Using a mHealth system to recall and refer existing clients and refer community members with health concerns to primary healthcare facilities in South Africa: a feasibility study

Figures & data

Flowchart 1. Settings in which the study was implemented

Table 1. Supervisor and LHW demographics

	Sub-district 1		Sub-district 2
	Supervisors	LHWs	Supervisors	LHWs
Female	2	29	4	62
Male	-	-	-	2
Average age	58	35	58	34
Age range	55 – 63	22 – 59	47 – 68	23 – 60
Average number of years working as supervisor or LHW	8	6	3	5
Years in post – range	4 months – 7 years	1 – 10 years	6 – 10 years	3 – 10 years

No demographic data were collected about the clerks.

Figure 1. mHealth recall and referral system

Figure 2. Example of the recall format of correspondence between the LHW and clerkfacility

The figure shows pseudonyms for client, LHW and facility, and LHWs in the study were referred to as community care workers (CCWs).

Figure 3. Example of the format for a referral sent by an LHW to the health facility

The figure shows pseudonyms for client, LHW and facility, and LHWs in the study were referred to as community care workers (CCWs).

Table 2. Example of qualitative analysis

Categories	Sub-categories	Example codes	Examples of extracts from the data
Lack of support and time	Need technical support Maintaining dual systems Additional workload After hour recalls	LHWs had difficulties in maintaining two systems	‘Some of them struggled to use paper and the phone. So I either carry on with the paper or I carry on with the phone … ’
Communication and interpersonal challenges	Users struggled adapting to mHealth LHW-facility staff relationships	LHW: difficulties in the beginning because not familiar with smart phone	‘like I’ve said, in the beginning when I first went for this training I was nervous. Because I have never used something like this in my life. The only time I might have used a phone, then it was a phone with buttons. But it’s not these modern phones.’
Closing recalls and referrals	Facility staff communication delay System description Immediacy	NC: mH offered immediacy to LHW-facility communication	‘And when I walk in there the sister would quickly tell me, listen, I’ve passed on this or that to the tablet, or I’ve given this and that to that person. And almost miraculously, when I get to those carers and I’ve already got it from the sister early in the morning, then I get to the CCWs: you know what, I got this and that referral.’
Effects of mHealth	Remote settings Improved communication and reporting Improved recalls Paper vs mHealth	NC: very difficult to get data from remote living LHWs	“ … I got those every second week. I had to arrange it with them because we have to stick to our petrol budget; in other words, I can’t drive to [Place A] and [Place B] every week. I was able to go about once a month, and then I had it delivered every second week at the [Place C], that’s the satellite, so I had an arrangement with that man that I would collect it on a Friday.”

Categories, sub-categories and example codes and quotes (sub-category in bold where codes and quotes are related).

Table 3. Recall success rates according to the recall reason

Reason for recall		Sub-district 1 N (%)	Sub-district 2 N (%)	Total across sub-districts N (%)^a
Children < 5 years (e.g. deworming, Vitamin A, immunisation)	Successful recalls	101 (64%)	75 (21%)	176 (34%)
	Total recalls	158	356	514 (23%)
Diagnostic tests (being tested or receiving results for all conditions excluding TB/HIV and AIDS)	Successful recalls	22 (44%)	11 (9%)	33 (20%)
	Total recalls	50	117	167 (8%)
Finding defaulting clients (including TB/HIV clients)	Successful recalls	4 (44%)	11 (15%)	15 (19%)
	Total recalls	9	72	81 (4%)
Medication collection	Successful recalls	16 (55%)	51 (15%)	67 (17%)
	Total recalls	29	348	377 (17%)
Non-communicable disease care	Successful recalls	5 (83%)	7 (39%)	12 (50%)
	Total recalls	6	18	24 (1%)
Obstetrics/Gynaecology (including family planning)	Successful recalls	4 (27%)	3 (5%)	7 (9%)
	Total recalls	15	62	77 (3%)
Reminding clients about facility appointments	Successful recalls	86 (57%)	9 (11%)	95 (41%)
	Total recalls	150	80	230 (10%)
TB/HIV/AIDS care	Successful recalls	8 (44%)	10 (16%)	18 (21%)
	Total recalls	18	64	82 (4%)
Other^b	Successful recalls	55 (43%)	150 (29%)	205 (31%)
	Total recalls	127	525	652 (30%)
Total	Successful recalls	301 (53%)	327 (20%)	628 (28%)
	Total recalls	562 (26%)	1,642 (74%)	2,204 (100%)

^aThe % reported for the total of each recall reason is the proportion of the total recalls across sub-districts.

^bIncluded a range of health issues, such as wound care, eye care, having to see the occupational therapist or social worker, and mental healthcare. It also included unspecified reasons, when the recall/referral simply stated that the client needed to seek care at the facility.

