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. 2024 Aug 27;8(8):CD015705.
doi: 10.1002/14651858.CD015705.pub2.

Healthcare workers' informal uses of mobile phones and other mobile devices to support their work: a qualitative evidence synthesis

Claire Glenton  1 , Elizabeth Paulsen  2 , Smisha Agarwal  3   4 , Unni Gopinathan  5 , Marit Johansen  5 , David Kyaddondo  6 , Susan Munabi-Babigumira  1 , Josephine Nabukenya  7 , Immaculate Nakityo  8 , Rehema Namaganda  9 , Josephine Namitala  10   11 , Tom Neumark  12   11 , Allen Nsangi  9 , Neil M Pakenham-Walsh  13 , Arash Rashidian  14 , Geoff Royston  15 , Nelson Sewankambo  8 , Tigest Tamrat  16 , Simon Lewin  17   18   19
Affiliations

Healthcare workers' informal uses of mobile phones and other mobile devices to support their work: a qualitative evidence synthesis

Claire Glenton et al. Cochrane Database Syst Rev. .

Abstract

Background: Healthcare workers sometimes develop their own informal solutions to deliver services. One such solution is to use their personal mobile phones or other mobile devices in ways that are unregulated by their workplace. This can help them carry out their work when their workplace lacks functional formal communication and information systems, but it can also lead to new challenges.

Objectives: To explore the views, experiences, and practices of healthcare workers, managers and other professionals working in healthcare services regarding their informal, innovative uses of mobile devices to support their work.

Search methods: We searched MEDLINE, Embase, CINAHL and Scopus on 11 August 2022 for studies published since 2008 in any language. We carried out citation searches and contacted study authors to clarify published information and seek unpublished data.

Selection criteria: We included qualitative studies and mixed-methods studies with a qualitative component. We included studies that explored healthcare workers' views, experiences, and practices regarding mobile phones and other mobile devices, and that included data about healthcare workers' informal use of these devices for work purposes.

Data collection and analysis: We extracted data using an extraction form designed for this synthesis, assessed methodological limitations using predefined criteria, and used a thematic synthesis approach to synthesise the data. We used the 'street-level bureaucrat' concept to apply a conceptual lens to our findings and prepare a line of argument that links these findings. We used the GRADE-CERQual approach to assess our confidence in the review findings and the line-of-argument statements. We collaborated with relevant stakeholders when defining the review scope, interpreting the findings, and developing implications for practice.

Main results: We included 30 studies in the review, published between 2013 and 2022. The studies were from high-, middle- and low-income countries and covered a range of healthcare settings and healthcare worker cadres. Most described mobile phone use as opposed to other mobile devices, such as tablets. We have moderate to high confidence in the statements in the following line of argument. The healthcare workers in this review, like other 'street-level bureaucrats', face a gap between what is expected of them and the resources available to them. To plug this gap, healthcare workers develop their own strategies, including using their own mobile phones, data and airtime. They also use other personal resources, including their personal time when taking and making calls outside working hours, and their personal networks when contacting others for help and advice. In some settings, healthcare workers' personal phone use, although unregulated, has become a normal part of many work processes. Some healthcare workers therefore experience pressure or expectations from colleagues and managers to use their personal phones. Some also feel driven to use their phones at work and at home because of feelings of obligation towards their patients and colleagues. At best, healthcare workers' use of their personal phones, time and networks helps humanise healthcare. It allows healthcare workers to be more flexible, efficient and responsive to the needs of the patient. It can give patients access to individual healthcare workers rather than generic systems and can help patients keep their sensitive information out of the formal system. It also allows healthcare workers to communicate with each other in more personalised, socially appropriate ways than formal systems allow. All of this can strengthen healthcare workers' relationships with community members and colleagues. However, these informal approaches can also replicate existing social hierarchies and deepen existing inequities among healthcare workers. Personal phone use costs healthcare workers money. This is a particular problem for lower-level healthcare workers and healthcare workers in low-income settings as they are likely to be paid less and may have less access to work phones or compensation. Out-of-hours use may also be more of a burden for lower-level healthcare workers, as they may find it harder to ignore calls when they are at home. Healthcare workers with poor access to electricity and the internet are less able to use informal mobile phone solutions, while healthcare workers who lack skills and training in how to appraise unendorsed online information are likely to struggle to identify trustworthy information. Informal digital channels can help healthcare workers expand their networks. But healthcare workers who rely on personal networks to seek help and advice are at a disadvantage if these networks are weak. Healthcare workers' use of their personal resources can also lead to problems for patients and can benefit some patients more than others. For instance, when healthcare workers store and share patient information on their personal phones, the confidentiality of this information may be broken. In addition, healthcare workers may decide to use their personal resources on some types of patients, but not others. Healthcare workers sometimes describe using their personal phones and their personal time and networks to help patients and clients whom they assess as being particularly in need. These decisions are likely to reflect their own values and ideas, for instance about social equity and patient 'worthiness'. But these may not necessarily reflect the goals, ideals and regulations of the formal healthcare system. Finally, informal mobile phone use plugs gaps in the system but can also weaken the system. The storing and sharing of information on personal phones and through informal channels can represent a 'shadow IT' (information technology) system where information about patient flow, logistics, etc., is not recorded in the formal system. Healthcare workers may also be more distracted at work, for instance, by calls from colleagues and family members or by social media use. Such challenges may be particularly difficult for weak healthcare systems.

