Esther Dissertation

MOBILE HEALTH AND PERFORMANCE OF COMMUNITY HEALTH WORKERS: A
CASE OF BRAC COMMUNITY HEALTH WORKERS IN IGANGA

REGION-UGANDA
NAKINTU ESTHER
19/MBA/KLA/WKD/0040
A DISSERTATION SUBMITTED TO THE SCHOOL OF MANAGEMENT SCIENCE

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD
OF A MASTER’S DEGREEE IN BUSINESS ADMINISTRATION
OF UGANDA MANAGEMENT INSTITUTE
OCTOBER, 2023
DECLARATION
I, NAKINTU ESTHER, declare that this dissertation titled “Mobile health and performance of
community health workers: a case of BRAC community health workers in Iganga region-
Uganda” is my own original work and it has not been presented to any other institution for any
academic award. Where other people’s work has been used, this has been duly acknowledged.
Sign ……………………………………. Date………………………………..

NAKINTU ESTHER
19/MBA/KLA/WKD/0040
i
APPROVAL
This is to certify that this dissertation by NAKINTU ESTHER titled, “Mobile health and
performance of community health workers: a case of BRAC community health workers in
Iganga region-Uganda” has been submitted for examination with my approval as the Institute
supervisor.
Sign ……………………………………. Date………………………………..

DR. ORYEMA DAN
SUPERVISOR,
Uganda Management Institute, Kampala.
Sign ……………………………………. Date………………………………..

DR. KAMUKAMA JAMES
SUPERVISOR,
Uganda Management Institute, Kampala.
ii
DEDICATION
This dissertation is dedicated to my family for their financial support, moral encouragement and
prayers during my entire study.
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ACKNOWLEDGEMENT
I am deeply indebted to my research supervisor Dr. ORYEMA DAN and Dr. KAMUKAMA
JAMES for his patience with my inadequacies as he guided me through the research process.
Without your parental and professional input, this research would have been difficult to elevate
to its current level.
I acknowledge with gratitude the contributions and co-operation made by the staff and all
respondents from Iganga region for their willingness to provide the necessary information when I
visited the organization during the research process. Without their cooperation, this study would
have been impossible to accomplish.
I also thank my colleagues at Uganda Management Institute, persons who dealt with secretarial
work and those who read through the questionnaires and perfected the draft report.
Above all, I thank the Almighty God for his protection and guidance throughout this work.
I deeply treasure the contributions of all the above persons and ask God Almighty to richly bless
them.
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TABLE OF CONTENTS
DECLARATION............................................................................................................................i
APPROVAL...................................................................................................................................ii
DEDICATION..............................................................................................................................iii
ACKNOWLEDGEMENT...........................................................................................................iv
TABLE OF CONTENTS..............................................................................................................v
LIST OF TABLES........................................................................................................................xi
LIST OF FIGURES.....................................................................................................................xii
LIST OF ACRONYMS AND ABBREVIATIONS..................................................................xiii
ABSTRACT................................................................................................................................xiv
CHAPTER ONE............................................................................................................................1
INTRODUCTION.........................................................................................................................1
1.1 Introduction...........................................................................................................................................1
1.2 Background to the Study.......................................................................................................................1
1.2.1 Historical Background................................................................................................ 3

1.2.2 Theoretical Background.............................................................................................. 4
1.2.3 Conceptual Background.............................................................................................. 4
1.2.4 Contextual Background...............................................................................................5
1.3 Problem Statement.................................................................................................................................6
1.4.1 General Objective.......................................................................................................7
1.4.2 Specific Objectives.....................................................................................................7
1.5 Research Questions...............................................................................................................................7
1.6 Hypothesis.............................................................................................................................................8
1.7 Conceptual Framework..........................................................................................................................8
1.8 Justification of the Study.......................................................................................................................9
1.9 Significance of the Study.......................................................................................................................9
1.10 Scope of the Study.............................................................................................................................10
1.10.1 Content scope.........................................................................................................10
1.10.2 Geographical scope.................................................................................................10
1.10.3 Time scope.............................................................................................................10
1.11 Operational Definitions of terms and concepts..................................................................................10
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CHAPTER TWO.........................................................................................................................12
LITERATURE REVIEW...........................................................................................................12
2.1 Introduction.........................................................................................................................................12
2.2 Theoretical Review..............................................................................................................................12
2.3 Mobile Health and Performance..........................................................................................................14
2.3.1 Mobile health...........................................................................................................14

2.3.2 Performance of Community Health Workers...............................................................14
2.4 Mobile health Tools.............................................................................................................................15
2.5 Mobile health acceptance....................................................................................................................17
2.6 Mobile health technical support...............................................................................................18

2.7 Summary of the literature review........................................................................................................19
CHAPTER THREE.....................................................................................................................20
METHODOLOGY......................................................................................................................20
3.1 Introduction.........................................................................................................................................20
3.2 Research Design..................................................................................................................................20
3.3 Study Population.................................................................................................................................21
3.4 Sample size determination...................................................................................................................21
3.5 Sampling techniques and procedure....................................................................................................22
3.6 Data Collection Methods.....................................................................................................................22
3.6.1 Questionnaire survey................................................................................................ 22

3.6.2 Interview................................................................................................................. 22
3.7 Data collection instruments.................................................................................................................23
3.7.1 Questionnaire...........................................................................................................23
3.7.2 Interview guide........................................................................................................ 23
3.7.3 Document review checklist........................................................................................23
3.8 Validity and reliability.........................................................................................................................23
3.8.2 Reliability of instruments.................................................................................................................25
3.9 Procedure of Data Collection...............................................................................................................25
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3.10 Data Analysis....................................................................................................................................26
3.10.2 Qualitative data analysis..........................................................................................26

3.12 Ethical considerations........................................................................................................................27
CHAPTER FOUR.......................................................................................................................29
PRESENTATION, DISCUSSION, AND ANALYSIS OF FINDINGS..................................29
4.1 Introduction..............................................................................................................................29
4.2 Response rate...........................................................................................................................29
4.3 Background information..........................................................................................................30
4.3.1 Gender of respondent............................................................................................................30
4.3.2 Age of respondents...............................................................................................................30
4.3.3 Educational Level of the Respondents.................................................................................31
4.3.4 Staff category........................................................................................................................32
4.3.5 Years of services...................................................................................................................32
2.4.6 Working devices...................................................................................................................33
4.4 Empirical findings from the study...........................................................................................33
4.4.1 Performance of Community Health Workers in Iganga region............................................34
4.4.2 The relationship between mHealth Tools and performance of Community Health Workers
.......................................................................................................................................................37
4.4.3 The relationship between mHealth Acceptance and performance of Community Health
Workers..........................................................................................................................................39
4.4.4 The relationship between mHealth Technical support and performance of Community
Health Workers..............................................................................................................................41
CHAPTER FIVE.........................................................................................................................45
SUMMARY, DISCUSSION, CONCLUSIONS AND RECOMMENDATION.....................45
5.1 Introduction..............................................................................................................................45
5.2 Summary of the study findings................................................................................................45
.......................................................................................................................................................45
Workers..........................................................................................................................................46
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Health Workers..............................................................................................................................46
5.3 Discussion of results................................................................................................................47
.......................................................................................................................................................47
Workers..........................................................................................................................................48
Health Workers..............................................................................................................................49
5.4 Conclusions..............................................................................................................................49
.......................................................................................................................................................49
Workers..........................................................................................................................................50
Health Workers..............................................................................................................................50
5.5 Recommendations....................................................................................................................50
.......................................................................................................................................................50
Workers..........................................................................................................................................51
5.5.3 The effect of mHealth Technical support on performance of Community Health Workers 51
5.6 Contribution to knowledge......................................................................................................52
5.7 Implications of theory..............................................................................................................52
5.8 Implications for policy and practice........................................................................................53
5.9 Recommendations for further Research..................................................................................53
5.10 Limitations of the study.........................................................................................................53
REFERENCES............................................................................................................................55
APPENDICES:............................................................................................................................61
APPENDIX 1: WORK PLAN...........................................................................................................61
APPENDIX 2: BUDGET..................................................................................................................62
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Appendix 3: Questionnaire...............................................................................................................63
Appendix 4: Interview guide.............................................................................................................66
APPENDIX III: SAMPLING GUIDE.......................................................................................68

