Mobile Technology to Improve Maternal and Newborn Health Outcomes_Dennis Cherian_4.25.13
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Mobile Technology to Improve Maternal and Newborn Health Outcomes_Dennis Cherian_4.25.13
- 1. Mobile technology to improve maternal and newborn health outcomes Karuk district Herat province, Afghanistan Better Health for Afghan Mothers and Children project 2008-2013 Dennis Cherian, BHMS, MHA, MS, Senior Director Jahera Otieno, MPH, Program Management Officer, Health and
- 2. Introduction – Program Overview • Project Goal: Achieve sustained improvements in the survival and health of mothers, newborns and children • Partners: The DOPH in Herat, MOPH, BDN, USAID Mission in Kabul and Dimagi
- 3. Introduction – Program Overview • Location: 74 villages in Chisht-e-Sharif Karukh, Kohsan, Zindajan districts of Herat province
- 4. Technical Interventions and LOE • Maternal and newborn care, MNC (35%) • Infant and Young Child Feeding (20%) • Prevention and Control of Diarrhea (20%) • Pneumonia Case Management (15%) • Immunization (10%)
- 5. Overall strategies -Overview • Home Based Life Saving Skills (HBLSS) • Baby Friendly Hospital Initiative (BFHI) • Positive Deviance (PD)-Hearth • Timed and targeted counseling (TTC) • Improve CHW capacity and outreach campaigns
- 6. Introduction – OR Objective and Outcomes To test if the use of CommCare can: • Increase uptake of Healthy Actions by pregnant women- Utilization • Increase knowledge of Important Information points-Knowledge • Improve communication and coordination by CHWs with higher-trained health workers- Access • Improve pregnancy and newborn outcomes through improved routine care- Access • Document socio-cultural, gender, and community factors influencing effective use of mphones apps
- 8. Research Design & Process • Study Design: Case-Control • 5 remote village pairs in Karuk district • Baseline and endline studies • 20 months of implementation • Study population: CHWs, mothers of children age 0-23 months, and health facility staff in both intervention and control sites
- 9. Research Design & Process • 2009 Assessment trip with Dimagi • 2010 Baseline Module Design & Refinement • 2011 CommCare Module Training • 2012 Observation and field support • Jan 2013 Endline
- 11. Findings
- 12. Operational challenges • CHW literacy • Security in the province • Cultural acceptability of using mobile phones for health issues • Understanding and use of the research tool by CHWs • Healthcare worker capacity and knowledge • Community access and use of health facilities • Need additional manpower to support OR study • Overall lengthy and labor intensive process
- 13. Lessons Learned • Facilitated dialogue with families on the need for facility births and helping them plan better for births • mHealth tool helped facilitate dialogue with families and key community leaders • Having flexibility in design and rollout of tool was helpful • Take time to find the most appropriate partner • Tool was job aid, communication tool, and monitoring system—especially in remote locations
- 14. Next Steps • WV Afghanistan secured CIDA funding • Scale up plans to additional locations • Lessons learned applied within WV mHealth interventions: • Mozambique • Motech
- 15. mHealth Theory of Change Natl & Intl Goals to which project contributes Improved linkages between facility and community services for quality improvement Improved linkages between facility and community services for quality improvement Develop Operating Plan Develop Operating Plan Refine business needs & requirements Refine business needs & requirements CHW/V adherence to behavior change communications protocols CHW/V adherence to behavior change communications protocols CHW/V adherence to case management protocols* CHW/V adherence to case management protocols* Foundational activities immediate outcomes Outcomes to which project primarily contribute Finalise M&E plan and conduct baseline Finalise M&E plan and conduct baseline Consolidate sustainability plan and partner relationships Consolidate sustainability plan and partner relationships Establish programme management Establish programme management Training, curriculum and partner development Training, curriculum and partner development Improved preventive health behavior among pregnant women and caregivers at the household level Improved preventive health behavior among pregnant women and caregivers at the household level Access to health information and complementary social services Access to health information and complementary social services Build and sustain