Country and region: Ten counties in Kenya, including Mombasa, Nairobi, Kwale, Migori, Kisii, Homabay, Siaya, Kakamega, Embu and Meru county.
Organisation: Amref Health Africa in Kenya
Point person and Role: Rogers Moraro, Project Officer (Hygiene and Behaviour Change Coalition) Amref Kenya
Population served by the programme: 3,600,000 people in communities reached through a network of 60,000 Community Health Volunteers
Unique characteristics of the setting: The ten counties mainly encompass rural populations with low access to accurate and timely health-related information, primary healthcare services and health referral services. Most of these communities rely on trained Community Health Volunteers (CHVs) for health information and services, although CHVs might only have basic health knowledge and need continuous training on emerging conditions like COVID-19.
Number of cases and deaths due to COVID-19 at time of publishing: Nationally there has been 101,534 cases and 1,776 deaths
Briefly describe the key components of your COVID-19 response programme.
Community Health Volunteers (CHVs) are one of the most trusted sources of health information at the community level in Kenya. Eighty-five percent of them are female issued from the community, aged between 18 and 55 years. Typically, CHVs spend their days undertaking door-to-door households visits with families, conducting outreach activities and providing basic health services to communities. With the onset of the COVID-19 pandemic in Kenya, CHVs suddenly found themselves standing at the frontline of Kenya’s response to the pandemic. Given the unprecedented scale and complexity of the COVID-19 pandemic, CHVs were not prepared from the outset to effectively engage with communities and comprehensively respond to the rapid spread of the virus in the country.
To fill in this gap, we launched the Leap mHealth learning platform, a phone-based learning platform to facilitate remote training of CHVs on COVID-19. The Leap mHealth learning platform uses two key mobile phone technologies, simple text messages and Interactive Voice Recordings (IVR), to provide CHVs with information and two-way dialogue about COVID-19. Topics covered in our training programmes include COVID-19 symptoms’ identification for surveillance, referral protocols, contact tracing, home-based care, preventive measures and advice on how to limit COVID-19-related stigma.
The Leap mHealth learning platform also allows CHVs to collaborate with their peers and supervisors through dedicated group chats. To monitor understanding and progress of the CHVs throughout the training process, a weekly assessment is conducted through an interactive set of quizzes and simple games. We have translated our training content in all the local dialects spoken in our counties of intervention to increase uptake among CHVs. The platform is free-of-charge for all CHVs; they can both receive the training materials and IVR messages and answer with text and audio messages for free. All costs are covered by our organisation.
The trained CHVs then reach their communities doing door-to-door visits and avoiding any community gathering. They had to observe a strict protocol to limit risk of transmission, including staying outside, washing their hands with soap or hand sanitiser upon arrival at the household, wearing a facemask and maintaining a physical distance of at least 2 metres with household members. At the onset of the pandemic, a maximum of 3 people could be engaged at a time. CHVs were encouraged to use mnemonics to demonstrate key preventative behaviours to increase memorability among community members. Doing door-to-door visits has remained possible throughout the pandemic because CHVs are well-known people in their communities, who live among their peers and are trusted and valued for their awareness raising activities. When the restrictions were eased in communities, CHVs also took advantage of reopening of places of worship and schools, where physical distancing measures are observed, to lead further outreach activities.
What process did you use when designing your COVID-19 response programme?
The Leap mHealth learning platform has been designed as part of a Hygiene Behaviour Change Coalition funded-project in Kenya. The broader goal of the coalition is to prevent and control the spread of SARS-CoV-2 by developing rapid and appropriate behaviour change programmes and activities.
In Kenya, Community Health Volunteers are the primary providers of interpersonal behaviour change communication materials in all communities, and are especially the case in rural areas. To ensure accurate information about COVID-19 preventive behaviours are disseminated in all communities, it is key that CHVs are timely and adequately trained first. Before the COVID-19 pandemic, CHVs were usually trained and certified by County Health Ministries after following several face-to-face workshops and classroom-based sessions. In the context of the pandemic, conducting face-to-face training with CHVs on a regular basis was not possible due to movement restrictions and safety concerns. Nonetheless, their presence in communities was essential to ensure accurate information about COVID-19 is widely disseminated.
We decided to use the existing Leap mhealth learning system and launch our national platform to meet the need for accurate, up-to-date and accessible training content for CHVs. We chose this platform as we knew it is an easy-to-use, efficient and low-cost system adapted to our local context. It had also been used in the past to deliver tuberculosis and malaria programmes in the country and some CHVs had previous and successful experience working with this platform.
We developed the training sessions in partnership with County Departments for Health. Our training materials were then approved by the Ministry of Health in Kenya and other countries we are active in, including Uganda, Zambia and South Sudan.
What is one thing that has been working really well so far and is there something other programmes could learn from this?