APPENDIX IV: PLAGIARISM REPORT...............................................................................69
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LIST OF TABLES
Table 1: Category of respondents from Iganga region..................................................................22
Table 3.2: Results of content validity for research tools...............................................................25
Table 3.3: Reliability test results of research instruments.............................................................26
Table 4.4: Response rate................................................................................................................30
Table 4.5: Gender of respondents..................................................................................................31
Table 4.6: Staff category................................................................................................................33
Table 4.7: Working devices...........................................................................................................34
Table 4.8: Opinions of respondent on performance of Community Health Workers in Iganga
region.............................................................................................................................................35
Table 4.9: Opinions of respondent on mHealth Tools at Iganga region........................................38
Table 4.10: Correlation matrix for mHealth Tools and performance of Community Health
Workers..........................................................................................................................................39
Table 4.11: Opinions of respondent on mHealth Acceptance at Iganga region............................40
Table 4.12: Pearson correlation for mHealth acceptance and performance of Community Health
Workers..........................................................................................................................................42
Table 4.13: Opinions of respondents on mHealth Technical support in Iganga region................43
Table 4.14: Pearson correlation coefficient for mHealth Technical support and performance of
Community Health Workers..........................................................................................................45
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LIST OF FIGURES
Figure 1.1. The Conceptual Framework showing relationship between mHealth and performance.
.........................................................................................................................................................9
Figure 4.2: Age of respondents......................................................................................................32
Figure 4.3: Level of education of respondents..............................................................................32
Figure 4.4: Working experience....................................................................................................33
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LIST OF ACRONYMS AND ABBREVIATIONS
CHW: Community Health Worker
DHIS: District Health Information System
DV: Dependent Variable
EHC: Essential Health Care
ICCM: Integrated Community Case Management for childhood illnesses
IV: Independent variable
MNCH: Maternal Neonatal and Child Health
MOH: Ministry of Health
RCT: Random Control Trial
S-CHP: Super Community Health Promoter
TAM: Technology Acceptance Model
TTF: Task Technology Fit
UNMHCP: Uganda National Minimum Health Care Package
VHT: Village Health Team
WHO: World Health Organization
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ABSTRACT
The study focused on the relationship between rewards and performance of Community Health
Workers. The study was guided by three research objectives namely; to examine the relationship
between mHealth Tools and performance of Community Health Workers, to examine the
relationship between mHealth Acceptance and performance of Community Health Workers
and to examine the relationship between mHealth Technical support and performance of
Community Health Workers. The study adopted a cross-sectional survey design where both
quantitative and qualitative approaches were used. In this study, out of 246 the questionnaires
distributed 241 were fully filled and returned reflecting a 100% response rate. 07 of the planned
interviews were conducted which gave a response rate of 100%. Pearson correlation results as
presented in table 4.10 depicts a strong positive relationship between mHealth Tools and
performance of Community Health Workers (r = .688). The study results further indicated a
significant statistical relationship between the study variables given that p-value (p=.000<0.05).
Hence, the results have confirmed that mHealth Tools has positive significant relationship with
performance of Community Health Workers. Further, Pearson correlation results as presented in
table 4.12 depicts a strong positive relationship between mHealth acceptance and performance of
Community Health Workers (r = .669). The study results further indicated a significant statistical
relationship between the study variables given that p-value (p=.000<0.05). Finally, Pearson
correlation results as presented in table 4.14 depicts a strong positive correlation between
mHealth technical support and performance of Community Health Workers (r=.569). The study
results further indicated a significant statistical relationship between the study variables given
that p-value (p=.000<0.05). The study recommended that although poor network coverage was a
reality in both settings, this could be ameliorated by providing CHWs in locations with poor
coverage with a dual SIM phone. The impact of providing phones with a reduced battery life
needs to be considered, and solar chargers may be a solution. The MoH should provide solar
chargers to health facilities without electricity to enable them charge their phones at no cost since
many pay a cost to charge their phone of which they use to send message. There should be
improved staffing of the facilities where community units are linked in order to strengthen
referrals and linkage systems especially taking into consideration the spatial distribution and
population density. This will improve support supervision from CHWs during their community
work
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CHAPTER ONE
INTRODUCTION
1.1 Introduction
This chapter covered background of the study, the problem statement, the general and particular
study objectives, the research questions, the study hypotheses, the study's scope, the importance,
justification, operational definitions of terms and concepts. This study aims to evaluate the
relationship between Mobile Health (or mHealth) and performance of BRAC Community
Healthy Workers in Iganga region. The region comprises of Jinja, Kamuli, Mayuge, Iganga,
Kaliro, Namutumba, Pallisa, Busia and Namayingo districts. In the current study, “Mobile
health” is conceived as the independent variable (IV) while “performance of Brac Community
Health Workers” as the dependent variable (DV). mHealth was measured in form of availability
of ICT tools, mHealth acceptance and mHealth technical support. Performance of community
health workers was measured in terms of efficiency, quality of healthcare given to communities,
as well as Community Health Worker (CHW) output in form of performance reporting for
number of households visited, number of under-five (5) child assessments and treatments as
explained in the conceptual framework (Section 1.7).
1.2 Background to the Study
Access to healthcare is still a problem in Uganda, especially in rural regions. As part of the
Uganda National Minimum Health Care Package (UNMHCP), the Ministry of Health (MOH)
developed the Village Health Team (VHT) concept in 2001 (MOH, 2001). The nation's CHWs
have been instrumental in raising health consciousness, demand and use of healthcare thus
greatly reducing congestion at medical facilities by promptly treating malaria, diarrhea and
pneumonia among under 5 children. The CHW strategy has not been satisfactorily implemented
in Uganda. Despite CHWs contribution to health systems there are issues with how well they
perform (Musoke et al., 2019).
The inadequate household visits done, low performance output in terms of number of malaria,
diarrhea and pneumonia cases treated has insignificantly contributed to health outcomes. The
quality of health care remains low due to challenges in dozing efficacy which is attributed to
CHW’s level of knowledge and skill. The rise of Mobile Health (mHealth) presents exceptional
opportunity to tackle some of the health initiative's most challenging issues at the local level.
One of the most promising and active mHealth efforts is the use of mobile phone technology in
community-based health systems to provide first-line treatment in Integrated Community Case
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Management of Children Illnesses (ICCM). The use of mobile smartphones and other wireless
technology in healthcare is known as mobile health (Rouse, 2018).
The current study seeks to examine the relationship between mobile health and performance of
Community health workers. The use of mobile apps like BRAC Afya app where systematic
workflows on patient assessment and treatment are prompted through the App can yield more
efficient, effective and better performance output.
Despite use of mobile health apps to obtain performance data on treatments of under five
children and provide appropriate prescription in community health, there still exist performance
gaps in output, quality of healthcare and efficiency. The low CHW performance and limited
uptake of mHealth is attributed to skills gap where most elderly CHWs have not correctly
mastered the skill of proper data entry. In Uganda, CHW performance was poor, especially in the
areas of maternal and child health (Bagonza, 2014).
The incomplete household data entry and failure to capture some performance output data in the
app has greatly reduced the number of CHWs that can attain minimum level of performance
reporting as manual data is considered invalid for reporting. Poor community perception, lack of
awareness among some communities, security and privacy of records has made recording of
performance data complicated (Franz, Springer, & Mburu, 2013).
The quality of health services delivered by CHWs may be compromised due to limited technical
support in the form of low device maintenance where some phones are non-functional due to
inability to install app updates or failure to sync performance data captured in the mHealth
system leading to poor performance among community health workers (Geldsetzer et al., 2017).
Use of mHealth in community-based health care has enabled participatory health monitoring of
under-five assessments, treatments and referrals done at community level, thus, leading to
reduced health cost and improvement in healthcare quality. The research therefore, aimed at
understanding the relationship between mHealth and performance of Community health workers.
To fill this gap, the current research focused on investigating the relationship between available
mHealth ICT tools, acceptability of technology task characteristics, level of technical support
and performance of CHWs in terms of output, efficiency and perceived service quality. The
background to the study was divided into historical, theoretical, conceptual and contextual
background.
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1.2.1 Historical Background
Government CHW performance programs began to be implemented at the national level in
Indonesia, India, Nicaragua, Honduras, and other Latin American nations in the 1970s and
1980s. The first worldwide conference on Primary Healthcare for CHWs was conducted by
WHO and UNICEF in 1978 and it resulted in the declaration of "Health for all” by community
health workers. The foundation principle for the "health for all" initiative was based on the ideas
of equity, illness prevention, and decentralization of healthcare to rural areas (WHO, 1978).
However, due to political instability, unfavorable economic policies and financial constraints in
the 1980s, CHW performance declined due to inadequate training, low compensation, inadequate
support supervision and limited medical supplies to treat at community level (Maryse, 2018).
The emergence of mHealth initiatives to improve CHW performance started in United Kingdom
plus other developed countries like Denmark, Netherlands, Sweden in 1995 and Finland
followed in 1997. The integration of mHealth solutions into patient treatment to improve
performance of CHWs was attributed to mHealth adoption levels, the level of digitization and
mHealth Regulatory Framework (Waegemann, 2016). Recent developments in wireless and
mobile phones technologies are making m-health solutions more appealing in community health.
Reports in quarter one of 2021 indicate that approximately 1,000,000 m-health Apps were listed
in Apple and Android (Baxter et al., 2020).
In Africa, mHealth strategies were launched in Ghana in 2010. In sub-Saharan Africa mHealth
was first piloted in Malawi in 2014 where mHealth technology was geared towards improving
performance of CHWs, reduction of patient monitoring costs, medical adherences and
improvement of health care worker’s communication in rural areas. Smaller CHW projects in
Africa were also started in Tanzania, Zimbabwe, Malawi, and Mozambique by non-
governmental organizations (NGOs). In Mozambique, mHealth interventions have been used in
Integrated Community Case Management for childhood illnesses but performance of community
health workers remained below required standard due to limited involvement of CHWs in the
design of mHealth interventions. (Thondoo, Strachan, Nakirunda, & Ndima, 2015).
In Uganda mHealth initiatives to improve performance of CHWs was adopted in 2014 to aid
CHWs in remote transmission of data and effective communication of treatment in community
healthcare. The CHW strategy has not been satisfactorily implemented in Uganda and CHW
performance remains low despite their contribution to the health systems (Musoke et al., 2019).
3
Many NGOs in Uganda have adopted mHealth and several initiatives have come up to address
the health information requirements of public health workers. Brac Uganda Health Program
rolled out Brac-Afya app in 2016 in order to enhance performance efficiency and effectiveness
of community health workers through improved health care service delivery. BRAC’s Afya App
has automated features that guide the CHPs on under five (5) sick child assessment and treatment
procedures, clearly highlighting the conditions to be referred. The task bar has an automated alert
for all treatment follow up, referral follow up and follow up of high-risk mothers.
1.2.2 Theoretical Background
It is necessary to validate integrated service models in mobile health and to clarify theoretical
conceptualizations in order to advance research on service quality. The current research was
underpinned by the “Task-Technology Fit theory”.
The theory emphasizes how crucial it is for technology and user tasks to match up in order to
improve user performance. According to the theory, performance is influenced by a person's
abilities, technology features, and task requirements (Goodhue & Thompson, 1995).
The Task-Technology Fit theory illustrates the importance of a good fit between technology and
human tasks in improving individual performance. According to Goodhue (1995), effective
implementation requires the alignment of people, processes, and technology. The theory was
modified for use with mobile health (Goodhue & Thompson, 1995).
The task- Technology Fit theory aligns technology, processes and the users thereby providing
means of quantifying the effectiveness of Mobile-health in-built procedural tasks to boost
performance of CHPs and quality of service delivery.
1.2.3 Conceptual Background
“Mobile health” is the application of wireless technology such as mobile phones to the delivery
of medical treatment (Rouse, 2018). Mobile Health was operationalized by use of mHealth tools
like dashboards, apps and smartphones with task-technology features and inbuilt workflows that
aid in improving treatment efficacy by ensuring compliance to standard guidelines for
community healthcare service delivery.
Mobile devices are used for disease surveillance, train people on preventive healthcare, treatment
and monitoring in order to guide development towards more effective and efficient health care
solution. Akter (2013) proposed that development of an integrated model for service quality
requires reframing the quality of service as a reflective construct in order to assess its impact
usage and positive satisfaction of m-health users (Akter, 2013). mHealth presents several
4
chances to increase quality, cut costs, and enhance access to care (Dussault, Lapoa, & Gilles,
2017).
“Performance” is an outcome obtained in management economics that shows efficiency,
effectiveness and competitiveness (Verboncu, 2005). Performance of CHW was operationally
defined as the ability of a CHW to do household visit, assess and treat under five children
through the use of automated mobile app workflows in a mobile phone. In this research,
Performance was measured in terms of number of children assessed and treated through the
mobile app. CHWs in underserved rural regions provide integrated community case management
to children suffering from malaria, pneumonia, and diarrhea. It is important to align technology,
process and people in order to have useful mHealth solutions for the modern world. Behavioral
trends in regard to CHW phone use perception, usability and software friendliness are key to
acceptability of mHealth usage in communities. Improvement in CHW performance can be
achieved through better efficiency through on-time assessment, treatment, referral and Post Natal
Care follow up coupled with availability of internet to allow synchronizing of performance data
into the mHealth System. mHealth was measured in form of availability of ICT tools, mHealth
acceptance and mHealth technical support. Performance of community health workers was
measured in terms of efficiency, quality of healthcare given to communities, as well as
Community Health Worker (CHW) output in form of performance reporting for number of
households visited, number of under-five (5) child assessments and treatments as explained in
the conceptual framework
1.2.4 Contextual Background
mHealth is a subset of electronic health that focuses on delivery of medical services and
information via mobile devices (WHO, 2019). M-health apps provide health system
strengthening tools that aid in dozing efficacy and electronic management of health information
to inform policy. The Village Health Team (VHT) model in Uganda's public health system
incorporates a framework for routine performance evaluations. However, performance data
shows that much of the work done by CHWs is not integrated in the District Health Information
System (DHIS). The annual health sector performance report 2020/2021 indicated that no region
was able to meet the target for reporting on ICCM related activities done by CHWs with average
ICCM quarterly reporting rate of 27.9% for districts within Busoga region (MOH, 2021).
BRAC Uganda has prioritized the use of dashboard software to enhance CHW performance
under the Essential Health Care (EHC) program since 2015. Use of dashboard software
5
empowers organizations to progressively analyze and measure key performance indicators in real
time. Data analytics of key performance indicators avails valuable insight for quick and accurate
decision making. However, the performance of CHWs remains low and only 52% of the CHW
are able to consistently submit performance monthly reports through the mobile app (BRAC,
2022). There is a decline in performance output indicators by 8% and this is attributed to
increasing number of stolen phones, phones failing to install updates and syncing issues with the
dashboard.
Despite the above, there is a skills gap especially among elderly CHWs who still have challenges
in using the in-built timer to count breath per minute for pneumonia assessments and malaria
assessments for under 5children are still low due to inadequate supply of Malaria Rapid
Diagnostic test (mRDTs). There is reluctance to do treatment and referral follow up and this is
attributed to irregular use of the task bar therefore the task completion rate remains at 12%
(BRAC, 2022). The low levels of mHealth acceptance among CHWs have caused a decline in
performance metrics. The integration of digital technologies handles aspects of disease
surveillance and patient notification for health facility appointment dates or taking their
medications (Kamulegeya et al., 2019).
1.3 Problem Statement
mHealth plays a significant role in strengthening health systems to achieve universal health
coverage and the health related sustainable development goals (WHO, Use of appropriate digital
technologies for public health, 2018). In Uganda, mHealth has great potential to overcome
challenges in health care delivery by providing medical updates, learning resources and
reminders which improves the performance of community healthcare professionals through
accelerating the development of more effective and efficient health solutions (Kamulegeya L. H.,
2019). Brac Essential Health Care (EHC) program has transitioned to digital health through use
of Brac Afya app and distributed 4,082 android phones to its CHWs who were trained on the
workflows in the 72 districts of operation (BRAC, 2022). In March 2023, more 705 replacement
phones were distributed to fill the phone gap. The CHWs avail healthcare to approximately 7,983
households and the under-five child mortality has reduced by 27%, infant death by 33% and
neonatal mortality by 28% in the catchment areas (Brac Internatinal, 2019).
Despite the enormous benefits of mHealth, evidence suggests that CHW performance is still low
due to low perception of mHealth technologies’ usability among CHWs (Hoque, 2016). The low
acceptance levels to the Brac Afya mobile app among elderly CHWs coupled with poor network
6
in some areas, reckless handling of phones and inadequate technical support have contributed to
low performance reporting on key health indicators. HMIS reporting of CHWs on key
performance indicators in Busoga region is at 27.9% (MOH, 2021). The treatment efficacy and
compliance to procedural workflows in assessment of pneumonia is still challenging and has
greatly affects the performance efficiency of Brac CHWs in Iganga (Iganga, 2021). The
performance data quality is still low due to incomplete household data entered in the system
where only 40% beneficiary phone contacts are entered in the mobile app thus complicating
verification from the back-end of the system (BRAC, 2022).
Consequently, reluctance to handle malaria, pneumonia and diarrhea cases at community level
has increased the national health burden as the national malaria incidence rate has risen from
293 to 303 cases in 2020/221 (MOH, 2021) thus increasing congestion at health facilities. Low
CHW performance reporting misinforms management decisions in planning, budgeting and
implementation as key priority areas may be assigned inadequate budget due to available data.
Based on the above situation, this research therefore investigated the relationship between
mHealth tools, mHealth system acceptance and mHealth technical support and the performance
of CHWs in Iganga region.
1.4 Objectives of the study
1.4.1 General Objective
The general objective of the study was to investigate the relationship between mHealth and
performance of Community Health Workers.
1.4.2 Specific Objectives
i. To investigate the relationship between mHealth Tools and performance of Community
Health Workers.
ii. To examine the relationship between mHealth Acceptance and performance of
Community Health Workers.
iii. To assess the relationship between mHealth Technical support and performance of
1.5 Research Questions
i. What is the relationship between mHealth Tools and performance of Community Health
Workers?
ii. What is the relationship between mHealth Acceptance and performance of Community
Health Workers?
7
iii. What is the relationship between mHealth technical support and performance of
Community Health Workers?
1.6 Hypothesis
1. Mobile health tools have a significant relationship with performance of Community
Health Workers.
2. Mobile health acceptance has significant relationship with performance of Community
Health Workers.
3. Mobile health technical support has a significant relationship with performance of
1.7 Conceptual Framework
The Task- Technology Fit theory served as the basis for the approach used in this investigation.
This emphasizes how crucial it is for technology to be a good fit for user tasks in order to
improve individual performance (Goodhue & Thompson, 1995). We shall analyze how mHealth
tools, general acceptance and mHealth technical support affects the performance of Community
health workers.
