title: Adoption and Usage of mHealth Technology on Quality and Experience of Care Provided by Frontline Workers: Observations From Rural India.
abstract: BACKGROUND
  mHealth apps are deployed with the aim of improving access, quality, and experience of health care. It is possible that any mHealth intervention can yield differential impacts for different types of users. Mediating and determining factors, including personal and socioeconomic factors, affect technology adoption, the way health workers leverage and use the technology, and subsequently the quality and experience of care they provide.
  
  
  OBJECTIVE
  To develop a framework to assess whether mHealth platforms affect the quality and experience of care provided by frontline workers, and whether these effects on quality and experience are different depending on the level of technology adoption and individual characteristics of the health worker. Literacy, education, age, and previous mobile experience are identified as individual factors that affect technology adoption and use, as well as factors that affect the quality and experience of care directly and via the technology.
  
  
  METHODS
  Formative research was conducted with 15 community health workers (CHWs) using CommCare, an mHealth app for maternal and newborn care, in Bihar, India. CHWs were first classified on the level of CommCare adoption using data from CommCareHQ and were then shadowed on home visits to evaluate their levels of technology proficiency, and the quality and experience of care provided. Regression techniques were employed to test the relationships. Out of all the CHWs, 2 of them refused to participate in the home visits, however, we did have information on their levels of technology adoption and background characteristics, which were included in the analysis as relevant.
  
  
  RESULTS
  Level of technology adoption was important for both quality and experience of care. The quality score for high users of CommCare was higher by 33.4% (P=.04), on average, compared to low users of CommCare. Those who scored higher on CommCare proficiency also provided significantly higher quality and experience of care, where an additional point in CommCare proficiency score increased the quality score by around half a point (0.541, P=.07), and experience score by around a third of a point (0.308, P=.03). Age affected CommCare user type negatively, with an increase in age increasing the likelihood of belonging to a lower category of CommCare adoption (-0.105, P=.08). Other individual characteristics did not affect adoption or the predicted values estimating the relationship between adoption and quality and experience of care, although illiteracy was able to affect the relationship negatively.
  
  
  CONCLUSIONS
  mHealth technology adoption by frontline workers can positively impact the quality and experience of care they provide. Individual characteristics, especially literacy and age, can be important elements affecting technology adoption and the way users leverage the technology for their work. Our formative study provides informed hypotheses and methods for further research.
authors.affiliation: Dimagi Software Innovations, Nairobi, Kenya. sangyakaphle@gmail.com.
authors.forename: Sangya
authors.identifier: http://orcid.org/0000-0002-0598-2272
authors.initials: S
authors.lastname: Kaphle
authors.forename: Sharad
authors.identifier: http://orcid.org/0000-0002-1225-3537
authors.initials: S
authors.lastname: Chaturvedi
authors.forename: Indrajit
authors.identifier: http://orcid.org/0000-0002-8248-4402
authors.initials: I
authors.lastname: Chaudhuri
authors.forename: Ram
authors.identifier: http://orcid.org/0000-0002-5918-2684
authors.initials: R
authors.lastname: Krishnan
authors.forename: Neal
authors.identifier: http://orcid.org/0000-0003-0027-3247
authors.initials: N
authors.lastname: Lesh
keywords: CommCare; community health workers; mHealth; technology adoption