The Leap mHealth learning platform has been an efficient, low-cost and remote based programming tool to scale up training delivery to CHVs during the pandemic. It has allowed to limit the risk of COVID-19 transmission associated with face-to-face interactions and training workshops mixing CHVs from different communities, which are the traditional way of training CHVs. With our learning platform, we have been able to rapidly reach over 60,000 CHVs across Kenya with adequate training materials.
In Focus Group Discussions conducted in December 2020, CHVs reported trusting the Leap mHealth platform to be a reliable source of information and facilitate their daily work. Interactive Voice Recordings (IVR) used as a two-way communication between the platform and the users were reported to be the most exciting part of the training. CHVs notably highlighted the possibility of retrieving the recording messages for future use. Group chats were less appreciated by CHVs as some conversations went off topic and did not relate to training content or materials.
Counties’ authorities have also been highly receptive towards the Leap mHealth platform. Since the onset of the COVID-19 pandemic, the platform has been deployed across 47 counties in Kenya.
What is one challenge that you have encountered, and how are you trying to overcome this?
In some remote areas and among nomadic communities, low literacy and phone ownership levels among CHVs limit the number of CHVs we can engage with our training materials. Mobile network coverage can also be challenging in some places, especially the most remote ones. Yet, a 2016 report by the Global Economy reported more than 90% 2G coverage and more than 80% 3G coverage, slightly lower to the global average of 94%. This coverage has improved over time, along with phone ownership levels.
To try mitigating these challenges, we encourage peer-learning between CHVs. CHVs with phones are invited to share training materials with CHVs who do not own a phone. In some remote counties, we have also issued roughly 5,850 phones since 2018, which are used for data collection via the Leap mHealth platform and other software.
How have you been engaging volunteers throughout your programme, and what feedback have you received?
We have been virtually engaging with Community Health Volunteers (CHVs) throughout the entire training programme. On the Leap mHealth platform, CHVs can use free-of-charge SMS or audio messages to ask questions and provide feedback on the training content and the design of the platform.
Overall, feedback has been positive towards the platform. CHVs notably highlighted flexibility as a huge advantage of online training materials, as training materials are available for seven days after being uploaded. CHVs therefore can arrange their time to complete the training when it is more suitable for them. Materials which have expired can also be re-accessed easily by any CHV by contacting the platform help desk.
Based on feedback received from the CHVs, we have also been able to adapt the content of our training materials to meet information needs of CHVs. For instance, we included additional modules on disposal of Personal Protective Equipment, especially face masks, as CHVs felt it was needed.
What systems are in place to monitor programme outcomes? What tools are being used?
In communities, Community Health Volunteers are usually supervised by trained Community Health Assistants (CHAs). In conjunction with supervising County and Sub-County Community Strategy Coordinators, Community Health Assistants have been key in encouraging and monitoring CHVs’ progress completing their training on the Leap mHealth platform. The Leap mHealth platform also allows County and Sub-County Coordinators to track individual CHV concerns expressed in written messages or directly via phone calls.
CHVs’ work has also been monitored by gathering direct feedback from community members. In two counties, Kajiado and Taita-Taveta, feedback sessions were conducted with community members to assess the involvement of CHVs in responding to the COVID-19 pandemic. Feedback from communities have been highly positive on the role played by CHVs in disseminating information about COVID-19 and promoting behaviour change, especially hand hygiene and face masks use in public places.
How might your experiences responding to COVID-19 change the way your organisation designs and delivers hygiene programming in the long-term?
In the context of the COVID-19 pandemic, the Leap mHealth platform has been really efficient at rapidly relaying reliable knowledge, information and messages to essential health workers working in communities. It has also revealed the potential of mobile phones as efficient tools to train and mobilise health workers remotely, and provides an opportunity for regular dialogue and follow up. Going forward, Amref Health Africa and our Kenyan branch believe that online platforms and mobile phones should be promoted as key media to build capacity among Community Health Volunteers and Promoters, especially under our Public Health Emergencies and Response programmes.
The Amref Health Innovations Unit, under which we have promoted the Leap mHealth mobile solution, has commenced a partnership with the Ministry of Health to adapt their existing face-to-face training curriculum into a number of online modules beyond the COVID-19 ones. The objective is to increase the number and type of delivery channels available and to equip Governments and Non-Governmental Organisations with a menu of options (remote mobile training versus face to face training) when training healthcare workers. Modules which are currently being adapted include training on delivering hygiene promotion activities in households and schools and behaviour change approaches for hand and environmental hygiene promotion.
We believe that increasing access to training content using Leap mHealth platforms will strengthen Community Health Volunteers capacity to engage, promote and disseminate behaviour change messages and activities to communities in Africa. This shall offer an opportunity to build the skill set of CHVs in Information Technology and capacity building approaches (individual and peer-to-peer learning), and shall indirectly increase the number of CHVs who have access to mobile phones, which can be used for other purposes (e.g. transfer of mobile money, communication with family, fellow CHVs in neighbouring counties).
Article first published on HygieneHub