mHealth Tools included mHealth platforms and functional ICT tools like Smart phones, tablets
and laptops where mHealth Apps are installed where entered performance data synchronizes in
the database to reflect as performance output reports of CHWs on the dashboard. mHealth
acceptance is the trust that individuals attach to the m-health platforms.
mHealth Acceptance is the ability of a CHW to efficiently use the app inbuilt workflows to
perform under five assessments, treatment and referrals.
MHealth technical support to CHWs includes adequate training in order to reduce CHW
resistance to new technology. Capacity building and support supervision is essential for
implementation of m-health. Technical support included management and maintenance of
mHealth tools. The quality of health care support is a measure of effectiveness, safety and
responsiveness of mHealth solutions. Technical support also ensures proper data quality checks,
usage and compliance to set storage guidelines.
8
Figure 1.1. The Conceptual Framework showing relationship between mHealth and
performance.
Source: Goodhue and Thompson (1995) “Task Technology Fit” and modified by the researcher.
1.8 Justification of the Study
Limited studies have been done under the Brac health program to assess the relationship between
mHealth and performance of Brac CHWs. More efforts are required to integrate performance of
Brac community health interventions into the national Health system in order to sustain impact
(Brac Internatinal, 2019). The study addressed the contextual gap on relationship between
mHealth platforms and performance of CHWs in terms of their contribution to Maternal
Neonatal and Child Health (MNCH) outcomes.
1.9 Significance of the Study
This study investigated the relationship between mHealth platforms and performance
Community health workers. The study may help Brac management team and staff to understand
how an integrated community healthcare system plays an important role in effectively serving
rural and inaccessible population during pandemics thus utilizing the missed opportunities in
community health service delivery.
Implementing Partners may assess how the usability of m-health platforms has improved
efficiency and quality of community healthcare service delivery. It will also give implementing
9
partners an insight into m-health adoption rate, level of acceptance in relation to individual
attitudes, behavioural traits and perception by communities where CHWs are working.
The study may also provide evidence to Policy makers for justifying policies that enabled an
optimal digital integration of CHW performance into the National Health care delivery system. It
will further give insight into the national roadmap for Digital Health among Community health
workers.
1.10 Scope of the Study
The scope of the study comprised of content scope, geographical scope and time scope.
1.10.1 Content scope
The main goal of the study is to establish relationship between mobile health and performance of
Brac CHWs in the Iganga region. The study examined relationship between available mHealth
tools, mHealth acceptance, mHealth technical support and performance output of CHWs.
1.10.2 Geographical scope
The geographical focus of the study was Brac health program Iganga region which comprises 9
districts in Busoga sub region namely; Iganga, Kaliro, Mayuge, Jinja, Kamuli, Namutumba,
Pallisa, Bugiri, and Namayingo found in Eastern Uganda.
1.10.3 Time scope
The research study focused on the project period of intervention by Brac’s Essential Health Care
program in Iganga region from 2016-2023. This is chosen because it is the period when mHealth
was piloted in the region to promote the use of technology to facilitate integration of community
health worker performance data into the health system in order to enhance timely service
delivery and reporting.
1.11 Operational Definitions of terms and concepts
Mobile Health; This refers to the usage and commercialization of mobile phones in the
healthcare industry. It may involve the use of short messaging service (SMS), as well as more
sophisticated features and apps, such General Packed Radio Service (GPRS), third and fourth
generation mobile telecommunications (3G and 4G) systems.
mHealth acceptance; Mobile health acceptance is one’s perception of a system after use.
mHealth acceptance was measured in terms of technology usage or how often someone logs into
the system.
10
mHealth technical support; This is assistance given to users of computer infrastructure and
web technologies. It involves trouble shooting both hardware and software issues.
Community Health Worker; A community health worker is defined as any healthcare
personnel who engages in activities related to the provision of health care and has received some
training specific to their positions to manage community-based services like the management of
minor illnesses in children, mobilization for public health interventions, and health education.
Performance; Performance is an outcome in management economics that shows efficiency,
effectiveness and competitiveness to task completion in accordance to established procedures.
Output; Refers to performance reports submitted through the mobile app.
Quality; Refers to compliance to the app workflows in the execution of under 5 sick child
assessments and treatments.
Efficiency Refers to the task completion rates in terms of treatment follow up and referral follow
up done by CHWs.
Minimum performance reporting by CHWs; This is the ability of a CHW to register 2 newly
identified pregnancies, conduct 40 under five sick child assessments and treat 24 children in a
month.
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CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
The literature was organized according to objectives and this chapter provides an overview of
studies that have been done, arguments and establishments on mHealth. The study goal is to
establish relationship between mHealth and performance of CHWs. The sources of literature
included books, journal articles, conference papers and theses of previous researchers. These
different sources were subjected to both historical and self-study reviews in order to identify
controversies and agreements. The review protocol comprised of purpose of the research
questions, search process screening, appraisal, extraction and synthesis of information for studies
done.
2.2 Theoretical Review
“The task-technology fit theory”
"Task- Technology Fit" refers to how well technological functionality aligns with task needs and
individual capabilities (Goodhue & Thompson, 1995). The term "Task Technology Fit" (TTF)
refers to how much technology enhances a person's ability to perform a variety of tasks. Task-
technology fit is the congruence of technology functionality, individual skills, and the tasks to be
accomplished. The technology's users can judge how well it interacts with both the task at hand
and people in general.
According to Goodhue (1995), the ideal information system will vary if task characteristics or
user characteristics change because technology is developed to be appropriate for the task and
the user. The study, emphasis was on fit as matching for individual abilities and tasks to be
performed. The cognitive cost/benefit analysis of the Task Technology Fit shows how different
data representations affect each person's performance (Vessey, 1991). According to Vessey
(1991), when the problem representation matched the task, performance for symbolic tasks
significantly improved. Therefore, users shouldn't mentally synthesize data prior to solving a
problem in order to meet the required minimum performance standard.
The assumption of task technology fit principle states that utilization of an information system
only leads to improved performance when the technology's capability matches users' job needs
(Goodhue & Thompson, 1995).
In this study we conceptualise utilisation as the level at which the information system has been
integrated to user’s work routine by organisational mandate since it reflects individual’s choice
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to accept the system. User involvement in system design potentially affects user attitudes and
commitment to utilise the system thus improving quality of technology-fit. Therefore, user
acceptance of task technology fit was influenced by technology features, the nature of the task,
and technical support, which in turn influences system utilization and consequently influences
people's performance more.
According to Gooodhue (1995) the users can evaluate task-technology fit in order to predict
performance. Therefore, technology has to be used first before it impacts performance. It's
crucial to make sure that technology, tasks, and user attributes are properly aligned in order to
get the anticipated performance outcome from system utilization (Seddon, 2004).
The performance construct refers to a group of tasks with various interdependent outcome
metrics that relate to the quantity and quality of data input into the system. Performance was
improved by a system with a higher task technology fit since it more closely matches the user's
work requirements (Thompson, 2014). While the theory has aspects of task and technology fit to
boost performance, there are gaps that need further study. However, the absence of a link
between tasks to be accomplished and people attributes empowers technology to generate the fit
depending on the individual and task to be done (Goodhue & Thompson, 1995).
According to Goodhue and Thompson 1995, measurement of constructs remains a concern in
this research. The TTF measure entails IT technical support for user tasks and execution of
routine transactions which propels further study and potential areas for improvement (Goodhue
& Thompson, 1995). Additionally, measures of characteristics information systems are crude
with minimal standard measurement for information comparability.
The TTF theory was expanded by Dishaw and Strong (1999) by taking into account the
Technology Acceptance Model (TAM) and TTF theory. They claimed that as technology is used
more, the perceived usefulness of the technology rises, leading to behavioral intention and
continuous use (Strong, 1999). Furthermore, Dishaw and Strong (1999) argued that although the
TTF theory heavily relies on task characteristics and technology acceptance as an assumption,
the complexity of a task is also a factor in a person's interest in using a particular technology.
Dishaw and Strong (1999) also stated that by extending the TTF model and combining it with the
TAM, the utilization construct was improved, which will improve the TTF model's low
predictive power.
Letchumanan and Tarmizi (2011) addressed the research gap and argued that individuals with a
poor attitude towards technology may accept and adopt to it because it increases their
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performance (Tarmizi, 2011). The purpose of this study is to expand the scope of testing to a
more diverse setting with differing individual abilities in order to get clarity on relationship
between mHealth and performance of CHWs through utilization of mHealth workflows and
feedback on perceived consequences of use. The task technology fit theory suits the current
study since it is ideal for linking mobile health technological characteristic and task workflows to
performance indicators of CHW as they conduct under five sick child assessments and
treatments at community level. The performance attribute therefore depends on the task chosen
as the input variable where app task-workflows and personal attributes influence performance.
2.3 Mobile Health and Performance
2.3.1 Mobile health
mHealth is a subset of electronic health that focuses on delivery of medical services and
information via mobile devices (W.H.O., 2019). In order to facilitate healthcare connectivity and
better service delivery, mobile health is a complementary idea linked to the technological and
processing characteristics of smart phones.
Istepanian and Woodard (2017) argued that the fundamental scientific tenets of mobile health are
completely incompatible with the mHealth reorientation from the post-smartphone age
(Istepanian & Woodward , mHealth: Fundamentals and Applications, 2017). Istepanian (2022)
further agreed that the 'known unknowns' related to the beginning and development of mobile
health are not properly understood or communicated as reorientation drivers (Istepanian , 2022).
Rowland and Fitzgerald (2020) agreed that there is a lack of evidence regarding the clinical
efficacy, cost effectiveness, patient acceptability and usage of mobile health applications, which
casts doubt on the larger body of evidence regarding the advantages of global healthcare,
security and privacy among other things (Rowland & Fitzgerald, 2020).
2.3.2 Performance of Community Health Workers
Performance is an outcome obtained in management economics that shows efficiency,
effectiveness and competitiveness (Verboncu, 2005). Kok and Dieleman (2015) made the case
that self-esteem, motivation, attitudes, competence, adherence to recommendations, work
satisfaction, and the ability to support urgent community health needs are all interrelated traits
that contribute to CHW success at the individual level. They also concurred that outcomes
relevant to clients, such as the use of health services, can be used to gauge CHW performance
(Kok, Dieleman, & Broerse, 2015).
14
Kok and Dielemaman (2017) further agreed that performance of CHW is impacted by
transactional social processes between CHWs and their environment but also takes into account
interactions with beneficiaries and other players in healthcare service delivery (Kok &
Dieleman , 2017).
Hackett (2015) recommended investigation to establish causal linkage between CHW job
satisfaction, performance and Maternal Neonatal and Child Health (MNCH) outcomes (Hackett
& Sellen, 2015). Hackett (2015) further argued that it is imperative to explore the readiness of
the health system to adopt mHealth interventions in order to have meaningful CHW performance
outcomes. In order to positively impact performance deliverables, care should be given while
creating mobile health applications and platforms so that they are ideally aligned to fulfill the
program's objectives and user characteristics of CHWs (Bautista, 2017).
Service quality positively triggers users’ cognitive response by improving usefulness, perceived
ease of use and trust which positively drives continuance adoption and performance (Yi Li,
2022).The proposed mHealth model needs to show that it integrates factors including perceived
value, perceived usability, social influence and service quality that was rendered by the targeted
users (Majharul Talukder, 2023).
Furthermore, Aranda and Loukanova (2014) argued that the quality of mobile healthcare services
is not at required level since confidentiality rights, patient security risk, regulations and high
technology costs affect both data and service quality which remains a challenge in dissemination
of mHealth (Clara B. Aranda-Jan, 2014).
2.4 Mobile health Tools
Mobile health is the use of technologies such as mobile phones and personal digital assistants to
provide health services and information (W.H.O, 2018). mHealth tools consists of input devices,
output devices and peripherals that healthcare professionals utilize to gather, evaluate and store
data that is helpful for making decisions.
There are 60.53 registered mobile phone subscriptions for every 100 people in Uganda as per
2020 statistics report (Taylor, November 2021). The mobile phone penetration rates have
increased to 67% according to UCC (Uganda communications commission) report for 2021.
However the smart phone adoption rate is still at 16% (Okeleke, 2019). The increased
availability of mobile phones and other ICT tools has led to increased mobile health
interventions in the underserved communities thus bringing healthcare services closer. A
15
number of smart phone applications or telemedicine applications are used for diagnostic
purposes and healthcare management.
Goodhue and Thompson (1995) argued that technology characteristics and personalization of
mobile apps boosts performance efficiency and effectiveness of the system by increasing the
success rates of system rollout among target groups through change in technology usage
behavior (Goodhue & Thompson, 1995).
M-health developers should focus on the content of the m-health workflows as security and
privacy concerns associated greatly affect uptake of mHealth interventions at community level.
The language used in m-health interventions should be clearly understood. Precise workflows
reduce workload burden for CHWs thus making the system user friendly to enhance greater
adoption and performance by CHWs. Moore and Benbasat (1996) agreed that increasing
intentions to use mobile apps is influenced by user attitudes and other situational factors
(Benbasat, 1996). The persuasive technology characteristics and features like the task bar
improves CHW performance efficiency by prompting CHWs to do timely treatment and referral
follow up on all physical activities done through the mobile phone app.
A study was done for junior clinicians at Guatemalan clinic to pilot an app that would guide
junior clinicians to correctly calculate prescription dosages. The study findings confirmed that
use of dosing apps improves treatment efficacy and reduces prescription errors. However, the
study did not take into account medical prescription errors from improperly shortened treatment
durations. The mHealth app provides patients with directions that are easy to read and
understand, but didn’t put into consideration errors attributed to miscommunication by health
worker (J Bradley Segal, September 9,2015). Additionally, there is insufficient data on efficacy
of mHealth tools and lack demonstrated success (J Bradley Segal, September 9,2015). Therefore,
medical instructions must be phrased in accordance to specific cultural contexts in order to
improve communication of the health worker. There is still a challenge of beneficiaries
intentionally disregarding the recommendation from the mHealth app since some perceive it as
slow thus affecting user trust, efficacy and adoption.
Yim and Gomez (2018) argued that everyday use of mobile apps enhances proper
communication and information retrieval. The use of m-health app saves time for work by
providing up-to date information related to tasks thus increasing productivity and improving
quality of work. The mHealth capability enhancer improves levels of adoption by enabling
Community health workers to confidently handle ICCM related childhood illnesses in respective
16
communities (Gomez, 2018). The use of mHealth apps increases knowledge awareness in
treatment context as CHWs keep following the programmed prescriptions according to age and
patient weight. Gisore (2012), Hartman (2017), Illozumba (2018) and Marcus (2015) agreed that
mHealth platforms should be developed and rolled out in a way that has cultural relevance to the
community. They further concured that mHealth apps that are not tailored to cultural practices
and beliefs are ineffective (Early, Gonzalez, & Gordon-Dseagu, 2019).
2.5 Mobile health acceptance
According to Adell (2010), mobile health acceptance is the level at which a person intends to use
a system and incorporates the system in doing his tasks (Adell, 2010). Mobile health acceptance
is the process through which technology users go beyond merely adopting to the mHealth
systems and instead makes it their own by incorporating it into their roles and social norms (Bar
F, 2016). Nadal (2020) defined mHealth acceptance as users perception of a system after
interfacing with it (Nadal C, 2020). Mohammad (2020) argued that behavioral Intention has the
strongest impact on the actual acceptance and usage behavior (Mohammad Zahedul Alam,
2020).
Andreia (2019) argued that performance expectations, effort expectations, social influence, and
enabling factors have a substantial impact on system acceptability (Andreia Nunes, 2019). The
greater the perceived usefulness of m-health apps, the higher the intention to use them in
boosting performance. mHealth apps that are perceived as easy to use in CHW context should
yield higher acceptance levels in order to improve performance efficiency and outcome.
Majharul (2023) argued that the current mHealth models demonstrate absence of a standardized
measurement framework for measuring technology acceptance (Majharul Talukder, 2023).
Nadal and Majharul agreed that technology acceptance is a process and mHealth acceptance
measurement tools should be developed to measure technology acceptance across the different
stages of the users’ journey (Nadal C, 2020).
Feroz, Kadir and Saleem (2018) concurred that there is an ongoing debate to explore health
system readiness for adopting m-health technology to address non-communicable diseases in
developing countries. The level of preparedness of health sector, availability of fund, mindset
change and willingness of community health workers are key determinant factors for health
system readiness and adoption of m-health (Anam Feroz, 2018). The willingness of health
workers to adopt to m-health is influenced by ability of m-health platforms to address health
issues in local context and health worker capability to use the system. Applications for
17
monitoring physical activity that are properly designed increase user adoption and give users
greater evaluative insight into which features are most effective for public health initiatives that
aim to change behavior. Because features have such a big impact on user acceptance and
adoption, mHealth application designers and developers need to concentrate on specific features
that are pertinent to the type of application in question in order to increase user adoption and
evaluation. The built-in features enhance behavioral change interventions (Emre Sezgin, 2018).
The most popular behavior change strategies include goal setting, tracking progress and giving
performance feedback (Middelweerd A, 2014). However, Arul (2014) asserted that technology
acceptance and adoption procedures at individual and subcultural levels are not understood due
to limited theoretical explanations for technology adoption that reflect a positive outcome in the
healthcare system (Arul Chib, 2014). Atnaafu and Bisrat (2016), argued that health systems in
developing countries are faced with complex decision making in regard to competing priorities
which affects the levels of acceptance and adoption (Asfwa Atnafu, 2016).
Despite the many achievements, there seems to be a challenge of failure to integrate m-health
component with the CHW current Job description and service delivery structure thus limited
levels of acceptance among elderly CHWs due to apprehension about workload and prolonged
workflows. Lack of comprehensive training and minimal support supervision to the CHWs
reduces acceptance and adoption levels. Welch (2019) argued that it is hard to quantify the
sociotechnical perspective by the end users which is a core determinant for technology use
despite mobile health improving accessibility and reachability regarding exchange of information
(Welch, 2019). It is therefore crucial to understand the drivers that propel acceptance decision by
users and continuous investigation may reflect changes in usability trends and performance.
2.6 Mobile health technical support
Mobile health rollout and implementation requires technical support to promote the match
between delivery of professional healthcare service and capability of the system users. Mobile
health technical support ranges from system maintenance, end-user trainings, device
maintenance and management, fixing basic problems and performing triage for bigger issues.
Technical support promotes quality at all levels of the mHealth implementation by strengthening
relationships within the system through prompt identification and resolution of problems
(Tegegne, 2018).
Fehringer and Marshall (2014) argued that support supervision through trainings has positive
outcomes to mHealth adoption, CHW productivity and positive behavioral intention among
18
CHWs (Fehringer & Marshall, 2014). Avortri, Nabyonga and Nabukalu (2019) agreed that
through regular support supervisory visits, trainings, coaching and mentoring that perceived
reliability on mHealth is improved and was reflected in dependability, safety and accuracy of
quality service delivery (Avortri, Nabukalu , & Nabyonga, 2019).
However, the providers’ relationships with communities during entry of data in mHealth may
have introduced bias as some members of the community perceive data entry by CHWs for
financial gains thus influencing beneficiary responses and acceptability of mHealth.
Bradley, Arevo, Franke and Palazuelos (2015) disagreed on grounds that m-health apps are
developed for users well versed with English yet there is need to review mHealth programs to fit
the needs or preferences of the users (J Bradley Segal, September 9,2015). Therefore, Integration
of m-health with Work load and short field visits with limited time for counseling complicate
