CHPs Experiences with SMS Supported Diarrhoea Disease Case Management in Kakuma Ward, Kenya: A Qualitative Approach

Abstract

Purpose: In low-resourced settings such as Turkana County, diarrhoeal disease is a leading cause of morbidity and mortality among children under five years of age (WHO.,2024).  The burden of diarrhoeal disease is particularly high in settings with poor Water, Sanitation and Hygiene (WASH) conditions in arid and semi-arid (ASAL) areas, such as Turkana County (WHO, 2024). In Kenya, despite the critical role Community Health Promoters (CHPs) play as the first point of contact for caregivers at the community level in community case management of diarrhoeal disease under Kenya’s Community Health Policy (2020–2030), knowledge gaps persist in maintaining consistent adherence to integrated community case management of diarrhoeal disease. While Short Message Service (SMS) mobile Health (mHealth) interventions have shown promise in bridging the knowledge gap by reinforcing knowledge in community case management of common childhood diseases. The effectiveness of SMS-supported interventions in low-literacy settings remains limited (Greve et al., 2022). Kakuma Ward in Turkana West Sub-County was purposively selected for its population dynamics and the burden of diarrhoeal disease. This study addressed CHPs gaps in community case management by documenting the experiences and perceived impact of an SMS intervention on community case management of diarrhoeal disease. The findings are expected to benefit CHPs, caregivers of children under five, Sub-County Health Management Teams (SCHMT), and mHealth program designers working in similar low-resource settings.

Methodology: This study was underpinned by the Social Cognitive Theory and the Capability, Opportunity, Motivation - Behaviour (COM-B) model. The Social Cognitive Theory is described in Bandura’s book, The Social Foundations of Thought and Action (Bandura, 1986), and the COM-B model is a behavioural framework by Michie et al (Michie et al., 2011). Data was collected through focus group discussions with caregivers (n = 16) and CHPs (n = 32) and Key Informant Interviews (n = 6) with Community Health Officers and Assistants within four community units in Kakuma Ward. The FGD and KII transcripts were analysed using the six phases of thematic analysis outlined by Braun and Clarke (2006). Thematic saturation was reached across all participant groups.

Findings: Participants in the study viewed the SMS messages as a way to reinforce existing knowledge on community case management of diarrhoeal disease, build confidence as they perform their roles in the community, and support decision-making when they visit households with children under 5 years of age who have diarrhoeal disease. The SMS supported intervention was associated with improved recognition of danger signs and improved community case management practices, through increased use of Oral Rehydration Salt (ORS) and zinc as standard commodities for managing diarrhoea among children under 5 years of age at the community level.

Unique Contribution to Theory, Practice and Policy: SMS supported interventions should integrate literacy inclusive features, such as interactive voice response and pictorial aids, with in-person training. Supportive supervision by Community Health Assistants (CHAs) and a reliable supply of ORS and Zinc should also be emphasised in mHealth community health programs. Future longitudinal qualitative research is recommended to assess the behavioural sustainability and knowledge retention across different literacy levels among CHPs in mHealth programs in low-resource settings.