Authors' conclusions: By finding their own informal solutions to workplace challenges, healthcare workers can be more efficient and more responsive to the needs of patients, colleagues and themselves. But these solutions also have several drawbacks. Efforts to strengthen formal health systems should consider how to retain the benefits of informal solutions and reduce their negative effects.

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Conflict of interest statement

Claire Glenton (CG) declares a grant from Norges Forskningsråd (Research Council in Norway) paid to institution. Until 2022, CG was an Editor with Cochrane Effective Practice and Organisation of Care (EPOC). She was not involved in the editorial process for this review.

Elizabeth Paulsen (EP) declares that she has no conflicts of interest.

Smisha Agarwal (SA) declares grants and contracts from the Gates Foundation to study digital health (to understand how countries are using digital tools to improve primary healthcare services). SA has several academic papers in this area of work. SA serves on the Board of Directors (non‐fiduciary) of Reach Digital (South Africa), a not for profit company that provides services that develops mobile based health programs.

Unni Gopinathan (UG) declares a grant from Norges Forskningsråd (Research Council of Norway, project no. 316145); paid to institution (to cover salary and operational costs of the project).

Marit Johansen (MJ): until January 2023, MJ was the Information Specialist for Cochrane EPOC, hosted by the Norwegian Institute for Public Health. MJ was not involved in the editorial process for this review.

David Kyaddondo (DK) declares that he has no conflicts of interest.

Susan Munabi‐Babigumira (SMB) works in health services research at the Norwegian Public health Institute. She is a former Editor with Cochrane EPOC. She was not involved in the editorial process for this review.

Josephine Nabukenya (JNAB) declares that she has no conflicts of interest.

Immaculate Nakityo (IN) declares that she has no conflicts of interest.

Rehema Namaganda (RN) declares that she has no conflicts of interest.

Josephine Namitala (JNAM) is a PhD candidate on the mHEALTH INNOVATE PROJECT.

Tom Neumark (TN) declares that he has no conflicts of interest.

Allen Nsangi (AN) declares that she has no conflicts of interest.

Neil Pakenham‐Walsh (NMPW) is a global health professional and runs a non‐profit global network called Healthcare Information For All (HIFA; www.hifa.org). HIFA is supported by more than 400 health and development organisations including Cochrane. A number of these may have an opinion or interest, or both, in the topic.

Arash Rashidian (AR) is a health professional by background, and now works as a director within the WHO, who have a stated policy to support countries by enhancing the use of digital health to support health systems and respond to people needs. He declares that he has published papers on digital health. AR is an EPOC Editor, but was not involved in the editorial process for this review. AR also declares that he holds a professorship position in health policy (however, he is on unpaid leave from this position while he works for the WHO).

Geoff Royston (GR) is a member of the Steering Group for HIFA (www.hifa.org), who have declared an opinion or position on the topic. GR reports that he is a co‐author of two papers relevant to the review: (PAPER 1) Royston G, Pakenham‐Walsh N, Zielinski C. Universal access to essential health information: accelerating progress towards universal health coverage and other SDG health targets. BMJ Global Health 2020;5:e002475. DOI:10.1136/ bmjgh‐2020‐002475; and (PAPER 2) Royston G, Hagar C, Long L‐A, et al. Mobile health‐care information for all: a global challenge. Lancet Glob Health 2015;3:e356–7.

Nelson Sewankambo (NS) declares that he has no conflicts of interest.

Tigest Tamrat (TT) declares that she has no conflicts of interest.

Simon Lewin (SL) declares a grant from the Research Council of Norway – he is Co‐investigator on the mHEALTH‐INNOVATE research project (prosjektbanken.forskningsradet.no/en/project/FORISS/325476), paid to institution but managed by SL (covered person‐time related to this review, including writing the review). SL is the Fiduciary Officer and CoLead for Cochrane Person‐Centred Care, Health Systems and Public Health Thematic Group; unpaid position. SL was employed as the Joint Co‐ordinating Editor of Cochrane EPOC, paid to institution. He was not involved in the editorial process for this review. SL declares that he was on the Trial Steering Committee, which received no funding, for a trial that was linked to one of the included studies (Anstey 2018).

A number of non‐financial issues, including personal, political, and academic factors, could have influenced the review authors’ input when conducting this review. The review authors have discussed this further in the sections on reflexivity in the Methods section.

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