health worker’s ability to address risk factors, danger signs and precautionary aspects to prevent
disease. Despite heavy investments in mHealth infrastructure, Governments still finds it difficult
to evaluate, scale up and integrate mHealth technologies despite the agenda for broad use of
digital health strategies and solutions to satisfy the variety of patient and population demands.
Lack of comparison standards and methods for evaluating the functionality, scalability and value
of digital health systems has complicated mHealth technical support (WHO, Use of appropriate
digital technologies for public health, 2018).
2.7 Summary of the literature review
Goodhue and Thompson (1995) and Moore and Benbasat (1996) agreed that personalization of
mHealth apps boosts performance efficiency and effectiveness of CHWs. mHealth Apps need to
be integrated into the national health system and DHIS through establishing a roadmap that
coordinates the current partnerships between government, private healthcare systems and
community health workers for successful m-health implementation
Mohammad Zahedul Alam (2020) and Andreia (2019) agreed that behavioral intention and
system acceptability greatly boosts performance efficiency and outcome. It is therefore essential
to include various stakeholders in order to assess uptake and contribution of mHealth initiatives
to CHW performance outcomes. This study examined the relationship between mHealth
acceptance and performance by examining how Brac Afya app features correspond with
conceptual indicators of CHW performance to improve health outcomes. It also aimed at
establishing key drivers to m-health acceptance in the public health space and strategies that can
be adapted to boost performance through m-health system use among CHWs.
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CHAPTER THREE
METHODOLOGY
3.1 Introduction
This chapter primarily described the methods that were used to gather, analyze and interpret the
data to solve the research problem. The majority of the information was gathered through survey
questionnaires, document review and interviews. The chapter also outlines the procedures for
data capture and data analysis. Survey questionnaires were used to understand performance
drivers that may influence unique personalities and perceptions towards mHealth acceptance and
adoption. To address the research topics, the study employed mixed method approach which
combines aspects of quantitative and qualitative research. It had a trans-disciplinary approach by
involving supervisors and selected Community health workers from the start of the study. It
applied a realistic perspective so as to better understand the relationship between mHealth
platforms and performance of community health workers.
3.2 Research Design
This study employed a cross-sectional design using mixed methods approach. The mixed
methods approach uses a variety of data types to effectively answer the research questions
(Hayati. D, 2006). Because qualitative data is supported by the quantitative data, mixed method
approach increases the credibility of results (Creswell J. C., 2017).
The cross-sectional research design enabled the researcher to understand the population
characteristics, know frequencies of occurrence especially in use of mHealh tools and establish
whether there is a relationship between mHealth and performance of CHWs. A greater
understanding of the research questions resulted from the use of mixed method approach. The
mixed method approach was crucial in determining relationships between variables through
analysis of the attitudes, behaviors and perspectives of the research subject (Punch, Introduction
to social Reasrch- Qualitative and Quantitative approaches, 2005). This research used both
qualitative and quantitative methods as the quantitative approach described the population, and
determine the frequency of performance output occurrence whereas qualitative approaches
uncovered deeply rooted performance perceptions and potential negative drivers to low system
use among some community health workers. This study's goal is to identify the attitudes,
behaviors, actions, and perceptions of people that propel mHealth use to enhance performance
(Miles, 1994).
20
3.3 Study Population
The study covered Brac CHWs from 9 districts within the Busoga sub region. The study
population of 647 people as per Brac 2021 CHW status was used and a sample of 252
participants comprising of 246 CHWs and 6 Staff at supervisory level as computed with
Yamane’s formula. The reason for this is that these serve the majority of the rural populations
and are the most easily accessible since they bring health services closer to the community.
Furthermore, the study sampled a few CHWs from Busia to have a diversity context to enrich the
findings. This enhanced the usability of the study finding.
3.4 Sample size determination
Sampling is the process of selecting a subset of a target population or universe to serve as a
representative sample of that group (Punch, 2005). Supervisors and CHWs were chosen for the
study using systematic random and purposive sampling techniques. A list of CHWs per branch
in different district was obtained and there after ranked according to the level of performance.
CHWs to be investigated were chosen using random sampling. Choosing subjects for purposive
or judgment sampling entails selecting those who are most favorably situated or in the greatest
position to offer the necessary information. (Sekaran, 2003).
Purposive sampling was used to choose staffs who are the immediate supervisors to CHWs
since they are in best position to avail performance data and give insights into CHW
acceptability trends.
Sample size was determined by Yamane’s formula. n = N/[1+N(e)²]
Where n is sample size, N is population size and e is the acceptable sample error which was 5%
Brac CHW sample size= 640/ [1+640(0.05) ²] = 246 respondents
Supervisory team sample size = 7/[ 1+7(0.05)²] = 6.87 which is approximately 7 respondents.
Table 1: Category of respondents from Iganga region
No. Category of respondents Population Sample size (S) Sampling Technique
(N)
1 Supervisory team 7 7 Purposive sampling
2 Brac CHWs 640 246 Random sampling
Total 647 253
Source: Population drawn from Brac CHW status for Iganga region (2021).
21
3.5 Sampling techniques and procedure
The study employed both probability and non-probability-based sampling strategies. The non-
probabilistic sampling technique was used to select staff who provided performance data for the
Brac CHWs and give a broader understanding in regard to CHW performance analysis and data
input behavioural trend.
The probability based sampling technique was used to select the CHWs through systematic
random sampling to avoid selection of a biased sample.
3.6 Data Collection Methods
Data was collected through questionnaire survey, interview and document review.
3.6.1 Questionnaire survey
To identify the CHWs’ drivers to mHealth acceptance and performance, the current study used
an online questionnaire survey with Likert scale questions. A questionnaire is a straightforward,
efficient research technique that can minimize data distortions caused by potential "interviewer
bias" during the interview process (Neuman W. L., 2011). The questionnaire survey was opted
for to gather a number of responses from CHWs in order to have deep understanding of the
relationship between mHealth acceptance, usability and CHW performance such that the findings
can be extrapolated to a larger audience.
3.6.2 Interview
To evaluate peoples' attitudes and expectations as they engage with others within a community or
organization, qualitative tools like the interview are devised (Neuman W. L., 2011).In order to
comprehend and explore participants' viewpoints, behaviors and experiences, the current study
used in person interviews. Semi-structured interviews can be a flexible and effective way to get
detailed information and insight into a business (Babbie, 2016).
The interview enabled respondents to share their inner thoughts, attitudes, and perceptions in an
open manner because the research's objective is to find deeply rooted personal attitudes and
beliefs that influence adoption and performance. The supervisors was chosen for their personal
expertise on the research theme in order to understand the different CHW behavioral traits that
have led to successful adoption and use of Brac Afya App in under 5 assessments and
administering of first line treatment at community level.
3.6.3 Document review
In order to identify significant changes over time, this data gathering technique entails examining
the organization's current performance data records and documents. Analyzing monthly
22
performance reports for required minimum performance reporting levels and the CHW phone
status report was required. Document review helps to clarify the program operations of the study
area and will give deep insights on performance trends of CHWs over a stated period.
3.7 Data collection instruments
This study used mixed approaches to collect its data. This study's main issue can be best
understood by combining qualitative and quantitative approaches. In this regard, the
questionnaire, interview guide or schedule and document review checklist was employed as data
gathering tools.
3.7.1 Questionnaire
Under quantitative, the questionnaire was used as the prime data collection instrument for CHWs
at community level in order to understand CHW perception about treatments prompted through
mobile app and challenges attributing to low app usability or poor performance among some
CHWs. The structured questionnaire consisted of three parts. The demographic data is found in
Part A, while the questionnaires for the various components was found in Part B& Part C.
Answer options for the construct's items range from (1) "strongly disagree" to (5) "strongly
agree" on a 5-point Likert scale.
3.7.2 Interview guide
An interview guide is a list of open-ended questions or topics that the interviewer hopes to cover
during the course of an interview (Mauldin, 2012). The interview guide shall give direction to
the discussion flow among Project officers and regional I.T officer to ascertain how CHW
acceptance and usability of the task technology characteristics of mobile health App is impacting
CHW performance. These aimed at establishing supervisor’s perspectives on low adoption rates
among CHWs and deeply understand the drivers to low performance among some CHWs.
3.7.3 Document review checklist
A document analysis guide was used to analyze the progressive performance reports to establish
the performance trends of CHWs over the research period. This entailed review of relevant
monthly KPI performance reports, meeting minutes, memos and quarterly phone status reports.
3.8 Validity and reliability
The researcher's sense of validity in the study and paradigm assumption selection has an impact
on validity. (Creswell J. C., 2017). Both face and content validity was assessed to gauge how
well the instrument corresponds to the theoretical notion in the current investigation. Prior to
23
doing the research, Creswell emphasizes that a researcher should conduct a pilot study of the
data collection methods (Creswell J. W., 2007).
The researcher used stratified randomization of sample elements in order to reduce sample bias.
Proper quality controls were adhered to in sample selection, data collection and data analysis
such that the sample results can avail data that is representative of the whole population. The
internal consistency approach, which compares the results of items that measure the same
construct, was used to assess the reliability of the instruments in the current study. A pilot test
was carried out to identify any problems with the research methodology and data collection
techniques. Within the target population, a pilot study was carried out among a group of CHWs
from one branch to assess the questionnaire's readability, clarity, and cultural relevance. These
tests assisted in identifying potential hazards. Since it considers the sample size and variety of
possible responses, the Cronbach's Alpha test was used. Quantitatively, to establish validity the
researcher conducted the content validity index (CVI) test to check the validity of the
questionnaire contents. The CVI is computed using the following formula.
CVI = Number of items considered relevant
Total number of items
Table 3.2: Results of content validity for research tools
Dimensions No of Items Relevant CVI
MHealth Tools 03 03 1
MHealth Acceptance 03 03 1
MHealth Technical support 03 03 1
Performance of Community 08 07 0.875
Health Workers
Source: Primary Data (2023)
Table 3.2 presents averages of 0.96 and (1, respectively & 0.875) on all four variables had a
CVIs that were above 0.7, imply that the tool was validity since it was appropriately answering /
measuring the objectives and conceptualization of the study. According to Middleton (2023), the
tool can be considered valid where the CVI value is 0.7 and above as is the case for all the four
variables provided above.
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3.8.2 Reliability of instruments
Reliability refers to the likelihood of getting the same results over and over again if a measure
was repeated in the same circumstances. Reliability ensured that measures are free from error so
that they gave same results when repeated measurements were made under constant conditions.
In line with this, the researcher used a heterogeneous population and participants drawn from
across-section of stakeholders who was involved in the management. The instruments were per-
tested by selection of a few staff members who will review and improve it, to ensure reliability
before it was really applied in the study (Yusoff, 2019). The researcher personally administered
the questionnaires to the participants and was available for consultations and explanations while
the participants fill in the data. The researcher checked the questionnaires to ensure that all the
questions are answered appropriately. The pre-test contributed to the credibility, dependability
and trustworthiness of the questionnaires. The findings from the test were coded in the SPSS, a
computer package to test for reliability at the Cronbach’s alpha coefficient so as to assess the
internal consistency above 0.70.
Table 3.3: Reliability test results of research instruments.
Study variables Cronbach’s Alpha
MHealth Tools 0.986
MHealth Acceptance 0.986
MHealth Technical support 0.986
Performance of Community Health Workers 0.865
Average Cronbach Alpha coefficient for variables 0.953
The reliability of instruments was established using Cronbach Alpha Coefficient which tests
internal reliability and the average reliability test result for research was 0.953 which is
recommended as given table 3.3 above.
3.9 Procedure of Data Collection
The essential research team members was chosen and trained in data collecting once the study
materials are finished and authorization has been given. The main concerns in content analysis,
event observation, and interview techniques were covered. Social workers and Project officers
with a medical background and a wealth of expertise performing health-related research was
included in the multidisciplinary component of the participant selection criterion.
25
To instruct Project officers on the various data gathering procedures and important ethical
concerns, a virtual training was organized. The principal investigator supervised the Project
officers as they pre-test the instruments as part of the training. CHWs took the pre-test at the
branch.
3.10 Data Analysis
There are several analytical techniques that may be used to deduce inductive conclusions from
data and separate the signal or phenomenon of interest from the noise (statistical fluctuations) in
the data (Shamoo & Resnik, 2014). Researchers analyse data for patterns in observation through
the entire data collection phase (Robinson, 2005).
3.10.1 Quantitative data analysis
Before entering the statistical package for social sciences (SPSS) computer statistical application,
the researcher will check and clean the data. SPSS program was used to code and enter
quantitative data into computers. The data was analyzed using descriptive and inferential
statistics methods utilizing the SPSS (Statistics Package for Social Science) software. The mean,
frequency, and standard deviation of the data was determined through descriptive statistics. The
association between the IV and DV was determined using the correlation method and regression
coefficient. Inferential statistics are used to make influences concerning research proposition
applicability to the study population (Thomas B. Lawrence, 2006). However, improper statistical
analyses may distort scientific findings, mislead casual readers or may negatively influence
public perception of research (Shephard, 2002). Therefore, adherence to proper data analysis
procedures is vital in obtaining ethical evaluation and validity of findings.
Report writing was done by the researcher and after approval of the final report by management;
dissemination of results of the study was done through a virtual meeting with the research team.
In addition, a copy of the report was presented to the Brac Health Program management team.
Therefore, triangulation can yield corroborated findings and any weakness in a set of data can be
compensated for by the strength of other data in order to increase the validity and reliability of
the results.
3.10.2 Qualitative data analysis
Content analysis and thematic analysis was used to analyze qualitative data. In-depth interviews
was transcribed and translated as data collection is in progress. Information was critically
categorized to identify themes, patterns and connections in order to draw inferences. All relevant
26
sources of data were considered to allow for triangulation. Differences or contradictions between
data sources were examined and explanations sought.
Qualitative content analysis is an approach of empirical, methodological controlled analysis of
texts within their context of communication, following content analysis rules and step by step
models, without rash quantification (Neuman W. , 2011). Content analysis enabled the researcher
to identify patterns, attributes that can be coded by the researcher to easily attach meaning to the
outcome.
Data obtained through the questionnaire was recorded and transcribed. The content analysis
followed the criterion of underlying themes or keyword that were further sub grouped and
tabulated for presentation as frequency distribution. Information gathered was classified
according to themes and domains and presented in form of taxonomies that reveal emerging
patterns based on the assumption that cultural diversity and cultural competences are valued in
social work (Spradley, 1997).
3.11 Measurement of variables
The structured questionnaire was used in data collection from CHWs and consisted of three
parts. The nominal scale which is qualitative in nature will gather the demographic data in Part
A, while the interval scale which is quantitative in nature will measure subjective characteristics
of respondents in Part B& Part C. Answer options for the construct's items ranged from (1)
"strongly disagree" to (5) "strongly agree" on a 5-point Likert scale. For open ended interview
questions, the responses were categorized based on themes and grouped according to current
issues for qualitative analysis.
3.12 Ethical considerations
Specific approval of the Uganda Management Institute research committee was obtained for this
study. An endorsement letter with approval and permission was sought from Brac Uganda
Program Manager Health was obtained as authorization to conduct research in the study area.
Prior to recording interactional data, work must be done to adequately address the ethical,
practical, and relational aspects of data collection (Ruth Parry, 2016). Collecting interactional
data in a health care setting requires building trust with those from whom you are collecting it
and that can be assisted through careful consideration of how you will ensure the privacy and
security of the data (White, 2018).
The researcher strictly adhered to the ethical code of conduct and will give participants specific
instructions not to disclose their names or any other identifying information. We took all
27
necessary precautions to make sure that everyone who agrees to take part in the study is doing so
voluntarily and with full knowledge and consent.
The researcher with the assistance of research assistants associated with the research equitably
recruited CHWs for participation and will all be treated equally.
In order for the people in the study areas to comprehend all of the research's components, the
researcher explained the study's goals and objectives to them. Participants had the opportunity to
clarify any aspects that are unclear to them by asking questions in order to ensure informed
consent of participants.
For purposes of utmost confidentiality, data amassed during the course of the study was kept
private and that special ID numbers were used on research documents instead of respondent
names and contacts.
There was equal treatment of respondents and special protection of all vulnerable CHWs.
There was declaration and proper referencing of all primary and secondary sources of data as
compliance to anti plagiarism.
There was honest declaration of all study findings to all concerned parties.
28
CHAPTER FOUR
PRESENTATION, DISCUSSION, AND ANALYSIS OF FINDINGS
4.1 Introduction
This chapter presents the findings, analysis and interpretations to the findings on the relationship
between mHealth and performance of CHWs. The study was premised on the following research
objectives; to examine the relationship between mHealth Tools and performance of Community
Health Workers; to establish the relationship between mHealth Acceptance and performance of
Community Health Workers; and to determine the relationship between mHealth Technical
support and performance of Community Health Workers. This chapter starts with the
introduction, followed by the response rate; demographic data of the respondents; descriptive
statistics and inferential statistics interlinked with qualitative results.
4.2 Response rate
In the study, the researcher used both the interview guides and self-administered questionnaire to
aid the collection of data. The two were used because they are cost friendly, they cover a wide
population for the study and interviews provide first-hand information. Table 4.5 below presents
the response rate.
Table 4.4: Response rate
Tool (Planned/Scheduled) (Received/ Held) Response Rate
Questionnaires 246 241 98%
Interviews 07 07 100%
Total 253 248 98
From the Table 4.4 above, results returned indicate that out of 246 questionnaires issued, 242
were returned fully completed, constituting (98%). On the other hand, the researcher held, (07)
interview sessions as planned resulting in a (100%) percentage return. According to Amin
(2005), a response rate above 50% is good enough to represent a survey.
29
4.3 Background information
In order to get a detailed and more concrete picture of the study sample, the study examined the
background information, which included; gender, age of respondent and level of education,
employment status and duration of service. These results show the characteristics of the
institution.
4.3.1 Gender of respondent
The sex characteristics of respondents were investigated for this study to examine the effect of
each gender on the study. The findings are presented in Table 4.6 below.
Table 4.5: Gender of respondents
Gender of respondent Frequency Percentage (%)
Female 241 100
Total 241 100
Source: Primary Data, (2023)
Findings from the study as illustrated in Table 4.6 show that 100% of the respondents were
females who participated in the study implying that they were informed relationship between
mHealth and performance of CHWs.
4.3.2 Age of respondents
The study looked at age distribution of the respondents by age using frequency distribution. Data
on age was collected because it helps to examine how age of respondents affects the responses.
The results obtained on the item are presented in Figure 4.2 below.
45
40
35
30
25
20
15
10
5
0
18-25years 26-35years 36-45years 46-55years 56years and
above
30
Figure 4.2: Age of respondents
From Figure 4.2 above, majority of respondents 102(42%) were between 46-55 years, 84(35%)
of respondents were between 36-45 years, 36(15%) of respondents were between 26-35 years
and minority of the respondents 17(07%) were between 56 and above years and 18-25 years
were between 18-25 years respectively. This indicated that all categories of respondents in
reference to different age groups were represented in this study thus representing the response
rate of the institution.
4.3.3 Educational Level of the Respondents
The study looked at educational Level of the respondents by using frequency distribution. It was
important to establish the education level of respondents because it helps to understand how the
education levels affect the study. The results obtained on the item are presented in Figure 4.3
below.
Below S.4 S.4 Certificate Diploma

