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ReMiND Pilot Project - Lessons from CRS' work in India on mobile content development
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ReMiND Pilot Project - Lessons from CRS' work in India on mobile content development

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Catholic Relief Services is implementing the ReMiND Pilot Project in partnership with Dimagi Inc. and Vatsalya in 2 blocks (counties) of Kaushambi District in Uttar Pradesh (India). By equipping …

Catholic Relief Services is implementing the ReMiND Pilot Project in partnership with Dimagi Inc. and Vatsalya in 2 blocks (counties) of Kaushambi District in Uttar Pradesh (India). By equipping government community health workers (called ASHA) with mobile phone-based job aids using Dimagi's open-source CommCare software, ReMiND seeks to reduce maternal, newborn and child health by improving the quality and frequency of community health services provided by ASHA. This presentation summarizes some of the project's lessons to date on developing mobile content. This presentation was made at the mHealth Working Group's Deep Dive on developing mobile content for clients held in Baltimore Maryland.

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  • Introduction:The ReMiND Pilot Project is a 3-year initiative implemented by CRS in partnership with Dimagi, Inc. and Vatsalya. The project is implemented in Kaushambi District in the Indian state of Uttar Pradesh. CRS and its partners are working with government community health workers (called ASHA) to improve the quality of community-based care and support for women and children.The primary behavioral changes being addressed by the project are increased utilization of antenatal and delivery services and improved health and nutrition practices during the prenatal and postpartum/newborn periods. But as ReMiND evolves, the scope of intervention is expanding to target other key behaviors, such as routine immunization, prioritized by the Government of UP during the first 1,000 days.
  • Place and Time The decision to develop mobile content for what was to become the ReMiND Pilot Project was a combination of strategic choice and serendipity. Based on some early mHealth work in UP, CRS made the decision in late 2010 to begin design of an mHealth project that would address MNCH in one of the state’s poorer performing districts. (Click) CommCare Beta TestAt almost the same time that CRS made the decision to pursue mHealth programming in Kaushambi, Dimagi launched a call for development partners in India interested in participating in a beta test of its CommCare software using/adapting an existing pregnancy checklist. The timing of this opportunity and complementarity of CRS and Dimagi’s vision for using mobile technology to improve MNCH led to an early partnership that has helped to drive ReMiND’s mobile content development and innovation.(click) Who has phones?Another early factor that figured into the decision of not only why, but how mobile content would be developed was related to phone ownership. (click) All households…Assessment revealed that, while the majority of households in Kaushambi had a mobile phone, it was most often kept by the man (male head of household). Women’s limited or inconsistent access to mobile phones led the project to look for another way to reach pregnant and lactating women. ASHA’s responsibility to conduct pregnancy and postpartum home visits for counseling provides an alternate platform for reaching women with targeted mobile content. (click) LiteracyLow literacy rates—especially among women—also contributed to the decision to focus on development of mobile content that combined still images and audio rather than an SMS-based system. (Click) DecisionReMiND’s final decision was to develop multi-media content that would be used by ASHA equipped with basic feature phones (Nokia C2-01) operating CommCare-based job aids. With the help of audio and visual prompts from the mobile phone, ASHA are supported to systematically assess and counsel women and children.
  • The decision to work through ASHA as the channel for delivering the mobile content to clients strongly influenced the project’s content development process. BCC messages and assessment and referral protocols have been developed to align as closely as possible with the Government’s ASHA guidelines and existing training content.The ReMiND Project has thus far gone through two major content development processes. The first (and longest) was focused on content for the project’s pregnancy application. We began with an existing pregnancy checklist that Dimagi had developed in collaboration with World Vision in Afghanistan. From the basic framework provided by that checklist, content was revised using the government’s ASHA Training Modules to ensure that the assessment of the woman’s pregnancy-related behaviors and practices (e.g., use of antenatal services, IFA consumption, TT, increased nutrition and proper rest, etc.) and key counseling messages fully aligned with government guidance for ASHA pregnancy home visits. The field testing process included initial work with 10 pilot ASHA and local health authorities to help validate content and refine translations. Extensive observations of ASHA use of the mobile application with the clients were complemented with periodic interviews or focus group discussions with ASHA and with clients (separately) to get their feedback on content and successive revisions.A similar process is currently being followed for field testing postpartum application content. The postpartum app is much larger and more complex than the pregnancy application—and was developed “from scratch” rather than from an existing application. However, lessons learned from the pregnancy application development process about content formulation and how to maximize field testing are allowing the postpartum content to be developed in less time. (STOP)Content from the postpartum application was again drawn directly from the government ASHA training resources and guidelines, with maternal and newborn home visit assessment tools adapted directly from the government’s existing paper-based assessment tools used by ASHA.
  • Examples of major modifications or additions that have resulted through field testing mobile content with ASHA and clients include:Shifting from close-ended to open-ended questions. The mobile application was intended to be a conversation started between ASHA and their clients, but the initial use of close-ended questions to gauge client knowledge and behaviors was actually a “conversation stopper”. Modifying the audio content to prompt more open-ended responses helped to move the ASHA and clients toward a more interactive engagement during home visit counseling.Splitting checklist and counseling into separate tools. Early observation of the first versions of the pregnancy application quickly identified that it took too much time to go through the mobile content—and that too much counseling content was trying to be covered in a single visit. To address these challenges, the content focused on assessing/tracking service utilization and behaviors was separated from the counseling content. User-driven counseling with strategic logic. The counseling tool within the pregnancy application was further modified into separate topics. Rather than trying to cover a full range of pregnancy-related counseling topics during each home visit (antenatal care, nutrition, rest, birth preparedness, danger signs) the ASHA could choose from a list of available topics. Logic built into the application is used to adjust the list of available counseling topics based on the woman’s trimester of pregnancy or the number of days post partum. (STOP)This modification helped to not only address the issue of the earlier application taking too much time, but also allows ASHA to choose the type and number of topics on which she will counsel based on the individual client’s needs, interests and time available.Adapting for low-literate ASHA. The challenge of illiteracy (38%) among the ASHA themselves led to further modification of the application to include audio content and labels to facilitate navigation through the application. Planning ahead for the ‘wantedness of girls’. Sex-selective abortion of girls is increasing in India. In Kaushambi, there are only 859 girls born for every 1,000 boys born. Early content included generic messages about the value of the girl child, but concern about more strategically targeting these messages led to secondary review and primary research around this question. As a result, the app content has been modified to help identify pregnancies that fit the profile of high risk for sex selective abortion (i.e., second pregnancies following the birth of a girl child—based on analysis of Census 2011 data published in the Lancet). Work is currently ongoing to refine BCC messages for women/families who fit this profile.
  • Test, test, test—then scale. Plan sufficient time for field testing and application revision before scaling to a large number of users. Once an app is scaled-up, it is more challenging to introduce changes given the time and financial costs of re-installing and re-training users.It takes a team. Content development requires sectoral, technology, translation and implementation expertise. Take this into consideration and plan accordingly when developing mobile content for clients. Need to know or nice to know? The lure of “real-time data” can lead you to include lots of “nice to know” content into your mobile tool/application. This can lead to user fatigue due to loss of interest because the content is too long or complicated or even to fraudulent data entry. It also puts program managers or others are risk of not actually using all of the data that is generated through the mobile platform. Where mobile content includes data collection, focus only on the “need to know” information—and begin planning for how/when that data will be used at the time you are developing content. Share and learn, learn and share. Be willing to share—you (and others) will learn more that way. The sheer volume of mHealth work currently happening means that there is a lot of potential for learning. (STOP)Look for ways to share your content and lessons learned with other mHealth actors in your state/country; Share applications with others that use the same or compatible software platforms;Don’t be proprietary when sharing your content/learning with the government for scale-up. Be willing to work with other mHealth actors to adapt/consolidate content to respond to government priorities.
  • Transcript

