cross-boundary debates came about through the health workers’ socio-
professional participation in the media space. These impacted on the feelings of
connectedness of a professionally-isolated health workforce. The lengthy, parallel and
discontinuous streams of discussion that reached into the participants' private time zones were
can be associated with new forms of professional connectedness. The patterns observed
resemble what Timmis [30], drawing on [31], described in her instant messaging study of
students as 'telecocooning': the creation of a (new) zone of intimacy in which people can
continuously maintain their (professional) relationships. Intimacy was not exclusively a
product of the participants' interactions. In addition, it was created through ‘outeraction’,
borrowing a concept from Nardi et al. [32]. That is, the establishment of a sense of social
proximity through ostensibly purposeless communication, for instance the reassurance of
virtual co-presence. Although unrelated to primary health goals, these communication
practices are highly relevant for rural and mobile health personnel whose work realities are
typically disconnected from those of fellow workers, supervisors and facilitators and who are
dramatically affected by professional isolation [33].
The use of social media as a political instrument that facilitates horizontal connectivity
in social mobilisation is not limited to this study, but has been reported in prior work, most
prominently, perhaps, with respect to the so-called 'Arab Spring' [34]. With CHWs who
uttered needs related to the accomplishment of their work, the dynamics observed in the
digital space were not only lateral, but reached upwards through the hierarchy. A similar,
though even more intense, substantiation of political power was reported from Taiwan, where
more than a thousand emergency health personnel started articulating their professional
concerns (about overcrowding) in a Facebook group. The protests soared and even the health
minister participated in the group, breaking down previously impermeable hierarchical
structures [35].
Quality and limitations of research
Trustworthiness in this study was achieved through triangulating data, methods, investigators
and theory [36, 37]. The triangulation of data sources resulted from the involvement of two
intervention sites and health workers in different roles (CHWs, senior CHWS, and
facilitators). Methodological triangulation was grounded in the blend of observational and
perceptional data, such as the analysis of the written interactions and of interviews/focus
groups and surveys, respectively.
The use of well-established research methods added to the study's credibility [38].
Investigator triangulation was achieved by involving investigators from different
backgrounds, such as from social sciences and public health, who analysed the data
independently. In addition, and similar to [39], the co-operation of 'insiders' and 'outsiders'
was found to be highly valuable. 'Insiders' (i.e. local researchers from the project) were able to
interpret the findings in light of existing sociocultural practices, while 'outsiders' questioned
aspects that 'insiders' would have taken for granted. This further contributed to the study's
credibility because it ensured familiarity with the culture of the participating organisations
[38]. Theoretical triangulation resulted from comparing the emerging concepts with
frameworks and data from extant literature. To conclude, each of the RQs has been addressed
by involving one main and two supplementary sources and thus the findings can be deemed to
be relatively robust.
However, limitations in the study design are linked to the duration of the intervention, the
specific context in which the study was carried out, and the nature of outcomes reported.
Future research which examines the long-term usage and which studies the practices and
effects of MIM use in further cultural and organisational circumstances are thus required. In
addition, quantitative measures are needed to further measure and corroborate some of the
qualitative indicators identified in this analysis, such as professional connectedness.
Practical considerations
The forms and purposes of use identified can help health workers and project managers in
setting up similar designs. The flexible and dynamic forms of instrumental and participatory
communication observed in this study can be seen as valuable “add-ons” to more structured
and pre-defined mobile health data collecting systems. A quality of the use of WhatsApp in
the field of global health can be seen in its capacity to help geographically distant supervisors,
programme managers or district health officers to obtain a better understanding of the CHWs'
day-to-day trials and tribulations. In this sense, social media spaces can be used as a
qualitative seismometer, tracing the (e)motions of remote and distributed rural health
workforces. Given the broad and rapidly increasing availability of MIM, the WhatsApp group
design (as investigated in this study) can be scaled up in many other global health settings. To
leverage the potentialities of MIM for global health work and in primary health care settings
more systematically, programme managers and policy-makers need to be brought on board as
'active partners' instead of as 'passive” partners.