5% 2%
23%
70%
Figure 4.3: Level of education of respondents

Figure 4.3, indicate that majority of the respondents 166(69%) were below S.4, 56(23%) were
S.4 holders, 12(05%) were certificate holders while 04(02%) were diploma holders. Basing on
the academic background, all of the respondents had the potential to know basic knowledge on
the relationship between mHealth and performance of CHWs.
31
4.3.4 Staff category
The study looked at category of the respondents by using frequency distribution. It was
important to establish the category level of respondents because it helps to understand how affect
the study variables. The results obtained on the item are presented in Figure 4.3 below.
Table 4.6: Staff category
Category Frequency Percentage
Super CHW 193 80
Subordinate CHW 48 20
Total 241 100
Findings from Table 4.6 indicated that majority of the respondent were Super Community Health
Workers (CHW) and the rest were Subordinate Community Health Workers (CHW). This
implies that they were more knowledgeable about the study variables.
4.3.5 Years of services
The study looked at years of services of the respondents by using frequency distribution. The
results obtained on the item are presented in Figure 4.4 below.
80
70
60
50
40
30
20
10
0
Less than 1 year 1-2 years 3-4 years Greater than 4 years
Figure 4.4: Working experience

Findings from Figure 4.4 reveal that the majority of the respondents 178(74%) had worked for
more than 4 years, 55(23%) had worked for over 3-4 years and 02% of the respondents had
worked for Less than 2 years respectively. This implies that most of the respondents had enough
32
knowledge about the study variable, Uganda. This means that the findings from the study are
sounding from an experienced population.
2.4.6 Working devices
The study looked at the equipment use by respondents by using frequency distribution. The
results obtained on the item are presented in the Table
Table 4.7: Working devices
Category Frequency Percentage
Yes 226 94
No 15 06
Total 241 100
Findings from the Table 4.7 indicate that majority of the respondents 94% used phones to
execute their duties whereas the minority of the respondents 06% used other mechanism. This
implies that Mhealth devices were user friendly, less time consuming in terms of data capture
and more flexible compared to traditional methods of data capture.
4.4 Empirical findings from the study
This section presents the empirical findings of the study according to the objectives. The
empirical findings are analyzed using descriptive statistics, qualitative analysis and testing
hypotheses for the respective findings. For all descriptive findings in this section, item
statements were administered to respondents to establish the extent to which they agreed with
them. The responses were measured on a five point Likert scale ranging from (1 = Strongly
Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree and 5= Strongly Agree). Descriptive data was
analyzed using frequency, mean and standard deviation statistics. It was then collaborated with
qualitative data using narrative and thematic analysis before testing hypotheses. Firstly, this
section presents findings on performance of Community Health Workers followed by the
research objectives. The mean range 4.20-5.00 were interpreted as Very satisfactory, mean range
3.40-4.19 were interpreted as Satisfactory, mean range 2.60-3.39 were interpreted as Fairly
satisfactory mean range 1.80-2.59 were interpreted as Unsatisfactory and lastly mean range 1.00-
1.79 were interpreted as Very unsatisfactory.
4.4.1 Performance of Community Health Workers in Iganga region

