Development of an mHealth Behavior Change Communication Strategy: A Case-Study from Rural Uttar Pradesh in India

"...results support the potential contribution of mHealth interventions to increase access to health information in low-resource settings."

Targeted actions are needed to address immunisation gaps, especially for vulnerable populations. While digital technology may play a role in mitigating such disparities, their use poses challenges, especially in developing countries. This paper explores the Tika Vaani ("vaccine voice") intervention, which sought to improve immunisation uptake in rural Uttar Pradesh, India by combining an mHealth strategy with a face-to-face component to educate and empower an economically poor, low-literate population. Based on the World Health Organization (WHO) mHealth Technical Evidence Review Group's mHealth evidence reporting and assessment (mERA) checklist, the research team here outlines the process of development, implementation, and lessons for scaling up Tika Vaani.

An early-stage assessment of the intervention through a cluster-randomised pilot found that the model was feasible to deliver and could be a powerful strategy to strengthen delivery of immunisation and primary health care (see Related Summaries, below). In brief, this evaluation revealed that information delivery via mobile phone contributed to standardisation and scalability, while face-to-face interactions remained necessary to achieve equity and reach. To complement the main trial report, this paper addresses mERA core items through 5 questions:

1. What is the context? - India sees promise in mHealth innovations to improve rural health care due to the broad geographical coverage of communications infrastructure and the low cost and availability of mobile handsets.
2. What is the Tika Vaani intervention? Tika Vaani operated through 2 strategies:
   • mHealth (messages via mobile phone): The team developed 13 "pushed" edutainment and health information capsules; each week, families received a call with a specific capsule. Five days later, they received a reminder capsule. They also received 3 calls informing them that the child's vaccinations are due. In addition, a person residing in an intervention village could contact the interactive voice response (IVR) system to speak to an operator to facilitate linkage to content, to leave a question, or to comment. (The team opted to use this type of audio messaging due to the low literacy and technological comfort levels of the participants.) For the IVR system, the team chose the Mobile Vaani (MV) platform built by a social technology company located in New Delhi, called Gram Vaani. To ensure data security, the Gram Vaani team stored all data obtained through the MV IVR and app systems on servers hosted in a data centre in India.
   • Community mobilisation (face-to-face): During a large introductory meeting, the field team introduced the project to participating communities, explained the operation of the Tika Vaani IVR system, and distributed pamphlets and stickers featuring the Tika Vaani phone number. Three small-group daytime meetings were held separately for men and women to share feedback on a series of educational audio capsules. Meetings were replicated several times per village to enable widespread participation.
3. How was the intervention developed? - The approach used social marketing theory, which encourages an understanding of key audiences, identification of intervention channels, and development of appropriate messages. Specifically, intervention development involved 2 stages:
   • Definition of public health content - For example, key orientations for the behaviour change communication messages were established through a process evaluation of Village Health and Nutrition Days (VHNDs).
   • Adaptation to local populations - Formative research was conducted from January 1 2017 to January 10 2018 in Hardoi district. An iterative participatory approach was used to validate the need for the interventions and to develop a linguistically and culturally appropriate strategy. Content was initially not well received by communities for a variety of reasons; the formative research process continued until research and implementation teams were satisfied that the content could be of genuine benefit.
4. How did it perform in practice? - 387 (184 intervention; 203 control) households with children ages 0 to 12 months in 26 (13 intervention; 13 control) villages were included in the aforementioned study (more at Related Summaries). Overall participation in one or more interventions was 94% (173/184); it was 82% (144/184) for the face-to-face strategy and 67% (124/184) for the mHealth strategy. Owning a phone or having easy access to the phone by mothers were factors that shaped the intensity of uptake for mHealth strategies, while living far from the meeting site influenced attendance of small group meetings. The intervention was well received by participants, who also showed evidence of improvement in basic health knowledge. For example, with regard to the question "Do you know the immunisation schedule for children from birth to 5 years of age?", the probability of correct responses in the intervention group at endline was 66.67% (102/153) compared to 44.58% (74/166) in the control group.
5. What are the lessons for scale-up and replication? - Examples:
   • An mHealth strategy offers the potential to improve knowledge, but content must be adapted to meet the needs of less-literate users. In this study, story formats (for the mHealth capsules) were especially appreciated. Dramas that touched the heart and included a crisis, denouement, and humour were most successful. The ideal length was 1 to 5 minutes. Furthermore, the research team stresses that content should be designed to be inclusive of all social groups, particularly the marginalised. Aspirational stories placing female, minority, and disabled characters in positions of authority (e.g., doctors, government officers) were universally well received. By thoughtful choice of names and positive portrayal of characters, those designing content can increase relatability and foster a sense of inclusion and respect.
   • Women's empowerment was a transversal factor influencing uptake for both the mHealth and community mobilisation strategies; for example, active involvement in the intervention for men and families to share phones becomes necessary to attenuate gender barriers. To achieve equity and reach, both mHealth and in-person strategies are necessary. However, the logistical and economic challenge to offer the community mobilisation component on a large scale is significant.
   • Given the interest in and acceptability of the intervention by frontline health workers, the intervention could be incorporated with the Indian health system. Frontline health workers could be trained to become the pivots for community mobilisation given their experience and credibility, but it might be necessary to work with community-based non-governmental organisations (NGOs) to offer targeted support for community mobilisation activities.

In conclusion, an "mHealth intervention strategy adapted to the local context and combined with face-to-face communication is a promising method to educate and empower communities in resource-poor rural areas and an excellent way to reduce health inequities."