Improving health worker performance through text messaging: A mixed-methods evaluation of a pilot intervention designed to increase coverage of intermittent preventive treatment of malaria in pregnancy in West Nile, Uganda

PLoS One. 2018 Sep 6;13(9):e0203554. doi: 10.1371/journal.pone.0203554. eCollection 2018.


Poor health worker performance is a well-documented obstacle to quality service provision. Due to the increasingly widespread availability of mobile devices, mobile health (mHealth) has received growing attention as a service improvement tool. This pilot study explored feasibility, acceptability and outcomes of an mHealth intervention designed to increase coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) in two districts of West Nile, Uganda. In both districts, selected health workers (N = 48) received classroom training on malaria in pregnancy. All health workers in one district (N = 49) subsequently received 24 text messages reinforcing the training content. The intervention was evaluated using a mixed-methods approach, including four focus group discussions with health workers and three in-depth interviews with district health officials, health worker knowledge assessments one month (N = 90) and six months (N = 89) after the classroom training, and calculation of IPTp coverage from participating health facilities' (N = 16) antenatal care registers covering six months pre- and post-intervention. Complementing classroom training with text messaging was found to be a feasible, acceptable and inexpensive approach to improving health worker performance. The messages served as reminders to those who had attended the classroom training and helped spread information to those who had not. Health workers in the district where text messages were sent had significantly better knowledge of IPTp, achieving an increased composite knowledge score of 6.00 points (maximum score: 40) compared with those in the district where only classroom training was provided. Average facility coverage of three doses of IPTp was also significantly higher where text messages were sent (85.8%) compared with the district where only classroom training was provided (54.1%). This intervention shows promise for the improvement of health worker performance for delivery of IPTp, and could have significant broader application.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antimalarials / therapeutic use
  • Female
  • Guideline Adherence
  • Health Facilities
  • Health Personnel
  • Humans
  • Malaria / prevention & control*
  • Patient Acceptance of Health Care
  • Pregnancy
  • Pregnancy Complications, Infectious / prevention & control
  • Pregnancy Complications, Parasitic / prevention & control
  • Pyrimethamine / therapeutic use
  • Sulfadoxine / therapeutic use
  • Text Messaging*
  • Uganda


  • Antimalarials
  • Sulfadoxine
  • Pyrimethamine

Grant support

The study was conducted through COMDIS-HSD (, a Research Programme Consortium funded by the UK government ( It also received Programme Partnership Arrangement funding from the UK Government. However, the views expressed in this article do not necessarily reflect the UK government’s official policies. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.