33
Statements on performance of Community Health Workers in Iganga region were structured
basing on the objectives of the study. Statements were measured on a five-point Likert scale
where code 1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree and 5 = Strongly Agree.
The data was presented and analyzed basing on seven (07) statements which are statistically
tabulated and presented in the table below with the frequencies and percentages according to the
responses collected.
Table 4.8: Opinions of respondent on performance of Community Health Workers in
Iganga region
Statements [Percentage, (%)/Frequency] Mean SD
SD D N A SA
CHWs exhibit improved knowledge in 06% 04% 02% 26% 82% 4.46 1.12
dozing efficacy for malaria, diarrhea (15) (10) (05) (13) (198)
and pneumonia especially among under
5 children.
CHWs possess technical knowledge 01% 06% 04% 31% 57% 3.61 1.20
required for the efficient treatment and (03) (15) (10) (75) (138)
referral follow up through alerts by task
bar.
CHWs carry out assessments and 00% 00% 01% 34% 63% 3.50 1.06
treatments in accordance to specified (00) (00) (02) (84) (155)
policies and procedures as per SCJA
CHWs follow procedural tasks as 00% 04% 02% 42% 52% 3.40 1.03
prompted by the app and in accordance (00) (09) (06) (101) (125)
to MOH guidelines.
CHW effectively communicates 00% 00% 00% 49% 51% 3.67 1.02
prescription information to caregiver (00) (00) (00) (117) (124)
and do treatments or referral follow up.
There is increase in real time data 00% 05% 06% 40% 49% 3.30 1.56
capture and timely sharing of (00) (11) (14) (97) (119)
performance data by CHWs
Tracking and responding to health 00% 01% 03% 40% 55% 3.50 1.08
issues in a timely manner improves
34
health outcomes and reduces under 5 (00) (03) (08) (98) (132)
mortality.
With reference to the Table 4.7; as to whether CHWs exhibit improved knowledge in dozing
efficacy for malaria, diarrhea and pneumonia especially among under 5 children, 06% of the
respondents disagreed with the statement, 04% of the respondents strongly disagreed, majority of
the respondents 82% agreed with the statement. This is also supported by the mean value of 4.46
indicate those who agreed with the statement and the standard deviation of 1.12 that shows the
dispersion of responses close to the mean value.
Findings also reveal that 57% of the respondents strongly agreed with the statement that CHWs
possess technical knowledge required for the efficient treatment and referral follow up through
alerts by task bar, 31% strongly agreed, while minority of the respondents 06% disagreed with
the statement. This is also supported by the mean value of 3.61 indicting those who were
satisfied with statement and standard deviation of 1.20 indicated those deviating.
As to whether CHWs carry out assessments and treatments in accordance to specified policies
and procedures as per SCJA, 63% of the respondents strongly agreed with the statement whereas
34% agree with the statement and 01% of the respondents were neutral. The mean of 3.50
indicate those who were satisfied with the statement and standard deviation of 1.06 indicated
those with deviating responses from the statement.
Findings further indicated that majority of the respondents 56% agreed with the statement that
CHWs follow procedural tasks as prompted by the app and in accordance to MOH guidelines,
42% agreed with the statement, 02% were Neutral, whereas 04% disagreed with the statement
respectively. The mean of 3.40 indicated respondents who were fairly satisfied with the
statement and the standard deviation 1.03 indicated those deviating responses. This implies that
Mobile App is favorable because software content is preserved better, access to information is
easy and available anytime since we move with our phones, the information in App is easier to
follow during training, taking notes is safer, and easy to access, information can be easily
updated and published, the App can be used as a tool for collecting data from the community,
saves time transporting people for training, the easiest way to sensitize community members and
technical terms can be searched and meaning acquired right away.
As to whether CHW effectively communicates prescription information to caregiver and do
treatments or referral follow up, 51% of the respondents strongly agreed the statement, whereas
35
49% of the respondents strongly agreed with the statement respectively, The mean of 3.67
indicated those who were satisfied with the statement and the standard deviation of 1.02
indicated those with deviating responses from the statement. This implies that adequately trained
CHWs will acquire competencies to become frontline health workers who effectively deliver
health services in their communities through accurate diagnoses and on-site treatment using
high-quality medicines. They are also able to refer acute cases to health facilities and conduct
timely referrals to ensure a quality continuum of care for their clients.
On the statement there is increase in real time data capture and timely sharing of performance
data by CHWs majority of the respondents 49% strongly agreed with the statement whereas 40%
agreed and 06% were neutral with the statement respectively. The mean of 3.30 indicate those
who were unsatisfied with the statement and the standard deviation of 1.56 indicated those with
deviating responses. This implies that data submission by mobile phone was seen as a potential
avenue for improved feedback, as their supervisor could use the submitted data to judge their
performance and could then give feedback through a text, voice call, or face-to-face visit.
As to whether tracking and responding to health issues in a timely manner improves health
outcomes and reduces under 5 mortality, 55%% of the respondents strongly agreed with the
statement, 40% of the respondents agreed whereas 03% of the respondents were neutral. The
mean of 3.50 indicated those who were satisfied with the statement and the standard deviation of
1.08 indicated those with deviating responses from the statement. This implies that new
innovation assists CHWs in record keeping, reporting, monitoring, and providing basic maternal
and neonatal health services.
4.4.2 The relationship between mHealth Tools and performance of Community Health
Workers
The statements on mHealth tools were structured basing on the objectives of the study.
Statements were measured on a five-point Likert scale where code 1 = Strongly Disagree, 2 =
Disagree, 3 = Neutral, 4 = Agree and 5 = Strongly Agree. The data is presented and analyzed
basing on three (03) items, which are statistically tabulated and presented in the table below with
the frequencies and percentages according to the responses collected.
Table 4.9: Opinions of respondent on mHealth Tools at Iganga region
36
Statements [Percentage (%)/ Frequency] Mean SD
SD D N A SA
CHWs are availed with smart phones 00% 00% 00% 11% 89% 4.57 1.43
with app installed. (00) (00) (00) (27) (214)
Supervisors are given tablets and 00% 00% 10% 27% 55% 3.61 0.98
laptops for analyzing and tracking (00) (00) (24) (66) (132)
performance metrics
ICT tools have technical specifications, 00% 07% 05% 44% 44% 3.40 0.68
features like the task bar that sends (00) (17) (12) (107) (105)
alerts and reminders.
Table 4.8 presents that a statement as to whether CHWs are availed with smart phones with app
installed, 89% of the total respondents strongly agree with the statement, 11% agreed, whereas
none of the respondent disagreed with the statement. This is also supported by the mean value of
4.57 that indicate those who were satisfied with the statement and the standard deviation of 1.43
that shows the dispersion from the statement. This implies that use of mHealth apps increases
knowledge awareness in treatment context as CHWs keep following the programmed
prescriptions according to age and patient weight.
On the statement supervisors are given tablets and laptops for analyzing and tracking
performance metrics, 55% of the respondent strongly agreed with the statement, 27% of the
respondents disagreed with the statement where 10% of the respondents were neutral to the
statement. This is also supported by the mean value of 3.61 indicating those who were satisfied
with the statement and standard deviations of 0.98 indicating those deviating responses from the
statement. This implies that supervisors use the technology to guide them in their work planning
and supportive supervision. The application helps them prioritize critical tasks and guides them
through a supportive supervision visit with a customized checklist.
On the statement ICT tools have technical specifications, features like the task bar that sends
alerts and reminders, 44% of the respondents agreed with the statement respectively, whereas
07% of the respondents disagreed with the statement, 05% were neutral. The mean of 3.40
indicted those who were fairly satisfied with the statement and standard deviation of 0.68
indicated those with deviating responses from the statement. This implies although most CHWs
37
had been exposed to mobile phones, they had concerns about complex phone functions or apps,
but they felt they could cope if they were given training and support. The findings are supported
by the key informant for revealed that:
My main concern will be our ability to use these phones because it will be the first
time for most/all of us to use them for this kind of work. However, with the
constant training, I think we shall be able to slowly learn how to use them
(KII/008/19th/05/2023).
Table 4.10: Correlation matrix for mHealth Tools and performance of Community Health
Workers
MHealth Tools Performance of Community
Health Workers
MHealth Tools Pearson Correlation 1 .688**
Sig. (2-tailed) .0001
N 241 241
Performance of Pearson Correlation .688** 1
Community Health Sig. (2-tailed) .0001
Workers N 241 241
Source: Primary Data (2023) **. Correlation is significant at the 0.01 level (2-tailed).
Pearson correlation results as presented in table 4.10 depicts a strong positive relationship
between mHealth Tools and performance of Community Health Workers (r = .688). The study
that p-value (p=.000<0.05). Hence, the results have confirmed that mHealth Tools has positive
significant relationship with performance of Community Health Workers. Therefore the
alternative hypothesis has stated in chapter one is held.
H1: Mobile health tools have a significant relationship with performance of Community Health
Workers.
38
4.4.3 The relationship between mHealth Acceptance and performance of Community
Health Workers
The statements on mHealth acceptance were structured basing on the objectives of the study.
Items were measured on a five-point Likert scale where code 1 = Strongly Disagree, 2 =
basing on three (03) statements, which are statistically tabulated and presented in the table below
with the frequencies and percentages according to the responses collected.
Table 4.11: Opinions of respondent on mHealth Acceptance at Iganga region
Statements [Percentage (%) /Frequency] Mean SD
SD D N A SA
Mhealth devices are user friendly, less 00% 07% 01% 42% 51% 3.53 1.03
time consuming in terms of data (00) (16) (04) (102) (122)
capture and more flexible compared to
traditional methods of data capture.
Perceived usefulness and trust of 00% 01% 14% 45% 41% 3.35 1.08
mHealth platforms increases adoption (00) (04) (33) (109) (98)
intention among CHWs.
Social influence from fellow CHWs 01% 03% 13% 44% 41% 3.34 0.99
and performance expectancy increases (01) (07) (32) (106) (98)
mhealth adoption and minimum
performance reporting.
Table 4.9 presents a statement as to whether Mhealth devices are user friendly, less time
consuming in terms of data capture and more flexible compared to traditional methods of data
capture, 42% of the respondents agreed with the statement, 51% of the respondents strongly
agreed with the statement, 01% were Neutral whereas 07% of the respondents disagreed with the
statement respectively. The mean of 3.53 indicated those who were satisfied with the statement
and the standard deviation of 1.03 indicate those deviating responses. This implies that CHWs
submit numerical data, such as number of children treated, using a paper-based system. Data
submission by mobile phone was perceived as having the potential to enhance performance by
improving efficiency. The findings are supported by the key informant who asserts that:
39
If...we can send the statistical data via mobile phone...we would not be worried
more about the transportation, travel time to go and return from the health center
and the time lost in the health center in the process of data submission
(KII/008/19th/05/2023).
As to whether perceived usefulness and trust of mHealth platforms increases adoption intention
among CHWs, 45% of the respondents agreed with the statement, 41% strongly agreed, 14%
were Neutral whereas 01% of the respondent disagreed with the statement respectively. The
mean of 3.55 indicated those who were satisfied with the statement and the standard deviation of
1.08 indicated those with deviating responses from the statement. CHWs described the potential
for mobile phones to generate greater levels of community standing by increasing community
trust and credibility. The findings are supported by the key informant who indicated that:
A phone always has an impact on the community; it changes someone’s status
and people start trusting that person (KII/008/19th/05/2023).
The degree to which a phone could increase status was linked to its perceived value:
Those modern phones are beautiful and all the people know that they are
expensive. It would increase our status in the community as the people will
perceive that we are recognized by the government as people who are doing a
useful work (KII/008/19th/05/2023).
As to whether social influence from fellow CHWs and performance expectancy increases
mhealth adoption and minimum performance reporting, 44% of the respondents agreed with the
statement, 41% strongly disagreed with the statement, 13% were Neutral whereas minority of the
respondents 03% disagreed with the statement. The mean of 3.34 indicated those respondents
who were fairly satisfied with the statement and the standard deviation of 0.99 indicated those
with deviating responses. This implies that increased operability also heightens users’
expectations towards acquiring the desired performance for that technology.
Table 4.12: Pearson correlation for mHealth acceptance and performance of Community
Health Workers
MHealth Acceptance Performance of
Community Health
40
Workers
MHealth Acceptance Pearson Correlation 1 .775**
Sig. (2-tailed) .0001
N 241 241
Performance of Pearson Correlation .775** 1
Community Health Sig. (2-tailed) .0001
Workers N 241 241
*Correlation is significant at 0.01 level (2-tailed)
between mHealth acceptance and performance of Community Health Workers (r = .669). The
study results further indicated a significant statistical relationship between the study variables
given that p-value (p=.000<0.05). Hence, the results have confirmed that mHealth acceptance
has positive significant relationship with performance of Community Health Workers. Therefore
the alternative hypothesis has stated in chapter one is held
H2: Mobile health acceptance has significant relationship with performance of Community
Health Workers.
4.4.4 The relationship between mHealth Technical support and performance of
Community Health Workers
The items on mHealth Technical support were structured basing on the objectives of the study.
Items were measured on a five-point Likert scale where code 1 = Strongly Disagree, 2 =
basing on three (03) items, which are statistically tabulated and presented in Table 4.13 below
with the frequencies and percentages according to the responses collected.
Table 4.13: Opinions of respondents on mHealth Technical support in Iganga region

