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									                                                             HEALTH CARE

Use of mHealth for Quality Improvement in Guatemala

Background                                             Method
n   In June 2010, the Guatemalan                       n   Five focus group discussions (FGDs)
    Ministry of Health (MOH), with                         assessed the acceptability of mHealth,
    technical support from the USAID                       type of message desired, frequency,
    Health Care Improvement Project,                       and time of day preferred to inform
    managed by URC, tested the use                         the campaign design. Findings:
    of text messages to health workers                     – Messages should be motivational
    to promote quality improvement                            and promote quality performance
    as part of a larger intervention to                    – Participants should be informed
    implement a quality management                            and educated on the SMS
    system in the health sector.                              campaign in advance
n   Target populations were:                               – SMS should be sent no more than
    administrative staff from MOH                             3 times a week in the morning
    Guatemala City (n=371, approximately                      before work or during lunch time
    43% of central level administrative                    – There should be no cost to receive
    staff) and administrative staff and                       SMS
    health care providers (n=677,
                                                           – The sender should be the MOH
    approximately 17% of total staff) in
    the San Marcos Health Area, one of                     – Confidentiality of phone numbers
    29 health areas in the country.                           should be ensured
                                                                                                              Promotional posters were placed in health
n   This is the first experience in using              n   Messages for health workers were                   facilities to publicize the cell phone campaign.
                                                           pre-tested in FGDs                                 Photo by Elena Hurtado, URC. Poster design
    cell phones to promote improved                                                                           by Monica Gonzalez, URC.
    quality of public sector health                    n   A promotional campaign during
    services in Guatemala.                                 the four weeks prior to sending
                                                           SMS informed health workers                        n   Mid-campaign FGDs assessed
oBjectives                                                 of the purpose of the campaign                         coverage, recall and acceptability
The cell phone campaign addressed the                      and encouraged staff to enroll by                      of SMS; and reported changes in
following questions:                                       submitting a form to the MOH                           attitudes and practices
                                                           Health Promotion Coordinator
1. Are Short Messaging Services                                                                               n   An end-of-campaign random
   (SMS—or text messages) an                           n   SMS were sent to enrolled staff three                  sample telephone survey assessed
   acceptable communication medium                         times a week for approximately six                     health workers’ receipt of SMS and
   to public health workers?                               weeks (July–September 2010). 19                        reactions to the messages.
                                                           messages were sent in all, grouped
2. What are the options for establishing                   in five message themes (see Table 1);
   a SMS system for public health                          total SMS sent=18,864

noveMBer 2010
This work was supported by the American people through the United States Agency for International Development (USAID) and its Health Care Improvement
(HCI) Project. The HCI Project is managed by University Research Co., LLC (URC) under the terms of Contract Number GHN-I-03-07-00003-00. For more
information on the HCI’s work, please visit For more information on the use of mhealth for quality improvement in Guatemala, please contact
Nancy Newton at
resuLts                                                    – 80% health workers reacted                       n   Continue sending SMS to health
                                                              positively to the messages                          workers, by monthly theme, and
Focus Group Discussions:
                                                           – 82% found the messages helpful                       expand to other Health Areas
n   SMS are an acceptable communication
                                                           – 39% shared them with co-workers,                 n   Test the feasibility of more tailored
    medium to public sector health
                                                              family members, friends and                         messaging managed by the MOH at
    workers, if measures are taken to
                                                              community residents                                 the Health Area level
    gain their trust before and during the
    period of sending messages                             – Most often remembered messages                   n   Conduct further evaluation to
                                                              were those related to quality or                    measure the effects on health worker
n   SMS helped to create a sense of
                                                              were motivational in nature (see                    practices
    connection between public-sector
                                                              Table 1)
    health workers and their institution
    (the MOH): health workers felt like                Lessons Learned and
    the MOH remembered them                            recoMMendations
n   Health workers want to continue                    n   Public-private partnerships are
    receiving SMS regularly and to                         necessary for large-scale SMS
    include topics such as information                     campaigns to secure a mutually
    on events, more health topics,                         beneficial agreement for free air time
    emergency alerts, and MOH norms                        with a large national carrier.
Random sample telephone survey                         n   The MOH or other trusted sources
(n=105):                                                   must manage the cell phone number
n   Of the 105 health workers                              database and be the originator of
    telephoned, 5 (5%) had not                             SMS for health workers; MOH
    received the SMS, and 40 (38%)                         and USAID logos on promotional
    did not respond to the survey. Of                      materials helped to create trust
    the 60 (57%) health workers who                    n   To sustain SMS campaigns, a
    responded to the survey:                               mechanism to update the cell phone
    – 78% remembered the MOH as                            database regularly is needed, as
       the source                                          turnover of cell phone numbers is high

Table 1: Message Content and Recall

 Message                Number of messages             Number (%) who recalled
 theme                     (% of total)               this type of message (n=60)          Sample message
                                                                                           The MOH informs: We are all the MOH. If we work with
 Quality                        7 (37%)                           45 (39%)
                                                                                           quality, the institution will get better every day.
                                                                                           The MOH requests: During Reproductive Health Month, help
                                 4 (21%)                          17 (15%)                 people to choose freely the family planning method that they
                                                                                           want to use.
                                                                                           The MOH requests: Let’s work to guarantee breastfeeding in
 Breastfeeding                   3 (16%)                          18 (16%)
                                                                                           the first half hour after childbirth. World Breastfeeding Week.
                                                                                           The MOH informs: Today is Monday. Develop a work plan for
 Informational                   3 (16%)                          11 (10%)
                                                                                           the week and you will obtain better results.
                                                                                           The MOH wishes you a very happy Public Health Worker Day.
 Motivational                    2 (11%)                          25 (22%)                 We thank you for doing a job with quality and cordiality for the
                                                                                           Guatemalan people every day.
 totaL                         19 (100%)

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The contractor team for the USAID Health Care Improvement Project includes URC (prime contractor), EnCompass LLC, Family Health International, Health
Research Inc., Initiatives Inc., Institute for Healthcare Improvement, and Johns Hopkins University Center for Communication Programs (CCP). For more information
on HCI’s work, please visit or contact

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