user capacity & ownership Build and sustain user capacity & ownership Communicate project- roadmap, benefits, project management Communicate project- roadmap, benefits, project management More timely and effective use of health services on the part of pregnant women and caregivers More timely and effective use of health services on the part of pregnant women and caregivers Deployment activities Develop solution based on user needs Develop solution based on user needs Activity tracking, monitoring & evaluation Activity tracking, monitoring & evaluation Appropriate and timely use of program monitoring information Appropriate and timely use of program monitoring information Design budget & sustainable financial model Design budget & sustainable financial model Undertake user acceptance testing Undertake user acceptance testing Train users on all aspects of solution Train users on all aspects of solution • Lower maternal and child U5 mortality rates • Lowered child U5 morbidity • Improved maternal and child U5 nutritional status • Lower maternal and child U5 mortality rates • Lowered child U5 morbidity • Improved maternal and child U5 nutritional status Millenium Development Goals mHealth Theory of Change CHW/V motivation & retention CHW/V motivation & retention More sustainable and effective CHW/V workforce More sustainable and effective CHW/V workforce Referral closure rates between CHW/V and facilities Referral closure rates between CHW/V and facilities * i.e. ttC visit schedule or CCM clinical case management protocols
- 16. WV Program Coordination Unit Structure: A small team of dedicated professionals will coordinate the mHealth programming and work with the Motech Suite Team. The following Program Coordination Unit (PCU) will provide the management, coordination, strategic and technical support to existing and future mHealth programs. DM&E ExpertsDM&E Experts Project ManagerProject Manager Project SponsorProject Sponsor Health ExpertsHealth Experts PPP ExpertsPPP Experts ICT ExpertsICT Experts Technical Partner Team Technical Partner Team Business Advisory Group Business Advisory Group WV National Office Project Structure & Management Program/Project Governance Processes & Documentation: •Program & project charters •Annual planning process •Communications plan •Stakeholder management plan
- 17. WV Implementation Models prioritized for Motech Suite • CHW – Timed and Targeted Counseling (ttC) • Community Case Management (CCM) • cPMTCT • Community Care Coalitions (CCC) / Village Health Committees (VHC) • Citizen Voice & Action (CVA) Community Environment Yellow shading - Secondary priority Blue lettering - specialized or context-specific adaptations of models
- 18. Program Areas for mHealth Solutions Health System Strengthening Country Ownership Linkages to Health System & Services Community Community Mobilization & Sensitization CHW Recruitment, Training, Supervision, Incentives & Performance Evaluation CHW & Beneficiary Registration Household/Individual Home-Based Care Referral System Counseling & Behavior Change Communication Response to Urgent Care Scenarios Monitoring & Evaluation Data Collection Provision of Health Commodities Household based diagnostics/screening/case management tools KEY SOLUTION FUNCTIONALITY Registration Referral Process Alerts/Notifications Reporting Behavior Change Messages Integration with HMIS Testing/Rapid Diagnostics Urgent Response Supply Chain/Logistics CHW training, supervision, performance evaluation
- 19. Phase II (Summer/Fall 2013) Stock Out Tracking* Urgent Response* CHW training, supervision, performance evaluation* Integration with HMIS Testing/RDT Prioritized WV Functional Blocks Phase I (Spring 2013) 1.Registration* 2.Referral Process* 3.Alerts/Notifications* 4.Reporting* 5.Behavior Change Messages* WV Customization: White = live; Gold = Being finalized; Aqua= Initial preparation * Functionality already exists in Motech Suite
- 20. Second Priority Functionality Current Phasing First Priority Functionality Phase I Implementations DATES: January - March 2013 PROJECTS: Sierra Leone - ttC Uganda - ttC & CCM/malaria Zambia - CCM/malaria & ttC Tanzania - ttC Phase III Implementations DATES: TBD & Proposal Stage PROJECTS: -Ghana - ttC -Jerusalem/West Bank/Gaza – ttC & PS -Mozambique – CCM/Malaria & RDT -Haiti – HIV/AIDS -Niger – CCM & Nutrition -India – ttC/CCM & Advocacy Phase II Implementations DATES: April - September 2013 PROJECTS: India - MNCH Afghanistan - MNCH & Nutrition Sri Lanka – Nutrition Mozambique - ttC Malawi - ttC Zimbabwe - ttC
- 21. Key WV Collaborations Globally
- 22. Thank you!