Variable (N=103) [Percentage (%)/Frequency] Mean SD
SD D N A SA
Basic and refresher trainings avails 00% 00% 00% 09% 91% 4.72 1.28
41
CHWs with adequate knowledge and (00) (00) (00) (21) (220)
skills to interface with the mHealth
application.
Regular support supervision, coaching 01% 00% 00% 12% 87% 4.50 1.01
and mentorship improve CHW (04) (00) (00) (30) (210)
perceived usefulness of mHealth app
and promote positive behavior.
System management and device 01% 09% 16% 47% 27% 3.08 0.99
maintenance increases dependability of (01) (22) (39) (114) (66)
mhealth platforms through safety and
confidentiality of health information.
With reference Table 4.13, as to whether basic and refresher trainings avails CHWs with
adequate knowledge and skills to interface with the mHealth application, 91% of the respondents
strongly agreed with the statement, 09% of the respondents agreed with the statement
respectively. The mean of 4.72 indicated those who were stratified with the statement
respectively and the standard deviation of 1.28 indicated those with deviating responses from the
statement. This implies that refresher training could establish working relationships between
CHWs and other health workers and enhance respect from other health workers towards CHWs
because of upgraded knowledge. The findings above are supported by the key informants who
assert that:
All CHWs spoke highly of the training they had received and said that acquiring
health knowledge was one of the main benefits of being a CHW. Both high- and
low-performing CHWs said they would like more training in the future. Most
CHWs said that the person who had initially trained them was their supervisor
(either their current or previous supervisor). Although there were no explicit
differences in their descriptions of training, the comments made by CHWs suggest
that some CHWs experienced training differently to others. For example, one
CHW said she didn’t know how to fill in her patient register, because she took
over from another CHW and didn’t receive the same training that the previous
CHW had received (KII/008/19th/05/2023).
42
On the statement regular support supervision, coaching and mentorship improve CHW perceived
usefulness of mHealth app and promote positive behavior, 87% of the respondents strongly
agreed with the statement whereas 12% disagreed with the statement respectively. The mean of
4.50 indicate those who were satisfied with the statement and standard deviation of 1.01
indicated those with deviating responses. This implied that CHWs proved capable of mastering
all of the required mobile phone skills and no differences were identified relative to previous
educational level achieved. The findings above are supported by the key informants who assert
that:
The supervisor’s support in this example highlights another way in which
supervisors can influence performance. Most discussions of supervision framed it
as a means for verification; a process for checking that the CHW is doing their
job, and doing their job correctly. But several comments by CHWs and
supervisors explicitly highlighted two different goals of supervision to encourage
and motivate CHWs, and to advocate for them as legitimate health care providers
(KII/008/19th/05/2023).
Findings further indicate that system management and device maintenance increases
dependability of mhealth platforms through safety and confidentiality of health information, with
47% agreeing with the statement, 27% of the respondents strongly whereas 16% of the
respondents were neutral. The mean of 3.08 indicate those who were not satisfied with the
statement and standard deviation 0.99 indicated those with deviating responses. This implies that
in both settings, CHWs felt that the impact of mHealth interventions would be undermined by
patchy network coverage and system overload, but felt that this could be overcome by using
phones with dual SIM cards. CHWs also expressed concern over the maintenance of the
equipment and theft or damage:
What about if I lost the supplied phone or if it was stolen from me? Are you going
to arrest me or ask for replacement/payment? I’m wondering because I can’t
afford it (KII/008/19th/05/2023).
Table 4.14: Pearson correlation coefficient for mHealth Technical support and
performance of Community Health Workers
43
Correlation coefficients
MHealth Performance of Community
Technical support Health Workers
MHealth Pearson correlation 1 .569
Technical Sig.(2-tailed) .000*
support N 241 241
Performance of Pearson correlation .569 1
Community Sig.(2-tailed) .000*
Health Workers N 241 241
*Correlation is significant at 0.01 level (2-tailed)
Pearson correlation results as presented in table 4.14 depicts a strong positive correlation
between mHealth technical support and performance of Community Health Workers (r=.569).
The study results further indicated a significant statistical relationship between the study
variables given that p-value (p=.000<0.05). Hence, the results have confirmed that mHealth
Technical support has positive significant relationship with performance of Community Health
Workers. Therefore the alternative hypothesis has stated in chapter one is held.
H3: Mobile health technical support has a significant relationship with performance of
44
CHAPTER FIVE
SUMMARY, DISCUSSION, CONCLUSIONS AND RECOMMENDATION
5.1 Introduction
This study focused on effect of organizational factors on performance of Community Health
Workers in Iganga region, Uganda. This chapter presents a summary, discussion of findings,
conclusions and recommendations made by the study, and all these are in line with the research
objectives which include; to examine the relationship between mHealth Tools and performance
of Community Health Workers, to establish the relationship between mHealth Acceptance and
performance of Community Health Workers and to determine the relationship between mHealth
Technical support and performance of Community Health Workers.
5.2 Summary of the study findings
This section provides a summary to the study findings according to research objectives which
include, to examine the relationship between mHealth Tools and performance of Community
Health Workers, to establish the relationship between mHealth Acceptance and performance of
Community Health Workers and to determine the relationship between mHealth Technical
support and performance of Community Health Workers.
Workers
between mHealth Tools and performance of Community Health Workers (r = .688). The study
that p-value (p=.000<0.05). Hence, the results have confirmed that mHealth Tools has positive
significant relationship with performance of Community Health Workers. Therefore the
alternative hypothesis has stated in chapter one is held.
H1: Mobile health tools have a significant relationship with performance of Community Health
Workers.
Qualitatively, respondents revealed that main concern was the ability to use these phones
because it was the first time for most/all of them to use them for this kind of work. However,
with the constant training, they were able to slowly learn how to use them
45
Health Workers.
between mHealth acceptance and performance of Community Health Workers (r = .669). The
study results further indicated a significant statistical relationship between the study variables
given that p-value (p=.000<0.05). Hence, the results have confirmed that mHealth acceptance
has positive significant relationship with performance of Community Health Workers. Therefore
the alternative hypothesis has stated in chapter one is held
H2: Mobile health acceptance has significant relationship with performance of Community
Health Workers.
Qualitatively, respondents revealed that modern phones are beautiful and all the people know
that they are expensive. It would increase our status in the community as the people will perceive
that we are recognized by the government as people who are doing a useful work.
Pearson correlation results as presented in table 4.14 depicts a strong positive correlation
between mHealth technical support and performance of Community Health Workers (r=.569).
The study results further indicated a significant statistical relationship between the study
variables given that p-value (p=.000<0.05). Hence, the results have confirmed that mHealth
Technical support has positive significant relationship with performance of Community Health
Workers. Therefore the alternative hypothesis has stated in chapter one is held.
H3: Mobile health technical support has a significant relationship with performance of
Qualitatively, All CHWs spoke highly of the training they had received and said that acquiring
health knowledge was one of the main benefits of being a CHW. Both high- and low-performing
CHWs said they would like more training in the future. Most CHWs said that the person who
had initially trained them was their supervisor (either their current or previous supervisor).
46
5.3 Discussion of results
This section presents discussion of results according to research objectives
Workers
The findings depicts a strong positive relationship between mHealth Tools and performance of
Community Health Workers. The findings revealed that increased availability of mobile phones
and other ICT tools has led to increased mobile health interventions in the underserved
communities thus bringing healthcare services closer. A number of smart phone applications or
telemedicine applications are used for diagnostic purposes and healthcare management. Okeleke,
(2019) assert that the mobile phone penetration rates have increased to 67% according to UCC
(Uganda communications commission) report for 2021.
The findings concur with Moore and Benbasat (1996) who agreed that increasing intentions to
use mobile apps is influenced by user attitudes and other situational factors. The persuasive
technology characteristics and features like the task bar improves CHW performance efficiency
by prompting CHWs to do timely treatment and referral follow up on all physical activities done
through the mobile phone app. M-health developers should focus on the content of the m-health
workflows as security and privacy concerns associated greatly affect uptake of mHealth
interventions at community level. The language used in m-health interventions should be clearly
understood.
The study findings are in agreement with Yim and Gomez (2018) who argued that everyday use
of mobile apps enhances proper communication and information retrieval. The use of m-health
app saves time for work by providing up-to date information related to tasks thus increasing
productivity and improving quality of work. The mHealth capability enhancer improves levels of
adoption by enabling Community health workers to confidently handle ICCM related childhood
illnesses in respective communities. The use of mHealth apps increases knowledge awareness in
treatment context as CHWs keep following the programmed prescriptions according to age and
patient weight. Illozumba (2018) and Marcus (2015) agreed that mHealth platforms should be
developed and rolled out in a way that has cultural relevance to the community. They further
concured that mHealth apps that are not tailored to cultural practices and beliefs are ineffective.
47
Health Workers
The finding depicts a strong positive relationship between mHealth acceptance and performance
of Community Health Workers. The findings are consistent with Andreia (2019) who argued that
performance expectations, effort expectations, social influence, and enabling factors have a
substantial impact on system acceptability. The greater the perceived usefulness of m-health
apps, the higher the intention to use them in boosting performance. mHealth apps that are
perceived as easy to use in CHW context should yield higher acceptance levels in order to
improve performance efficiency and outcome. Further, Majharul (2023) argued that the current
mHealth models demonstrate absence of a standardized measurement framework for measuring
technology acceptance.
The findings concurred with Anam (2018) that there is an ongoing debate to explore health
system readiness for adopting m-health technology to address non-communicable diseases in
developing countries. The level of preparedness of health sector, availability of fund, mindset
change and willingness of community health workers are key determinant factors for health
system readiness and adoption of m-health. The willingness of health workers to adapt to m-
health is influenced by ability of m-health platforms to address health issues in local context and
health worker capability to use the system.
The findings concur with Welch (2019) who argued that it is hard to quantify the sociotechnical
perspective by the end users which is a core determinant for technology use despite mobile
health improving accessibility and reachability regarding exchange of information. Despite the
many achievements, there seems to be a challenge of failure to integrate m-health component
with the CHW current Job description and service delivery structure thus limited levels of
acceptance among elderly CHWs due to apprehension about workload and prolonged workflows.
Lack of comprehensive training and minimal support supervision to the CHWs reduces
acceptance and adoption levels.
48
The finding depicts a strong positive correlation between mHealth technical support and
performance of Community Health Workers. The findings are consistent with Tegegne, (2018)
who revealed that Mobile health rollout and implementation requires technical support to
promote the match between delivery of professional healthcare service and capability of the
system users. Technical support promotes quality at all levels of the mHealth implementation by
strengthening relationships within the system through prompt identification and resolution of
problems. Mobile health technical support ranges from system maintenance, end-user trainings,
device maintenance and management, fixing basic problems and performing triage for bigger
issues.
The study findings agreed with Fehringer and Marshall (2014) who argued that support
supervision through trainings has positive outcomes to mHealth adoption, CHW productivity and
positive behavioral intention among CHWs. The findings included that through regular support
supervisory visits, trainings, coaching and mentoring that perceived reliability on mHealth is
improved and was reflected in dependability, safety and accuracy of quality service delivery.
The study findings disagreed with Bradley, Arevo, Franke and Palazuelos (2015) on grounds that
m-health apps are developed for users well versed with English yet there is need to review
mHealth programs to fit the needs or preferences of the users. Therefore, Integration of m-health
with Work load and short field visits with limited time for counseling complicate health worker’s
ability to address risk factors, danger signs and precautionary aspects to prevent disease. Despite
heavy investments in mHealth infrastructure, Governments still finds it difficult to evaluate,
scale up and integrate mHealth technologies despite the agenda for broad use of digital health
strategies and solutions to satisfy the variety of patient and population demands.
5.4 Conclusions
Workers
Mobile phones have proven effective for CHWs as it has improved routine CHWs workflows
such as, data collection and reporting, patient to provider communication, patient education,
decision making, supportive supervision, CHWs monitoring and evaluation.
CHWs with more positive attitudes, stronger intrinsic motivation, and who are more often
present in the village, appear to perform better, though manipulating the selection of CHWs may
49
be beyond the control of program implementers, given community-based CHW recruitment
mechanisms.
Health Workers
The study results indicate that although ease of use is clearly important, the usefulness of a
system is even more important, and should not be overlooked. Users may be willing to tolerate a
difficult interface in order to access functionality that helps them on their job, while no amount
of ease of use can compensate for a system that does not do a useful task.
Coupling of mobile technology with CHWs has the potential to benefit communities in
improving management of illnesses in children under-five. High quality evidence of impact of
such interventions on behaviour is relatively sparse and further studies should be conducted
using theoretically informed frameworks/models of behaviour change.
Training and implementation of a mobile health program could be scaled up with wider targets
for intervention in the future. Specifically, a mobile phone system could be expanded to
contribute to improved data collection in other health fields and may be particularly useful to
enhance antenatal, perinatal, and newborn care. By building on the experience described here,
further synergies between CHWs and more highly skilled health care workers at level IV health
centres and regional hospitals can be promoted.
From a health systems perspectives, this is an enormous opportunity to effect change, by more
fully engaging and equipping supervisors to provide higher-quality support to CHWs something
for which tangible strategies could be developed. Supervisors and community leaders might also
be supported to further incentivize CHWs, and to replace entrenched CHWs who are under-
performing.
5.5 Recommendations
The conclusion drawn in the previous section (5.4) of this study provided a basis upon which
recommendations are being made according to the study objectives.
Workers
Our study illustrates the importance of including end-users in the design of mHealth
interventions, which should become best practice for all those designing mHealth interventions.
50
In this study, CHWs were able to identify key feasibility issues such as the language in which
SMS text messages are sent and the balance between the relative importance of phone function
versus battery life. It is found that although poor network coverage was a reality in both settings,
this could be ameliorated by providing CHWs in locations with poor coverage with a dual SIM
phone. The impact of providing phones with a reduced battery life needs to be considered, and
solar chargers may be a solution.
The findings of the study posit that perceived usefulness was found to be more important in
influencing technology acceptance. Therefore the designer of the dynamics performance
management system should enhance perceived usefulness either by adding new functional
capabilities to the system, or by making it easier to invoke the functions which already exist.
The MoH should provide solar chargers to health facilities without electricity to enable them
charge their phones at no cost since many pay a cost to charge their phone of which they use to
send message. The District should put best rewards for phone users in all health facilities to
attract others to use the system.
Health Workers
Regarding mHealth apps that have the ability to capture and record large amounts of patient data,
physicians could implement and provide personalized health services through these mobile
platforms. Moreover, users have autonomous control in the processes of consulting and can
provide appropriate and relevant solutions to problems in mHealth apps.
The managers of mHealth apps could focus on increasing users’ e-satisfaction with the functions
of mobile platforms, thereby improving users’ intention of continues using mHealth apps to seek
health information and services. In addition, if users receive high-quality and friendly
personalized healthcare services, then they will be satisfied with their experience and the high
value of using such apps.
5.5.3 The effect of mHealth Technical support on performance of Community Health
Workers
There should be improved staffing of the facilities where community units are linked in order to
strengthen referrals and linkage systems especially taking into consideration the spatial
distribution and population density. This will improve support supervision from CHEWs to
CHWs during their community work
51
Plans to strengthen the community health workforce in Uganda must include the importance of a
harmonized and uniform incentive package for all CHWs, such that it is equitably structured
across cadres of healthcare workers and standardized across all CHWs, as well as accountability
mechanisms to ensure it is systematically and consistently implemented in practice.
The managers of mHealth apps should organize promotional activities and pay attention to the
roles of performance expectation and effort expectation. Users of mHealth apps should be
encouraged to use mHealth apps due to requiring less time and effort compared to the traditional
ways of waiting and visiting hospitals.
5.6 Contribution to knowledge
The findings from the study contribute to the larger debate on ICT adoption in health service
delivery and its benefits to the economy. There is a need to put in place policies and regulatory
framework support ICT access, use and adoption as a way of reducing unnecessary delays and
costs for proper coordination and monitoring of health service delivery.
The study findings also provide the benchmark for policy debates and arguments on which
mechanisms and strategies that can be utilized in improving access, use and adoption of ICT in
healthcare organization. It was noticed that most of the ICT projects in Uganda are donor funded.
Most of them have remained at pilot stage due to limited funds and this limits decision making
power of government to install ICT programmes.
The success of the new approaches that will be used will act as benchmarks for best practices
from both international and national ICT implemented projects. These can be used by future
researchers, academicians and policy makers in designing and implementation of ICT in
healthcare organization for effective service delivery.
5.7 Implications of theory
The theory provided a lens through which the formative research findings could be viewed and
helped the team make decisions about the design of the interventions and their potential impact.
We feel that the design of mHealth interventions would be strengthened by using theories that
help understand performance of community health workers, rather than those that focus solely on
acceptance and use of the phone. The theoretical basis presents opportunities for perspectives
that seek to discuss technological work representations.
52
5.8 Implications for policy and practice
By understanding CHWs’ needs, and by explicitly thinking about motivation, we were able to
identify specific modifications to mHealth interventions that could improve motivation. For
example, our findings suggest that intervention designers should consider how mobile phones
could increase the standing, visibility, and credibility of CHWs through strategies such as clear
branding of phones with the project’s logo. Other modifications that could be made to existing
applications to improve motivation include providing an SMS message response to CHW data
submission and sending SMS text messages about the importance of CHW work and
achievements, rather than just reminders or technical messages.
The study has shown that technology is implicated in the dynamics of visible and invisible work,
and the questions we raise here emphasize that system design and implementation should not
have a simplistic or reductionist view of work. This is easy based on our positions (physically
and socially). The findings make a practical contribution by drawing implications for visible and
invisible work through the mHealth system. These implications inform system design to not only
have an intimate knowledge of work but also take into account factors such as power differences
in health systems. Therefore, systems should be designed with the critical awareness of the issues
around visibility and the work context of CHWs. This is because; making work visible has
different implications for different actors in the health system to which it is made visible.
5.9 Recommendations for further Research
A study should be done assessment of information system on performance of Community Health
workers. Study should be done on how workload affects performance of community Health
workers. Future studies should conduct longitudinal research to discuss users’ perceptions and
attitudes toward mHealth apps over time. In future research, other types of sampling techniques
for collecting data should be considered to apply.
5.10 Limitations of the study
A limitation of the study is that respondents were talking hypothetically, and previous studies
have shown that enthusiasm for a mHealth intervention does not always correspond to uptake.
Participants were generally enthusiastic about the potential interventions; but this may be due to
social desirability affecting reporting, which may be particularly strong when a desired
commodity such as a mobile phone is being discussed. CHWs may not be in the best position to
evaluate problems in their technical abilities and skills, and this study would have been
strengthened by an objective assessment of CHWs’ skills.
53
Due to the nature of cross-sectional research, this study could not accurately explain users’
perceptions of mHealth apps within the time frame. Third, though amounts of constructs have
been considered in the current study, other constructs, such as health service quality, doctor-
patient interaction, and individuation, should be studied.
54
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APPENDICES:
APPENDIX 1: WORK PLAN
Activity Months
1 2 3 4 5 6 7 8 9 10 11 12
Identification of Research Topic
and approval
Writing Research Proposal:
61
Chapters 1-3
Submission of draft proposal for
supervisor review
Submission of fair copy of
research proposal
Develop Questionnaire
Defend Research Proposal
before UMI panel
Refine research proposal and
Questionnaire
Collect data from the field after
seeking approval
Analyze data
Write 1st & 2nd draft of research
report
Presentation of final report (viva
voce) before panel
Submit final Research
Report/Dissertation
APPENDIX 2: BUDGET
Item Qty Freq Unit cost Total Cost
(Days) (UGX.)
Research Assistant fees (lump sum pay) 5 3 100,000 1,500,000
Researcher transport (to & fro) 5 3 60,000 900,000
Researcher accommodation (overnight stay) 5 2 100,000 1,000,000
Stationery (lump sum) 1 1 400,000 400,000
Data analysis (SPSS software) 1 1 500,000 500,000
62
Report production (printing and binding) 1 1 500,000 500,000
Subtotal 4,800,000
Miscellaneous (other expenses e.g. airtime, 600,000
data, lunch, medical, etc.) – 15%
GRAND TOTAL COST 5,400,000
Appendix 3: Questionnaire
Introduction:
Dear Respondent, this research survey is being conducted to examine the relationship between
mobile health and performance Brac Community Health Workers in the Busoga sub region.
Please assist and fill out. Information shared was kept confidential and will not be used other
than research purposes.
Part A: Respondent Details (please circle the appropriate number)
A1. What is your Gender?
63
Male Female
1 2
A2. What is your Age?

