Mobile technology for health (mHealth), a strategy to strengthen the healthcare system and enhance delivery of care in developing African countries, has increased rapidly in the past decade. However, most mHealth projects target community health workers (CHWs) or clients as primary users and do not include important stakeholder groups such as nurses. Also, mHealth applications frequently do not integrate with other health information systems that would enable these projects to achieve their objectives. Nurses have strong health information needs and could benefit from mHealth applications. This is particularly true in low-resource settings, such as developing countries or rural and remote areas, where nurses work across a myriad of clinical specialties, manage clinics, and supervise teams of paid and volunteer workers. As part of the Primary Healthcare to Communities (PHC2C) Project, led by Intrahealth International and partially funded by Johnson & Johnson, we are looking at how mHealth and other health information technologies (HITs) can enhance the role of nurses in Zambia as both clinicians and leaders in the healthcare system by helping them to more effectively manage their responsibilities. Zambia was selected for this project because, in addition to the nursing shortage, Zambia's healthcare system is burdened with many challenges. For example, there is a high infant mortality rate, with 34 deaths per 1000 births and a maternal mortality rate of 591 per 100 000 live births.1 There is also a high prevalence of HIV/AIDS with an adult rate of 12.7%.2 This report outlines findings from a preliminary scoping assessment in Zambia to understand how nurses could benefit from mHealth and other health information tools. Dr Velez participated in this activity in the spring of 2015 as a focus of her Alliance for Nursing Informatics (ANI) Emerging Leaders project.
NURSING AND HEALTHCARE IN ZAMBIA
There are two types of nurses commonly found working in Zambia, enrolled nurses (ENs), a position that requires 2 years of postsecondary training, and RNs, who are required to complete 3 to 4 years of postsecondary training. With roughly 79 nurses per 100 000 population, there is a serious health worker crisis in Zambia, and the greatest shortage is in the poor provinces of Northern, Northwestern, Central, and Eastern.3,4 It was reported to us that 50% of nursing positions in Zambia are currently unfilled, and yet there are roughly 2000 unemployed new graduate nurses because of a recent hiring freeze. Because of this shortage of nursing staff, nurses, particularly those working in rural areas, often find themselves working outside their scope of practice or overburdened with many administrative duties.
For example, we found that many ENs and RNs working in rural areas were trained on the job by RN midwives to do deliveries because of lack of available midwives and/or difficult travel conditions. In one district we visited, pregnant women would have to travel as much as 70 km to reach a skilled birth attendant. This particular district had three ambulances, one which could not travel off the main paved road because of the sensitivity of the equipment, which made it useless to the many villages accessible only through rutted dirt roads. The other two ambulances had been in need of repairs for several months, but there was no funding available for repairs. Consequently, the ambulances sat parked in the grass unused. The nurses reported that laboring women would sometimes try and reach the health center by bicycle or ox cart, but would usually deliver at home or with the nurse at a nearby health post, if available. Zambian health posts are under construction as part of the Zambian 2030 Vision to build 650 health posts5 by 2016 to increase the proportion of rural households living within 5 km of the nearest health facility from 50 to 80 of a health facility.6 The number of posts is growing, but the facilities are often staffed only by a community health agent, and sometimes by an EN. Even though the health posts do have a maternity room in case a woman comes to the post to deliver, there are rarely skilled birth attendants available.
PENETRATION OF MOBILE TECHNOLOGY, MHEALTH, AND HEALTH INFORMATION TECHNOLOGY
Seventy-three percent of Zambians report having access to a mobile phone.7 So far in our research, all the nurses we have interviewed owned their own mobile phones, with many possessing smartphones (primarily Blackberries). The Zambian government, along with a number of NGOs and faith-based organizations, has invested in HIT to improve service delivery and follow-up in the country. For example, the Smart Care system is an electronic medical record system that uses Smart Cards containing patient's individual medical history. However, many of Zambia's rural facilities have not yet deployed this technology. As of February 2014, only 141 facilities had been equipped with staff trained to use these cards, with an uncompleted plan to expand use in 469 facilities.8 An mHealth tool widely used by CHWs is RemindMi, an SMS-based system for tracing postnatal visits, which has reached national scale.9 Using this system allows CHWs to register new births and receive messages to remind new mothers to attend postnatal visits or receive other services, such as laboratory results.
Despite Zambia's cutting-edge innovation with technologies such as Smart Care and RemindMi, none of the nurses we interviewed thus far have reported using mHealth or other HITs in their day-to-day jobs.
POTENTIAL APPLICATION OF HIT FOR NURSES IN ZAMBIA
In our initial scoping visit, we identified many examples where HIT would meet nurses' information needs and provide benefits to nurses in their responsibilities. For example, mHealth could be used to conduct quality of care assessments of nurses who receive on-the-job training in intrapartum care. This, along with mobile training tools that would supplement the hands-on instruction, could be used to prepare and qualify nurses to certify as skilled birth attendants. If linked to a health workforce database qualified or other databases that can track the certification and location of skilled birth attendants, this information could be used to track the distribution of skilled birth attendants across the country and continually highlight gaps in coverage of care.
Nurses would also benefit from data systems that helped them to manage care in the community. For example, coordination with community-based staff and volunteers, information uploads from handheld devices that feed into facilities-based systems will help nurses monitor visual mappings of women who are close to delivery or have high-risk pregnancies and implement responsive strategies. Similarly, tools that would help them to better manage clinical teams, track homes visited by CHWs, monitor which patients are due or overdue for care, and provide opportunities for supportive supervision and improved clinical governance would be beneficial.
CONCLUSION
There are many potential applications of mHealth and HIT that would help nurses in Zambia to better manage their teams to deliver quality services in low-resource settings. Zambian nurses could benefit from clinical decision support tools, human resources management tools, mobile learning applications, and other HIT. Despite Zambia's considerable investments in HIT, the nurses we interviewed had little interaction with mHealth or other HIT systems. Understanding how nurses in other countries have benefited from HIT and applying that to the Zambian context will be of value to Zambian nurses. In the fall of 2015, we will conduct a follow-up study to further refine our recommendations to key stakeholders in the Zambian healthcare system on how mHealth and HIT could strengthen the role of nurses.
The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
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