Table 4. Referral success rates according to the reason for referral

		Sub-district 1 N (%)	Sub-district 2 N (%)	Total across sub-districts N (%)
Reason for referral				Total (%)^a
Children < 5 years (e.g. deworming, Vitamin A, immunisation)	Successful referrals	8 (22%)	172 (57%)	180 (53%)
	Total referrals	36	303	339 (31%)
Diagnostic tests (being tested or receiving results for all conditions excluding TB/HIV and AIDS)	Successful referrals	2 (100%)	8 (29%)	10 (33%)
	Total referrals	2	28	30 (3%)
Finding defaulting clients (including TB/HIV clients)	Successful referrals	1 (50%)	19 (34%)	20 (34%)
	Total referrals	2	56	58 (5%)
Male medical circumcision	Successful referrals	0	5 (29%)	5 (29%)
	Total referrals	0	17	17 (2%)
Medication collection	Successful referrals	6 (32%)	30 (38%)	36 (37%)
	Total referrals	19	79	98 (9%)
Non-communicable disease care	Successful referrals	2 (50%)	5 (28%)	7 (32%)
	Total referrals	4	18	22 (2%)
Obstetrics/Gynaecology (including family planning)	Successful referrals	0 (0%)	50 (56%)	50 (56%)
	Total referrals	3	90	93 (9%)
Physical symptoms	Successful referrals	2 (33%)	38 (45%)	40 (44%)
	Total referrals	6	85	91 (8%)
Reminding clients about facility appointments	Successful referrals	2 (100%)	5 (31%)	7 (39%)
	Total referrals	2	16	18 (2%)
TB/HIV/AIDS care	Successful referrals	0	30 (65%)	30 (65%)
	Total referrals	0	46	46 (4%)
TB/HIV/AIDS testing	Successful referrals	2 (67%)	60 (43%)	62 (33%)
	Total referrals	3	140	143 (13%)
Other^b	Successful referrals	3 (43%)	35 (28%)	38 (29%)
	Total referrals	7	123	130 (12%)
Total	Successful referrals	28 (33%)	457 (46%)	485 (45%)
	Total referrals	84 (8%)	1,001 (92%)	1,085 (100%

^aThe % reported for the total of each referral reason is the proportion of the total referrals across sub-districts.

^bIncluded a range of health issues, such as wound care, eye care, having to see the occupational therapist or social worker, and mental healthcare. It also included unspecified reasons, when the recall/referral simply stated that the client needed to seek care at the facility.

Table 5. Reasons for failed recalls

	Sub-district 1 N (%)	Sub district 2 N (%)	Total N (%)
Client did not attend the facility	43 (16%)	86 (7%)	129 (8%)
Unclosed recall	161 (62%)	871 (66%)	1033 (66%)
LHWs did not view the recall	51 (20%)	215 (16%)	266 (17%)
Clerk error	6 (2%)	142 (11%)	148 (9%)
Total failed recalls	261	1,314	1,575

Box 1. Suggestions for future mHealth interventions

Integrate mHealth systems with existing health information systems in the implementation context. Support the implementation of mHealth systems with training directed to all facility staff. It may be helpful for this training to cover relevant interpersonal communication skills and communication channels. Explore ways of ensuring buy-in from all implementers. Ensure that mHealth applications do not result in significant increases in workload for staff assigned to manage the mHealth system. Explore ways of providing on-site technical support to teams, for example, through having an online support desk.

Table A1. Recall and referral reason categorisation

	Description
Children < 5	Checking that immunisation, deworming, and Vitamin A injections were up-to-date, and monitoring their growth and nutrition status
Diagnostic tests (excluding TB/HIV/AIDS)	Clients to collect test results or have a blood test done for non-communicable diseases
Facility appointment reminders	LHWs reminded clients about appointments or informed them about rescheduled appointments
Finding defaulting clients	Clients who have missed facility appointments, or whom the LHWs were concerned that they are not adhering to their treatment
Male medical circumcision	Encouraging males to have medical circumcision done; applied to referrals only
Medication collection	Reminding clients to collect their medication at the facility
Non-communicable disease care	Facility care for clients on hypertension and/or diabetes treatment
Obstetrics/Gynaecology	Females were referred or recalled for maternal care, such as papsmear tests, routine antenatal visits, and family planning advice
Physical symptoms	People who complained about aches, swollen limbs, skin rash, and similar symptoms; applied to referrals only
TB/HIV/AIDS care	Routine check-up visits
TB/HIV/AIDS testing	Encouraging community members to be tested for TB and HIV/AIDS; applied to referrals only
Other	A variety of issues, including wound care, eye care, having to see the occupational therapist or social worker, and mental healthcare. It also included unspecified reasons, when the recall/referral simply stated that the client needed to seek care at the facility