18-25years 26-35years 36-45years 46-55years 56years and above
1 2 3 4 5
A3. What is your highest academic qualification?

Below S.4 S.4 S.6 Certificate Diploma Bachelors
1 2 3 4 5 6
A4. Which staff category do you belong to?

Super CHW Subordinate CHW
1 2
A5. How long have you worked with Brac Health Program?
Less than 1 year 1-2years 3-4years Greater than 4years
1 2 3 4
A6. Do you have a working phone with app installed?

Yes No
1 2
Part B: Responses to CHW Performance

Please share your opinion of the statements indicating the extent to which you are satisfied about
CHP performance at your branch by ticking the appropriate number on the right in the box;
where 1 = Strongly disagree (SD), 2 = Disagree (D), 3 = Neutral (N), 4 = Agree (A) and 5 =
Strongly Agree (SA).
Item Efficiency SD D N A SA
EF1 CHWs exhibit improved knowledge in dozing efficacy 1 2 3 4 5
for malaria, diarrhea and pneumonia especially among
64
under 5 children.
EF2 CHWs possess technical knowledge required for the 1 2 3 4 5
efficient treatment and referral follow up through alerts
by task bar.
EF3 CHWs carry out assessments and treatments in 1 2 3 4 5
accordance to specified policies and procedures as per
SCJA
Item Quality SD D N A SA
Q1 CHWs follow procedural tasks as prompted by the app 1 2 3 4 5
and in accordance to MOH guidelines.
Q2 CHW effectively communicates prescription information 1 2 3 4 5
to caregiver and do treatment or referral follow up.
Q3 CHW submits complete and accurate information in the 1 2 3 4 5
app
Item Output SD D N A SA
O1 There is increase in real time data capture and timely 1 2 3 4 5
sharing of performance data by CHWs
O2 Tracking and responding to health issues in a timely 1 2 3 4 5
manner improves health outcomes and reduces under 5
mortality.
Part C: Responses to Mobile Health

Please share your opinion of the statements indicating the extent to which you are satisfied about
Mobile Health by ticking the appropriate number on the right in the box; where 1 = Strongly
disagree (SD), 2 = Disagree (D), 3 = Neutral (N), 4 = Agree (A) and 5 = Strongly Agree (SA).
Item Availability of ICT tools SD D N A SA
ICT1 CHWs are availed with smart phones with app installed. 1 2 3 4 5
ICT2 Supervisors are given tablets and laptops for analyzing 1 2 3 4 5
and tracking performance metrics
ICT3 ICT tools have technical specifications, features like the 1 2 3 4 5
65
task bar that sends alerts and reminders.
Item Acceptance SD D N A SA
A1 M health devices are user friendly, less time consuming in 1 2 3 4 5
terms of data capture and more flexible compared to
traditional methods of data capture.
A2 Perceived usefulness and trust of m health platforms 1 2 3 4 5
increases adoption intention among CHWs.
A3 Social influence from fellow CHWs and performance 1 2 3 4 5
expectancy increases m health adoption and minimum
performance reporting.
Item Technical support SD D N A SA
TS 1 Basic and refresher trainings avails CHWs with adequate 1 2 3 4 5
knowledge and skills to interface with the mHealth
application.
TS2 Regular support supervision, coaching and mentorship 1 2 3 4 5
improves CHW perceived usefulness of mHealth app and
promotes positive behavior.
TS3 System management and device maintenance increases 1 2 3 4 5
dependability of m health platforms through safety and
confidentiality of health information.
Thank you for your time and cooperation!

Appendix 4: Interview guide
INTERVIEW GUIDE
1. How do you view performance of CHWs at your branch?
2. How has mobile health contributed to performance of CHWs?
3. In relation to available ICT tools,
A. How does use of a functional phone with mHealth app installed contribute to minimum
performance reporting of CHWs?
B. Do the CHWs use the taskbar to do Pregnancy, treatment and referral follow up?
C. Do you have a backup plan to handle performance of CHPs without phones? How often
is phone replacement done?
66
4. In relation to m health acceptance,
A. Is mHealth acceptable among CHWs as a mode of data capture for performance metrics?
B. How regular is Brac Afya used by CHWs in capture of performance metrics?
C. How often do supervisors access performance indicators on the mHealth dashboard?
D. What can be done to improve mobile health acceptance levels among CHWs and their
beneficiaries?
5. In relation to Technical support,
A. How often is mHealth training needs assessment done?
B. What criteria does a staff follow to render support supervision to CHWs?
C. How has regular mHealth system management and device maintenance contributed to
minimum performance reporting?
D. What can be done to improve technical support especially for weak CHWs?
END
APPENDIX III: SAMPLING GUIDE
67
APPENDIX IV: PLAGIARISM REPORT
68

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MOBILE HEALTH AND PERFORMANCE OF COMMUNITY HEALTH WORKERS: A

CASE OF BRAC COMMUNITY HEALTH WORKERS IN IGANGA

A DISSERTATION SUBMITTED TO THE SCHOOL OF MANAGEMENT SCIENCE

Sign ……………………………………. Date………………………………..

Sign ……………………………………. Date………………………………..

Sign ……………………………………. Date………………………………..

1.2 Background to the Study.......................................................................................................................1

1.2.1 Historical Background................................................................................................ 3

2.2 Theoretical Review..............................................................................................................................12

2.3 Mobile Health and Performance..........................................................................................................14

2.3.1 Mobile health...........................................................................................................14

2.5 Mobile health acceptance....................................................................................................................17

2.6 Mobile health technical support...............................................................................................18

3.2 Research Design..................................................................................................................................20

3.3 Study Population.................................................................................................................................21

3.4 Sample size determination...................................................................................................................21

3.5 Sampling techniques and procedure....................................................................................................22

3.6 Data Collection Methods.....................................................................................................................22

3.6.1 Questionnaire survey................................................................................................ 22

3.8.2 Reliability of instruments.................................................................................................................25

3.9 Procedure of Data Collection...............................................................................................................25

3.10.2 Qualitative data analysis..........................................................................................26

Appendix 4: Interview guide.............................................................................................................66

APPENDIX III: SAMPLING GUIDE.......................................................................................68

Below S.4 S.4 Certificate Diploma

Figure 4.3: Level of education of respondents

Figure 4.4: Working experience

4.4.1 Performance of Community Health Workers in Iganga region

Table 4.13: Opinions of respondents on mHealth Technical support in Iganga region

A2. What is your Age?

A3. What is your highest academic qualification?

A4. Which staff category do you belong to?

A6. Do you have a working phone with app installed?

Part B: Responses to CHW Performance

Part C: Responses to Mobile Health

Thank you for your time and cooperation!

APPENDIX III: SAMPLING GUIDE

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