Implementing Health Communication Tools at Scale: Mobile Audio Messaging and Paper-based Job Aids for Front-line Workers Providing Community Health Education to Mothers in Bihar, India

"While the utilisation of mHealth tools is promising, particularly in low resource areas where access to information and health services may be limited, it is critical that they be designed with a human-centred approach and subsequently evaluated to assess the benefit for knowledge and health-related behaviours..."

To expand quality healthcare for marginalised populations in hard-to-reach places, mobile health (mHealth) services have been employed to empower frontline workers (FLWs) and their beneficiaries with novel methods of education and communication. India is a country with consistently high burdens of maternal and child deaths annually. Conducted in the state of Bihar, this study analyses the impacts of a package of mHealth audio messaging and paper-based job aids used by FLWs during government-sponsored village health, sanitation, and nutrition days (VHSNDs) on knowledge and practices of childbearing women across the reproductive, maternal, newborn, and child health and nutrition (RMNCHN) continuum of care.

As part of an investment by the Bill & Melinda Gates Foundation (BMGF) to support the Government of Bihar (GoB) to improve RMNCHN statewide, BBC Media Action implemented multiple communication tools to support FLW outreach as part of Ananya, a large-scale technical support programme (see Related Summaries, below). In order to achieve impact at scale, BMGF awarded a grant to BBC Media Action in 2011 to increase demand for health services through education and empowerment of healthcare workers promoting specific health behaviours across 8 innovation districts, reaching 28 million people, with plans to scale up effective interventions across all 38 districts of Bihar in 2014.

One component of Ananya was community-based interventions implemented at VHSNDs, monthly community events during which FLWs would provide health information and services to women and children. BBC Media Action developed supportive tools for FLWs working at these VHSNDs, including:

1. GupShup Potli (GSP), a mobile phone-based audio recording of 12 modules covering health content about a variety of RMNCHN behaviours. Having connected their phones to speakers using an auxiliary cord, FLWs played recordings for beneficiaries and then facilitated discussion and a question-and-answer session on health-related topics with women.
2. Interpersonal communication (IPC) tools, physical (paper-based) job aids with 4 demonstration modules to explain to groups of women key health messages regarding diarrhoea management, iron-folic acid (IFA) consumption, immunisation compliance, birth spacing, and contraception utilisation. Created using principles of human-centred design (HCD), the job aids were used to provide visual demonstrations of key health information during the conversations with groups of women.

To evaluate the impact of the VHSND communication tools, the ressearchers undertook a secondary data analysis of multiple cross-sectional surveys collected between July and September 2016. Of the 137 blocks in the 8 intervention districts, 13 intervention blocks were chosen through random selection for the GSP survey and 7 blocks for the IPC survey. Similarly, 13 blocks from the non-intervention districts were chosen, matched across demographic and key health indicators. A total of 2,608 women were surveyed for the GSP study and 2,002 women for the IPC study. The researchers analysed the data using logistic regression to compare health-related knowledge and behaviours between women who had been exposed to the tools at VHSNDs versus those who were unexposed.

Key findings:

• GSP (see table 3 in the paper): Knowledge was significantly higher among women exposed to GSP compared with those unexposed when asked about birth preparedness (odds ratio (OR) 1.3, 95% confidence interval (CI) 1.0-1.7, p=0.03), tetanus toxoid (TT) vaccines (OR 1.5, 95% CI 1.0-2.1, p=0.03), complementary feeding (OR 1.6, 95% CI 1.2-2.2), growth monitoring (OR 1.8, 95% CI 1.1-2.8), and pneumonia care (OR 4.9, 95% CI 1.8-13.1). Women who were exposed were more likely to take iron-folic acid (IFA) tablets (OR 1.5, 95% CI 1.1-2.2) and were twice as likely to be currently using contraception (OR 2.0, 95% CI 1.2-3.2). However: There was no difference in plans for future use of contraception (OR 1.0, 95% CI 0.7-1.4); there was no difference in the practice of complementary feeding, or in receipt of the TT vaccine; and women who were exposed were less likely to have had their children receive immunisations (OR 0.6, 95% CI 0.4-0.9).
• IPC (see table 4 in the paper): Women exposed to the IPC tools were twice as likely to report both correct knowledge and practice of IFA compliance than those who had not been exposed. Women exposed to the diarrhoea tool were 3 times as likely to know how to use oral rehydration salts (ORS) and zinc to treat diarrhoea as compared with the unexposed (OR 3.0, 95% CI 2.3-4.1); however, the practice of appropriate management was not significantly different. While the knowledge of birth spacing was not significantly different between groups, both the current use (OR 1.8, 95% CI 1.2-2.8) and plans to use contraception (OR 1.4, 95% CI 1.1-1.8) were more likely among the exposed group.
• Women exposed to both tools were generally at least twice as likely to subsequently discuss the messages with others.

Based on these findings, the researchers conclude that mHealth-based communication tools have the promise to significantly improve FLW communication with beneficiaries, as well as increased knowledge and uptake of key health behaviours. Also, paper-based visual demonstration tools, particularly when shaped by HCD principles, can engender understanding of new and complex concepts; these IPC tools were also associated with improved health-related knowledge and behaviours.

The researchers suggest further study to understand how mHealth tools can be utilised most effectively, and in what contexts. For instance, assessments could address whether digital health tools are more effective than paper-based visualisation tools, particularly for supporting less-educated or marginalised groups, or when and for what topics digitally facilitated communication is superior to direct-to-beneficiary digital tools. They urge that future evaluations of the effectiveness of mHealth interventions should also focus on health outcomes (versus simply self-reported behaviours, as in the present study), as well as the long-term sustainability of health-related improvements.

In conclusion: "These findings suggest important new opportunities for mechanisms of delivery of critical health messages, involving dissemination of educational information at significant scale through mobile technology to women who may not otherwise have access to facility-based healthcare."