Notas do Editor
- Project Objectives: 1. Improved health status of vulnerable target populations: increased knowledge, practice and coverage of key interventions; improved access to services, and quality and equity in service delivery 2. Increased scale of interventions: improved partner capacity and improved systems and policies 3. Contribution to excellence in child survival nationally and globally The OR study within the BHAMC project aimed to test if the use of CommCare™ increases utilization of maternal and newborn health services and knowledge of important information points and improves communication with higher trained health care workers. As a secondary objective, it aimed to explore cultural and technical barriers that exist in communities and health facilities that affect successful use of CommCare™ or other mobile applications for health. This was the first time a mobile application was used in the country for a health intervention. There were at least three facets to the intervention that was tested: one, the pregnancy and newborn care modules of CommCare™ in written, pictorial and audio formats; two, airtime for CHWs to communicate with facility-based staff; and lastly the availability of real-time data to the project team. aths of women in reproductive age result from complications of pregnancy and childbirth World Vision worked with the software consultancy firm Dimagi in adapting the latter’s software application, CommCare™ for CHWs in the OR intervention sites to develop two modules, one for antenatal care and another for postnatal care based on HBLSS. The modules were developed in Dari, the local language, in visual and audio formats. A database was also set up at the BHAMC office and at World Vision headquarters that can access data in real time. BHAMC trained five CHW couples in the use of these modules who were provided with mobile phones loaded with the application and with airtime to support them when they visited pregnant women at key times during pregnancy and postnatal and for making referral calls. The CHW couples visited pregnant women at specific times during pregnancy to discuss specific actions related to their health and to upload information related to their pregnancy on the mobiles. Key aspects discussed were: the need for antenatal care visits and delivering in a facility, planning and preparing for birth (transportation, saving money, coordination with health facility for delivery, essential newborn care items), danger signs during pregnancy, labor, delivery, and caring for a newborn. In particular, the CHWs discussed the need for facility birth with the family and facilitated related decisions. When the woman went into labor, the CHWs made a referral call and linked the woman’s family with a skilled provider at the nearest facility. In both intervention and comparison sites, as with the rest of BHAMC’s target communities, the HBLSS package was used to improve the same outcomes.
- Project Objectives: 1. Improved health status of vulnerable target populations: increased knowledge, practice and coverage of key interventions; improved access to services, and quality and equity in service delivery 2. Increased scale of interventions: improved partner capacity and improved systems and policies 3. Contribution to excellence in child survival nationally and globally The OR study within the BHAMC project aimed to test if the use of CommCare™ increases utilization of maternal and newborn health services and knowledge of important information points and improves communication with higher trained health care workers. As a secondary objective, it aimed to explore cultural and technical barriers that exist in communities and health facilities that affect successful use of CommCare™ or other mobile applications for health. This was the first time a mobile application was used in the country for a health intervention. There were at least three facets to the intervention that was tested: one, the pregnancy and newborn care modules of CommCare™ in written, pictorial and audio formats; two, airtime for CHWs to communicate with facility-based staff; and lastly the availability of real-time data to the project team. aths of women in reproductive age result from complications of pregnancy and childbirth World Vision worked with the software consultancy firm Dimagi in adapting the latter’s software application, CommCare™ for CHWs in the OR intervention sites to develop two modules, one for antenatal care and another for postnatal care based on HBLSS. The modules were developed in Dari, the local language, in visual and audio formats. A database was also set up at the BHAMC office and at World Vision headquarters that can access data in real time. BHAMC trained five CHW couples in the use of these modules who were provided with mobile phones loaded with the application and with airtime to support them when they visited pregnant women at key times during pregnancy and postnatal and for making referral calls. The CHW couples visited pregnant women at specific times during pregnancy to discuss specific actions related to their health and to upload information related to their pregnancy on the mobiles. Key aspects discussed were: the need for antenatal care visits and delivering in a facility, planning and preparing for birth (transportation, saving money, coordination with health facility for delivery, essential newborn care items), danger signs during pregnancy, labor, delivery, and caring for a newborn. In particular, the CHWs discussed the need for facility birth with the family and facilitated related decisions. When the woman went into labor, the CHWs made a referral call and linked the woman’s family with a skilled provider at the nearest facility. In both intervention and comparison sites, as with the rest of BHAMC’s target communities, the HBLSS package was used to improve the same outcomes.
