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How and why front-line health workers (did not) use a multifaceted mHealth intervention to support maternal and neonatal healthcare decision-making in Ghana
  1. Hannah Brown Amoakoh1,2,
  2. Kerstin Klipstein-Grobusch2,3,
  3. Evelyn Korkor Ansah4,
  4. Diederick E Grobbee2,
  5. Linda Yveoo5,
  6. Irene Agyepong5
  1. 1 School of Public Health, University of Ghana, Accra, Ghana
  2. 2 Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, The Netherlands
  3. 3 Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
  4. 4 University of Health and Allied Sciences, Ho, Ghana
  5. 5 Ghana Health Service, Research and Development Division, Dodowa Research Centre, Accra, Ghana
  1. Correspondence to Dr Hannah Brown Amoakoh; ansomaame{at}


Introduction Despite increasing use of mHealth interventions, there remains limited documentation of ‘how and why’ they are used and therefore the explanatory mechanisms behind observed effects on beneficiary health outcomes. We explored ‘how and why’ an mHealth intervention to support clinical decision-making by front-line providers of maternal and neonatal healthcare services in a low-resource setting was used. The intervention consisted of phone calls (voice calls), text messaging (short messaging service (SMS)), internet access (data) and access to emergency obstetric and neonatal protocols via an Unstructured Supplementary Service Data (USSD). It was delivered through individual-use and shared facility mobile phones with unique Subscriber Identification Module (SIM) cards networked in a Closed User Group.

Methods A single case study with multiple embedded subunits of analysis within the context of a cluster randomised controlled trial of the impact of the intervention on neonatal health outcomes in the Eastern Region of Ghana was performed. We quantitatively analysed SIM card activity data for patterns of voice calls, SMS, data and USSD. We conducted key informant interviews and focus group discussions with intervention users and manually analysed the data for themes.

Results Overall, the phones were predominantly used for voice calls (64%), followed by data (28%), SMS (5%) and USSD (2%), respectively. Over time, use of all intervention components declined. Qualitative analysis showed that individual health worker factors (demographics, personal and work-related needs, perceived timeliness of intervention, tacit knowledge), organisational factors (resource availability, information flow, availability, phone ownership), technological factors (attrition of phones, network quality) and client perception of health worker intervention usage explain the pattern of intervention use observed.

Conclusion How and why the mHealth intervention was used (or not) went beyond the technology itself and was influenced by individual and context-specific factors. These must be taken into account in designing similar interventions to optimise effectiveness.

  • mHealth
  • maternal health
  • neonatal health
  • clinical decision-making
  • low-resource setting

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  • Handling editor Stephanie M Topp

  • Contributors HBA, KKG, EA, LY and IAA designed and performed the study and analysed the data. HBA drafted the manuscript and KKG, EA and IAA reviewed the manuscript. DEG and LY provided critical comments on the review of the manuscript. All authors have read and approved the final manuscript.

  • Funding The Netherlands Foundation for Scientific Research, Global Health Policy and Health Systems Research Program (grant number: and the Julius Center, University Medical Centre, Utrecht, Netherlands, provided financial support. HBA has been supported by a Global Health Scholarship Grant from the University Medical Center Utrecht.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethics approval for this study was obtained from the Ghana Health Service Ethics Review committee (approval number: GHS-ERC: 04/09/16) before this study commenced.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available on request by emailing the corresponding author at

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