    • 1. ReMiND – Reducing Maternal & Newborn Deaths Pilot ProjectLessons from India on Mobile Content DevelopmentmHealth Working Group“Deep Dive” on Development of Mobile Content for Clients26 April 2013
    • 2. Why Mobile Content?• Place & Time– CommCare Beta Test• Who has phones?– All households, butkept by the man• Low literacy• Decision– Multi-media content (image & audio) on basic featurephones operating CommCare-based job aids for ASHA.
    • 3. Process & Timeline• Pregnancy Application (17 months)– Initial iteration of definition & app (March – May 2011)– Introduced to 10 pilot ASHA from May 2011– Multiple minor revisions of app (June – Dec 2011)– Major app revision and field testing (April – July 2012)– Scaled-up to 111 ASHA from August 2012– Revision targeting low-literate ASHA (Jan – March 2013)– Scaling to another 155 ASHA by May 2013 (in progress)• Postpartum Application (11 months)– Develop definition for postpartum, infant and referral modules(Sept – Oct 2012)– Application build (October 2012 – March 2013)– Field Testing with 14 pilot ASHA (March – July 2013)
    • 4. Modifying Content• Shifting from close-ended toopen-ended questions• Splitting checklist andcounseling into separate tools• User-driven counseling withstrategic logic• Adapting for low-literateASHA• Planning ahead for the “wantedness of girls”
    • 5. Lessons & Recommendations• Test, test, test—then scale.• It takes a team.• Need to know ornice to know?• Share and learn.Learn and Share
    • 6. Thank youContact for further info: marianna.hensley@crs.org