- Why Afghanistan: 2 nd worst maternal mortality rate and the highest infant mortality rate Only 24.3% of mothers receive skilled delivery assistance during delivery Only 20.8% mothers received post natal check by skilled health personnel after three days of delivery Almost half of all de Project Objectives: 1. Improved health status of vulnerable target populations: increased knowledge, practice and coverage of key interventions; improved access to services, and quality and equity in service delivery 2. Increased scale of interventions: improved partner capacity and improved systems and policies 3. Contribution to excellence in child survival nationally and globally The OR study within the BHAMC project aimed to test if the use of CommCare™ increases utilization of maternal and newborn health services and knowledge of important information points and improves communication with higher trained health care workers. As a secondary objective, it aimed to explore cultural and technical barriers that exist in communities and health facilities that affect successful use of CommCare™ or other mobile applications for health. This was the first time a mobile application was used in the country for a health intervention. There were at least three facets to the intervention that was tested: one, the pregnancy and newborn care modules of CommCare™ in written, pictorial and audio formats; two, airtime for CHWs to communicate with facility-based staff; and lastly the availability of real-time data to the project team. aths of women in reproductive age result from complications of pregnancy and childbirth World Vision worked with the software consultancy firm Dimagi in adapting the latter’s software application, CommCare™ for CHWs in the OR intervention sites to develop two modules, one for antenatal care and another for postnatal care based on HBLSS. The modules were developed in Dari, the local language, in visual and audio formats. A database was also set up at the BHAMC office and at World Vision headquarters that can access data in real time. BHAMC trained five CHW couples in the use of these modules who were provided with mobile phones loaded with the application and with airtime to support them when they visited pregnant women at key times during pregnancy and postnatal and for making referral calls. The CHW couples visited pregnant women at specific times during pregnancy to discuss specific actions related to their health and to upload information related to their pregnancy on the mobiles. Key aspects discussed were: the need for antenatal care visits and delivering in a facility, planning and preparing for birth (transportation, saving money, coordination with health facility for delivery, essential newborn care items), danger signs during pregnancy, labor, delivery, and caring for a newborn. In particular, the CHWs discussed the need for facility birth with the family and facilitated related decisions. When the woman went into labor, the CHWs made a referral call and linked the woman’s family with a skilled provider at the nearest facility. In both intervention and comparison sites, as with the rest of BHAMC’s target communities, the HBLSS package was used to improve the same outcomes.
- Why Afghanistan: 2 nd worst maternal mortality rate and the highest infant mortality rate Only 24.3% of mothers receive skilled delivery assistance during delivery Only 20.8% mothers received post natal check by skilled health personnel after three days of delivery Almost half of all de Project Objectives: 1. Improved health status of vulnerable target populations: increased knowledge, practice and coverage of key interventions; improved access to services, and quality and equity in service delivery 2. Increased scale of interventions: improved partner capacity and improved systems and policies 3. Contribution to excellence in child survival nationally and globally The OR study within the BHAMC project aimed to test if the use of CommCare™ increases utilization of maternal and newborn health services and knowledge of important information points and improves communication with higher trained health care workers. As a secondary objective, it aimed to explore cultural and technical barriers that exist in communities and health facilities that affect successful use of CommCare™ or other mobile applications for health. This was the first time a mobile application was used in the country for a health intervention. There were at least three facets to the intervention that was tested: one, the pregnancy and newborn care modules of CommCare™ in written, pictorial and audio formats; two, airtime for CHWs to communicate with facility-based staff; and lastly the availability of real-time data to the project team. aths of women in reproductive age result from complications of pregnancy and childbirth World Vision worked with the software consultancy firm Dimagi in adapting the latter’s software application, CommCare™ for CHWs in the OR intervention sites to develop two modules, one for antenatal care and another for postnatal care based on HBLSS. The modules were developed in Dari, the local language, in visual and audio formats. A database was also set up at the BHAMC office and at World Vision headquarters that can access data in real time. BHAMC trained five CHW couples in the use of these modules who were provided with mobile phones loaded with the application and with airtime to support them when they visited pregnant women at key times during pregnancy and postnatal and for making referral calls. The CHW couples visited pregnant women at specific times during pregnancy to discuss specific actions related to their health and to upload information related to their pregnancy on the mobiles. Key aspects discussed were: the need for antenatal care visits and delivering in a facility, planning and preparing for birth (transportation, saving money, coordination with health facility for delivery, essential newborn care items), danger signs during pregnancy, labor, delivery, and caring for a newborn. In particular, the CHWs discussed the need for facility birth with the family and facilitated related decisions. When the woman went into labor, the CHWs made a referral call and linked the woman’s family with a skilled provider at the nearest facility. In both intervention and comparison sites, as with the rest of BHAMC’s target communities, the HBLSS package was used to improve the same outcomes.