However, although the implementation of MIM in rural health systems in Sub-Saharan
Africa can be a worthwhile endeavour, it is certainly no panacea for the coordination of health
and health promotion work. Although the MIM tool in use was able to integrate online and
offline conversations, issues regarding power and connectivity remain. In addition, the use of
group messaging tools requires individual media skills. Although for most of the study
participants the use of the technological spaces presented no problem, “mobile literacy” was a
challenge for a few. To ensure equitable access for all health workers, specific support needs
to be offered in a sensible manner without exposing less technologically skilled health
workers in front of the group. One approach from this study was facilitators who observed
participation patterns over time and offered individual and discrete support to health workers
with restricted levels of contribution.
In addition to individual skills, the inherent tension between the realisation of
instrumental and participatory purposes needed to be constantly negotiated by all group
participants. The use of MIM spaces was found to be an ongoing learning and calibration
process for the whole group. To leverage fully the space's potential for global health
communication, the participants needed to address instrumental and participatory ends
simultaneously. A space used exclusively for instrumental purposes would not only minimise
its potential for ameliorating professional isolation (and inhibiting potential power dynamics),
but might even collapse as health workers would lose interest and abandon the space. To this
end, it turned out valuable to agree on a number of ground rules regarding the content and
style of contributions, explicitly allowing forms of socialising. It could be observed that the
guidelines which were presented and discussed in the introductory training were followed by
the CHWs. The WhatsApp analysis revealed no breaches of clients’ privacy, and no
discriminatory material was shared. However, the facilitators deemed it helpful to be able to
address and discuss tensions, which revolved around balancing work and social topics and the
timing of the messages, in the weekly meetings. In very rare occasions, they also used these
meetings to point to other inappropriate content, such as in one case in which witchcraft
believes were uttered.
It is also important to keep in mind that digital technology tends to reproduce rather
than transform existing structures. In this sense, MIM would not compensate for the effects of
bad supervision. Rather, it would worsen it, because in addition to technical and social skills,
supervisors and CHWs would also need to develop media literacy skills to handle the
dynamics of supervision in a digital space.
Conclusion
WhatsApp groups which were introduced in a rural and low resource community health
setting were used by health workers for instrumental (e.g. mobilising health resources) and
participatory (e.g., the enactment of emphatic ties) purposes. The identified benefits were
centred on the enhanced ease and quality of communication of a geographically distributed
health workforce, and the heightened connectedness of a professionally isolated health
workforce. Despite some challenges and constraints, the implementation of MIM was
received positively by the CHWs and was found to be a useful tool to support distributed rural
health work.
Acknowledgements
We wish to thank the Community Health Workers and the Millennium Villages Project for
the great collaboration and the Swiss National Science Foundation (SNSF) for their financial
support of this research.
Authorscontributions
Christoph Pimmer: Design of the research and of intervention; acquisition, analysis and
interpretation of data; writing the manuscript; Susan Mhango: Design of the intervention;
analysis and interpretation of parts of the data; Alfred Mzumara: Design of the intervention;
analysis and interpretation of parts of the data; Francis Mbvundula: Design of the
intervention; analysis and interpretation of parts of the data;
Disclosure statement
None of the authors have any competing interest.
Ethics and consent
Prior to the study, ethical approval was obtained from the Ethics Committee of North-western
and Central Switzerland (EKNZ) and the National Health Sciences Research Committee
(#1350) in Malawi. Additionally, written informed consent was sought from all participants
and measures were established to protect the privacy and confidentiality of all participants.
Funding information
Swiss National Science Foundation (P2ZHP1_155026)
Paper context.
Despite the popularity of mhealth and the increasing use of WhatsApp, very little is known
about the use and usefulness of these platforms in rural health settings. This study found that
CHWs in rural Malawi used WhatsApp groups for instrumental and participatory purposes.
The benefits were centred on the enhanced ease and quality of communication and on
heightened professional connectedness. Challenges included minor technical issues and
balancing instrumental and social usage.
7. ORCID (if available)
0000-0002-7622-6685 (Christoph Pimmer)
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