- Improve pregnancy and newborn outcomes in remote villages of Herat province through improved routine care and practice of pregnancy, and better access to higher-trained health workers
- The OR study used a pretest-post test design with baseline and end line household surveys carried out in intervention and comparison sites. The sample size of each of the 4 surveys was 103 mothers with children less than 24 months of age. Four surveys with sample size - 103 mothers with children under 24 months old
- The intervention area had 20% point improvement in women receiving at least one ANC (p=0.006), 12% more in having a birth plan (p=0.03) and 22% more facility births over the intervention period (p=1.06), than in the comparison sites
- The OR study showed that the addition of the mobile phone application to ongoing HBLSS intervention leads to further increase in utilization of MNC services. The intervention area significantly greater improvement over time than the comparison sites in ANC visits, birth planning and facility births. The mobile application served as a job aid in user-friendly formats, and helped CHWs communicate directly with facility staff and provided real-time data to the project team.
- Referral and follow up services - Continue to be poor with out ICT OR Identification of danger signs during pregnancy and intervention of skilled health personnel – remains a challenge Emergency care during pregnancy- in the absence of an ambulance Post natal visits – continue to be a challenge Basic information of newborn care and breastfeeding issues
- mHealth increased community and household dialogue with mothers and their household members leading to a significant increase in facility based births. This is especially important since f acility birth is a critical measure for the health and survival of newborns in a setting such as Herat where moving an asphyxiated newborn to a facility in time might be next to impossible.
- KEY POINTS: The goals are tied most closely to MDGs 4 and 5 but also contribute to some aspects of MDGs 1 (particularly nutritional status of pregnant women and children U5) and 6 (particularly HIV and malaria). At the outcome level, we expect the “value add” of mHealth to be reflected in these 4 areas. These metrics would only be gathered periodically with the purpose of documenting quantifiable change at the population, CHW workforce or community level. Immediate outcomes that would be tracked on an ongoing basis to both refine the application itself and document how the mHealth application has directly effected program beneficiaries. The information would either be sourced from standard M&E data tracked by the mobile application itself or by CHW supervisor records and the records kept by community-based structures that support the CHW program, for example, community health committees or advocacy groups. Strengthening community level structures is a central aspect of WV’s Maternal and Child Health and Nutrition strategy. NOTE that adherence to case management protocols can contribute to both the first and second outcome listed here – adherence to the ttC visit schedule for example, would also strongly affect the first outcome. Similarly, appropriate and timely use of program monitoring information can reinforce CHW supportive supervision systems and thus support both the 3 rd and final outcome listed here. We are in the process of developing an illustrative logical framework to propose appropriate indicators at both the output and outcome level.
- World Vision has piloted the first four mhealth functionalities in Afghanistan, Mozambique and Zambia, and is now moving forward on implementations with additional functionality and scope for ttC/CCM in another 4-6 countries, utilizing the Motech Suite, in collaboration with Gates Foundation, Grameen Foundation and Dimagi.